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THE JOURNAL

MENTAL SCIENCE.

EDITORS:

Henry Bayner, M.D. A. B. Urquhart, M.D.

ConoUy Norman, F.B.C.P.I. J. Chambers, M.D.

ASSISTANT EDITOR:

J. B. Lord, M.B.

VOL. LI 11.

LONDON:

J. & A. CHURCHILL,

7, GREAT MARLBOROUGH STREET.

MDCCCCVII.

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CATALOGUED

AUG 6 1908

E. H. B.

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

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THE

MEDICO- PSYCHOLOGICAL ASSOCIATION
OF GREAT BRITAIN AND IRELAND.

3 *

THE COUNCIL AND OFFICERS, 1906-7.

president.— ROBERT JONES, M.D., B.S., F.R.C.8.

president ELECT.— PETER W. MACDONALD, M.D,

EX-president.— T. OUTTERSON WOOD, M.D.

treasurer.— H. HAYES NEWINGTON, F.RC.P.Ed.

/'HENRY RAYNBR M.D.

editors OF journal J A * R - URQUHART, M.D.
editors OF journal, l CONOLLY NORMAN, F.RC.P.I.

UAMES CHAMBERS, M.D.

assistant editor (not.(ember of Council).—JOHN R LORD, M.B.
divisional secretary for stuth-eastern division.— R H. STEEN, M.D.
divisional, secretary for south- * * *rn division. —H. T. 8. AVELIN K, L.R.C.P.

DIVISIONAL SECRETARY FOR ; RTHERN AND MIDLAND DIVISION.

BEDFORD PIERCE, M.D.

DIVISIONAL SECRETARY FOR SCOTLAND.— LEWIS C. BRUCE, M.D.
DIVISIONAL SECRETARY FOR IRELAND.— WILLIAM R. DAWSON, M.D.
GENERAL SECRETARY.— C. HUBERT BOND, M.D., D.8c.
secretary of educational committeb.— MAURICE CRAIG, M.D. (appointed by
Educational Committee, but with seat on Council).
registrar.— ALFRED MILLER, M.B.

OF COUNCIL.

REPR ESENTATIVE.

DATED BOWER
DAYID G. THOMSON
JOHN TURNER
EBKBBT W. WHITE
P. W. MACDONALD
EDWIN MOD ALL
SAMUKL KDGERLEY
JOAN it SWAN
T. W. McDOWALL
ADAM R.TURNBULL la-— —
DAVID TKLL0WLEE8 j ScoTLA2n> *

' - [The above form

js.E. Dit.
| 8.W. Dit.

}h.

REFEEa ENT ATTTB.

MICHAEL J. NOLAN \ -
THOMAS DRAPES J lMLA * D -

A M. Dit.

NOMINATED.

FLETCHER BEtCH
JOSEPH 8. BOLTON
THOMAS 8..CLOCST0N
WILLIAM GRAHAM

george i l savage

R PERCY SMITH
the Council.]

AvnrmM. J FRANdS H. EDWARDS, M.D.
▲UDITOBS. j XHEa B HY8LOP, M.D.

ENGLAND I R0BERT J0NES ’ M.D.

ENGLAND | MAUKICB CRaIG y D

SCOTLAND J W1LLIAM A * PARKER. M B.

SCOTLAND^ OSWALD, M.B.

IRELAND ] THOMAS drapes, m B.

IRELAND ( WILL1am ^ DAWSON, M.D.

ExAminera for the Nuraiog Certificate of the AMoeiatiow *

CONOLLY NORMAN; ADAM R TURNBULL; EDMUND B. WHITCOMBR

PARLIAMENTARY COMMITTEE.

FLETCHER BEACH.

GEO. F. BLANDFORD.

C. HUBERT BOND.

DAVID BOWER (Secretary).
LEWIS C. BRUCE.

JOHN. CARSWELL.

DAVID M. CASSIDY.

THOS S. CLOUSTON.

WM. R DAWSON.
WILLIAM DOUGLAS.

A- D. V C. PINEGAN.

H. GARDINER HILL.
CHAS. K. HITCHCOCK.
THEO. B. HYSLOP.

J. CARLYLE JOHNSTONE.
ROBERT JONES.

HL ROOKS LEY.

T. W. G. McDOWALL.

CHAS. A. MERCIER
H HATES NEWJMTUN
CONOLLY N0RMA5
EVAN POWELL
HENRY RaTNER
GEO. H. SAVAGE.

R PERCY SMITH
J. BEVERIDGE AFOUL
DAYID G. THOMSON.

T. SEYMOUR TTTKE
ALEX. R URQUHaRT
LIONEL A WEATHEELY.
R B. WHITCOMBE.
ERNEST W. WHITE
JoSErH WIGI.ESWORIH
T. OCTTERSON WOOD.
DAYID TELLOWLEER

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EDUCATIONAL COMMITTEE.

FLETCHER BEACH.

C. HUBERT BOND.

LEW 18 C. BRUCE.

TH08. 8. CLOUSTON.
MAURICE CRAIG ( Secretary ).
WILLIAM R. DAWSON.
WILLIAM GRAHAM.

JOHN G. HAVELOCK.

THEO. B. HYSLOP.

J. CARLYLE JOHNSTONE.
ROBERT jfNES.

WALTER 8. KAY.

PETER % MACDONALD.
TH08. W. McDOWALL.

8. R. MACPHAIL.
HAMILTON G. MARE.
WILLIAM R MENZ1E8.

C. A. MERC1KR (Chairman).
WILLIAM J. MICKLE.
ALFRED MILLER.

GILBERT E. MOULD.

H. HAYES NEWINGTON.
MICHAEL J. NOLAN.

CONOLLY NORMAN.
BEDFORD PIERCE.
WILLIAM RAWE8.

HENRY RAYNER.

GEORGE M. ROBERTSON.
EDWARD C. ROGERS.
JAMES RORIE.

GEORGE H. SAVAGE.

T. CLAYE SHAW.

R. PERCY SMITH.

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

ADAM R. TURNBULL.
LIONEL A. WEATHERLY.
EDMUND B. WHITCOMBE,
ERNEST W. WHITE.
JAMES R. WHITWELL.
JOSEPH WIGLK8WORTH.
J. KENNEDY WILL.

T. OUTTERSON WOOD.
DAVID YELLOWLEES.

LIBRARY COMMITTEE.

FLETCHER BEACH. I T. OUTTERSON WOOD.

HENRY RAYNER. | ROBERT H. COLE

LIST OF CHAIRMEN.

1841. Dr. Blake, Nottingham.

1842. Dr. de Vitre, Lancaster.

1843. Dr. Conolly, Han well.

1844. Dr. Thurnam, York Retreat.

1847. Dr. Wintle, Warneford House, Oxford.

1851. Dr. Conolly, Hanwell.

1852. Dr. Wintle, Warneford House.

LIST OF PRESIDENTS.

1864. A. J. Sutherland, M.D., St. Luke’s Hospital, London.

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

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

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

1858. John Couolly, 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 Kirkinan, M.D., Suffolk County Asylum.

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

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

1866. 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. Sunkey, M.D., Sandy well Park, Cheltenham.

1869. T. Lay cock, M.D., Edinburgh.

1870. Robert Boyd, M.l)., County Asylum, Wells.

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

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

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

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

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Ill

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

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

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

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

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

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

1881. D. Hack Take, M.D., London.

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

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

1884. Henry Rayner, M.D., County Asylum, Han well.

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

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

1887. Fred. Needham, M.D., Barn wood House, Gloucester.

1888. T. S. Cions ton, M.D., Royal Edinburgh Asylum.

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

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

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

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

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

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

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

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

1897. Thomas W. Me Do wall, 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.

1902. J. Wiglesworth, M.D., F.R.C.P., Barnhill Asylnm, near Liverpool.

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

1904. R. Percy Smith. M.D., F.R.C.P., 38, Queen Anne Street, Cavendish

Square, London, W.

1906. T. Outterson Wood, M.D., F.R.C.P., 40, Margaret Street, Cavendish
Square, London, W.

1906 Robert Jones, M.D., Clay bury Asylum, Woodford Bridge, Essex.

HONORARY MEMBERS.

1896. Allbutt, T. Clifford, M.D., F.R.C.P., Regius Professor of Physic, Univ.
Camb., St. Radegund’s, Cambridge.

1881. Benedikt, Prof. M., Franciskaner Platz 5, Vienna.

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

1900. Bresler, Johanues, M.D., Kraschnitz, Schlesien, Germany. ( Corr . Mem.,
1896.)

1881. Broaius, Dr., Bendorf-Sayn, near Coblenz, Germany.

1876. Browne, Sir J. Crichton-, M.D.Edin., F.R.S., Lord Chancellor’s Visitor,
New Law Coarts, Strand, W.C. (President, 1878.)

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

1887. Chapin, John B., M.D., Pennsylvania Hospital for the Insane, Phila¬
delphia, U.S.A.

1902. Coupland, Sidney, M.D., F.R.C.P.Lond., Commissioner in Lunacy, 16,
Queen Anne Street, Cavendish Square, London, W.

1872 r Coartenay ’ E * Maziere » A.B., M.B., C.M.T.C.D., M.D., • Inspector of

iooiM Lunatics in Ireland, Lunacy Office, Dublin Castle. (Secretary for

1W1, 1 Ireland , 1876-87.)

1879. Echeverria, M. G., M.D.

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iv Honorary and Corresponding Members .

1892. F£r6, Dr. Charles, 22, Avenue Bugeaud, XVIe Arrt., Paris.

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

1872. Fraser, John, M.B., C.M., F.R.C.P.E., Commissioner in Lunacy, 19,

Strathearn Road, Edinburgh.

1868 1 Ghi’ ird,ier > Sir William T., K.C.B., M.D.Edin., F.R.S., formerly Professor
1 ftftft* r Medicine in the University of Glasgow, Physician to H.M. the King

' *' in Scotland, 32, George Square, Edinburgh. (President, 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.

1887. Lentz, Dr., Asile d’Alien6s, Tournai, Belgique.

1898. MacDonald, A. E., M.D., Columbia Court, 431, Riverside Avenue, cor.

115th Street, New York, U.S.A.

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

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

1897. Morel, M. Jules, M.D., States Lunatic Asylum, 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. (PBB8IDRNT, 1887.)

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

1881. Pesters, 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., Mai son Nationals de Charenton, St. Maurice, Paris. ( Corr .

Mem., 1890.)

1887* Schiile, Heinrich, M.D., lllenau, Baden, Germany.

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

1901. Toulouse, Dr. Edouard, Directeur du Laborstoire de Psychologic experi¬

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

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

CORRESPONDING MEMBERS.

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

1904. Bier&o, Caetano, 48, Rua Formosa, Lisbonne, Portugal.

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

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

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

1902. Estense, Benedetto Giovanni Selvatico, M.D., 116, Piazza Porta Pia, Rome.
1904. Koenig, William Julius, Deputy Superintendent, Dalldorf Asylum, Berlin.
1880. Kornfeld, Dr. Hermann, Gleiwitz, Silesia, Germany,

1889. Kowalowsky, Professor Paul, Kbarkoff, Russia.

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

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

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

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

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

1893. Semelaigne, Dr. R£n£, Secretaire des Seances de la Soci£t6 M£dico-
Psychologique de Paris, 16, Avenue de Madrid, Neuilly,Seine, France.

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MEMBERS OF THE ASSOCIATION.

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

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

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

Asylum, F&reliam.

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

1868. Adams, Josiah 0., M.D.Durh., F.R.C.S.Eng. f Brooke House, Upper

Clapton, London.

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

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

18, Walton Park, Liverpool.

1906. Alcock, Benjamin James, M.B.Aberd., Ch.B., James Murray's Royal
Asylum, Perth.

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

Devon.

1906. Alexander, Edward Henry, M.B., M.R.C.S., Physician Superintendent,
Ashbourne Hall Asylum, Dunedin, New Zealand.

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

1890. Alexander, Robert Reid, M.D.Aber., 19, Leinster Square, Bayswater.
1905. Allen, Robert George, L.R.C.P.&S.I., Burbury Street, Lozell, Birmingham.
1882. Alliott, A. J., M.D., Rosendal, Seven oak a.

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

Officer, District Asylum, Armagh.

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

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

near Hull.

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

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

Yorks.

1905. Archdall, Mervyn Thomas, L.S.A.Lond., L.R.C. P.&S.Edin., Resident

Licensee, Bisliopstone House, Bedford.

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. (J Ion,
Sec.for 8.W. Division since 1905.)

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

Southall, Midd.

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

Asylum, Han well, W.

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

County Asylum, Colney Hatch.

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

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

1876. Baker, Robert, M.D.Edin., 2, The Crescent, Blossom Street, York.
(P&B8IDKXT, 1892.)

1904. Barham, Guy Foster, M.B., B.A., B.C., M.R.C.S., L.R.C.P., Claybury

Asylum, Woodford Bridge, Essex.

1901. Barnett, Horatio, M.B., B.C.Cantab., M.R.C.S., L.R.C.P.Loud., Medical
Superintendent, Stretton House, Church Stretton, Salop.

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

Zealand.

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

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

Digitized by v^ooQle

Members of the Association .

1001. Baskin, J. Lougheed, L.R.C.P.&S.Edin., L.F.P.S.Glas., Fiehertou
House, Salisbury.

1902. Baugh, Leonard I). H. ( M.B., C.M., Gttrtloch Asylum, Gartcosb,Glasgow,
N.B.

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

1898. 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, Hartford; Winchester House, Kingston Hill,
Surrey, aud 79, Wimpole Street, W. (General Secretary, 1889—
1896. Pbbbidbnt, 1900.)

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

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.

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

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

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

1894. Blachford, James Vincent, M.D., B.S.Durham, Medical Superintendent,
Bristol Asylum, Fishponds, near Bristol.

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

1888. Blair, Robert, M.D., Braefort, Crook ston. Paisley.

1904. Blakesley, Henry John, F.R.C.S.Eng., L.R.C.P.Ediu., 66, Loudon
Road, Leicester.

1867. Blandford, George Fielding, M.D.Oxon., F.R.C.P.Lond., 48, Wimpole
Street, W. (Pbbbidbnt, 1877.)

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

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

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

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

Officer, County Asylum, Rainhill, Liverpool.

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

The Colony, Ewell, Surrey. {Hon. General Secretary.)

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

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

1898. Bowes, William Henry, M.D.Lond., Assistant Medical Officer Plymouth

Borough Asylum, Ivybridge, Devon.

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

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

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

1888. Boys, A. H., L.R.C.P.Ediu., Chequer Lawn, St. Albans.

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

1893. Bramwell, John Milne, M.B., C.M.Edin., 83, Wimpole Street, W.
1904. Brantbwaite, Robert Welsh, M.D. (Inspector under the Inebriates Act)»

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

1881. Brayn, R., L.R.C.P.Lond., Medical Superintendent, Broadmoor Asylum,
Crowthorne, Berks.

1896. Briscoe, John Frederick, M.R.C.S.Eng., Resident Medical Superintendent,
Westbrooke House Asylum, Alton, Hants.

Digitized by v^ooQle

Members of the Association . vii

1898. Bristowe, Hubert Carpenter, M.D.Lond., Wrington, R.S.O., Somerset.
1906. Brown, Harry Egerton, M.D., M.P.C., The Asylum, Pretoria, S. Africa.
1904. Brown, Josepnine, M.B.Lond., St. Michel Cottages, Glencoe Road, Bushey,
Herts.

1883. Brace, Lewis C., M.D.Editi., Druid Park, Murthly, N.B. (Hon. Divi¬
sional Secretary for Scotland since 1901.)

• Brushfield, Thomas N., M. D.St. And., The Cliff, Budleigh Sal ter ton. Devon.

1896. Babb, William, M.R.C.S., L.R.C.P.Loud., Senior Assistant Medical
Officer, Worcester County Asylum, Powick, near Worcester.

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

1904. Burrell, Arthur Ambrose, M.B., B.Ch., St. Bdmundsbury, Lucan, Co.
Dublin.

1891. Caldecott, Charles, M.B., B.S.Lond., M.R.C.S., Medical Superintendent,

Earlswood Asylum, Redhill, Surrey.

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

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

1908. Campariole, Paul Clem, M.B., C.M.Ed., Junior Assistant Medical Officer,
County Asylum, Melton, Suffolk.

1884. Campbell, Alfred Walter, M.D.Edin., Macquarie Chambers, 183, Mac¬
quarie Street, Sydney, New South Wales.

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

Asylum, Caterham.

1887. Campbell, Robert Brown, M.B., C.M.Edin., Medical Superintendent,
Inverness District Asylum, Inverness.

1887. Cappe, Herbert Nelson, M.LLC.S.Eng., L.R.C.P.Lond., Assistant Medical

Officer, Surrey County Asylum, Brook wood.

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

1881. Carswell, John, L.R.C.P.Edin., L. F.P.S.Glasg., Certifying Medical Officer,

Barony Parish, 6, Royal Crescent, Glasgow.

1886. Cashman, James P., M.B., B.Ch., B.A.O.Royal Univ. Irel., Assistant
Medical Officer, Cork District Asylum.

1908. Cassells, Alexander Henderson, M.B., Ch.B.Glasg., 6, Albert Road,
Gourock, N.B.

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

1888. Chambers, James, M.D., The Priory, Roehamptou. (Co-Editor of Journal

since 1905, Assistant Editor 1900-05.)

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

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

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

1906. Claque, Henry John. L.R.C.S., L.R.C.P.Edin., Assistant Medical Officer,
Glamorgan County Asylum, Bridgend.

1879. Clarke, Henry, M.D.Durh., L.R.C.P.Lond., H.M. Prison, Wakefield.
1901. Cleland, William Lennox, M.B., B.Ch.Edin., Park Side, Adelaide, South

Australia.

1868. Clouston, T. S. f M.D.Edin,, F.R.C.P.Edin., F.R.S.E., Physician Super¬
intendent, Royal Asylum, Morningside, Edinburgh. (Editor of
Journal , 1873—1881.) (Pbbsibbnt, 1888.)

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

1892. Cole, Robert Henry, M.D.Lond., M.R.C.P.Lond,, Moorcroft, Hillingdon,

Uxbridge.

Digitized by v^ooQle

viii Members of the Association .

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

1906. Collen, Edward Victor, M.D., B.Ch., B.A.O.Dubl., Junior Medical
Officer, North Biding Asylum, Clifton, York.

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

Asylum, Bexley, Kent.

1888. Cones, John A., M.R.C.S., 2, Portland Place, Kemp Town, Brighton.
1895. Conry, John, M.D.Aber., Fort Beaufort Asylum, South Africa.

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

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

1905. Cooper, K. D., 482-4, Falkland Road, Tardeo, Bombay, India.

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

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

Downpatrick.

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

BUliopston, Bristol.

1898. Cowen, Thomas Philip, M.D., B.S.Lond., Assistant Medical Officer,

County Asylum, Lancaster.

1884. Cox, L. F., M.R.C.S., Medical Superintendent, County Asylum, Denbigh.
1898. Craig, Maurice, M.A.,M.D., B.C.Cantab., M.R.C.P.Lond., Senior Assistant
Medical Officer, Bethlem Royal Hospital, Southwark.

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

Sussex Asylum, Helliugly, Sussex.

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

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

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

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

Barnes, S.W.

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

1894. Cullinan, Henry M., L.R.C.P.I., L.R.C.S.I., Senior Assistant Medical
Officer, Richmond District Asylum, Dublin.

1904. Cullum, Sydney John, M.B., B.Ch.Dubl., Crichton Royal Institution,

Dumfries.

1905. Cummins, Edmund Joseph, L.R.C.P.&S.Edin., Richmond Place, Clonmel,

Ireland.

1906. Darbyshire, Harold Stewart C., M.R.C.S.Eng., L.R.C.P.Lond., Grosvenor

House, West Ealing, W.

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

Hampshire.

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

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

1894. Dawson, William R.,M.D., B.Ch.Dubl., F.R.C.P.I., Medical Superinten¬
dent, Farnham House Asylum, Finglas, Dublin. (Hon. Divisional
Sec. for Ireland since 1902.)

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

1900. Despard, Rosin a C., M.D.Lond., The Dell, Colden Common, Winchester.
1888. De Lisle, Samuel Ernest, L.R.C.P., L.R.C.S.I., Three Counties Asylum,

Stotfold, Herts.

Digitized by v^ooQle

Members of the Association . ix

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

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

Asylum, Cane Hill, Coulsdon, Surrey.

1904. Devon, James, L.R.C.P. & S.Edin., 6, Cathedral Square, Glasgow.

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

Derbyshire.

1903. Dickson, Thomas Graeme, L.R.C.P. A S.Edin., Assistant Superintendent,
Wye House, Buxton.

1905. Dixon, J. Francis, M.D., B.Ch., B.A.O., B.A.Dubl., Three Counties

Asylum, Arlesley, Hitchin.

1879. Dodds, William J., M.D., D.Sc.Edin., Valkeuburg, 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.

1889. Donaldson, William Ireland, B.A., M.D., B.Ch.Univ. of Dubl., Medical

Superintendent, County of Loudon Manor Asylum, Epsom, Surrey.
1892. Donelan, John O'Conor, L.R.C.P.I., L.R.C.S.I., M.P.C., Deputy Super¬
intendent, Portrant* Asylum, Donabate, co. Dnblin.

1899. Donelan, Thomas O'Conor, L.R.C.P. & L.R.C.S.I., Middlesex County
Asylum, Napsbury, near St. Albans, Herts.

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

Goudhurst.

1905. Dove, Augustus Charles, M.D.Durh., M.B., B.S., “ Brightside," Crouch
End Hill, N.

1897. Dove, Emily Louisa, M.B.Lond., The School, Durham.

1903. Dow, William Alex., M.D.Durh., M.R.C.S.AP.Lond., H.M. Prison, Lewes.
1905. Drake-Brock man, Henry George, M.R.C.S., L.R.C.P., Middlesborough
Asylum, Cleveland, Yorks.

1884. Drapes, Thomas, M.B., Medical Superintendent, District Asylum, Ennis-
cortby, Ireland.

1905. Drew, Charles Milligan, M.A., M.B., Ch.B.Glas., Lt. R.A.M.C.

1902. Dudgeon, Herbert Win,, 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.AS.I., Senior Assistant Medical Officer,
County Asylum, Bodmin, Cornwall.

1905. Dunlop, James Craufurd, M.D.Edin., L.R.C.P.Edin., M.R.C.S.E., Super¬

intendent of Statistical Department, H.M. General Registry of
Births, Marriages, and Deaths, Scotland, 33, Chester Street, Edin¬
burgh.

1903. Dunston, John Thomas, M.D., B.S.Lond., Senior Assistant Medical

Officer, 'l*he Asylum, Pretoria.

1899. Eades, Albert I., L.R.C.P. A S.I., North Riding Asylum, Clifton, Yorks.
1903. Eady, Georue John, M.D., M.R.C.P.Edin., M.R.C.S.Eng., 78, Drayton
Gardens, S. Kensington, S.W.

1874. Eager, Reginald, M.D.Lond., M.R.C.S.Eng., North woods, near Bristol.

1906. Eager, Richard, M.B., Ch.B.Aber., Assistant Medical Officer, Devon

County Asylum, Exminster.

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., Moyalton, Fairlawn Park, Chiswick,

S.W.

1908. East, Guy Rowland, M.B.Durh., 66, St. George's Square, Newcastle-on-
Tyne.

1896. Easterbrook, Charles C., M.A., M.D., F.R.C.P.Ed., Medical Superin¬
tendent, Ayr District Asylum, Glengall, Ayr, N.B.

Digitized by v^ooQle

Members of the Association .

1904. Eddison, John Edwin, M.D.Ed., 6, Park Square, Leeds.

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

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

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

intendent, Camberwell House, S.E.

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

Horton, Epsom, Surrey.

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

Asylum, Leavesden.

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

Langley R.S.O., Herts.

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

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

Singapore.

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

Asylum, Castlebar.

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

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

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

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

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

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

County Asylum, Sleaford, Lines.

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

1906. Ewens, George Francis William, Major I.M.S. Bengal, c/o Messrs.
Grindlay k Co., 54, Parliament Street, S.W.

1894. Farqnharson, 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., Gray's Inn, London, W.C.
1903. Fennell, Charles Henry, M.A., M.D.Oxon, M.R.C.P.Lond., Seuior
Assistant Medical Officer, East Sussex Asylum, Hellingly, Sussex.

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

S.MT,

1897. Fielding, James, M.D., Victoria Univ., Canada, M.R.C.S.Eng., L.R.C.P.
Edin., Medical Superintendent, Bethel Hospital, Norwich.

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

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

Leicester.

1889. Finch, Richard T., B.A., M.B.Cantab., Orchard Stede, Asterberry Road,
Wimbledon.

1882. Finegan, A. D. O'Connell, L.R.C.P.I., Medical Superintendent, District
Asylum, Mullingar, Ireland. (Son. Divisional Sec. for Ireland ,
1898-1902.)

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

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

1903. Fitzgerald, Alexis, L.R.C.P. k S.I., L.M., District Asylum, Waterford.
1894. Fitzgerald, Charles E., M.D., F.R.C.S.I., Surgeon-Oculist to the King in
Ireland, 27, Upper Merrion Street, Dublin.

Digitized by v^ooQle

Members of the Association .

1888. Fitx-Gerald, Gerald C., M.D., B.C.Cantab., M.P.C., Medical Superin¬

tendent, Kent County Asylum, Cbartbam, nr. Canterbury.

1889. Fitzgerald, James J., M.D., B.Cb., B.A.O.R.U.I., Assistant Medical Officer,

Cork District Asylum, Carlow.

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

Officer, District Asylum, Cork.

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

1889. Flemming, Arthur L., M.R.C.S.Eng., L.R.C.P.Lond., 34, Alina Road,

Clifton, Bristol.

1894. Floury, Eleonora Lilian, M.D., B.Cb., 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, Donab&te, Dublin.

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

1906. Forster, R. A., M.B., Ch.B.Aber., Assistant Physician, Royal Asylum,
Aberdeen.

1906. Forsyth, James, M.B., C.M., Glasgow District Asylum, Woodilee, Lenxic,
N.B.

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

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

1896. France, Eric, M.B., B.S.Durh., No. 7, First Floor, 6, Church Square,
Cape Town, South Africa.

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

1906. Fraser, Thomas Peppd, M.B., Ch.B.Aberd., Sunderland Borough Asylum,
Ryhope, Sunderland.

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

Yorks.

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

Lewisham, S.E.

1906. Gane, Edward Palmer Steward, M.R.C.S.Eng., L.R.C.P.Lond., Fife and
Kinross Asylum, Cupar, Fife.

1904. Garden, W. Sim, M.B., Brankanenthan, Portsoy, N.B.

1893. Garth, Henry C., M.B., C.M.Edin., 36, Chowringee, Calcutta, India.

1890. Gaudin, Francis Neel, M.R.C.S., L.S.A., M.P.C., Medical Superintendent.

The Grove, St. Lawrence, Jersey.

1906. Gaviu, Noel John Hay, M.B., Ch.B.Edin., Norfolk County Asylum,
TTiorpe, Norfolk.

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

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

Borough Asylum, Berwick Lodge, Middlesbrough, Yorks.

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

1904. Gibb, James Alex., M.B., Ch.B., Valkenburg Asylum, near Cape Town,
South Africa.

1899. Gilfillan, Samuel James, M.A., M.B.Edin., Senior Assistant Medical
Officer, London County Asylum, Coluey Hatch.

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

1904. Gillespie, Daniel, M.B. (RJJ.L), Wadsley Asylum, near Sheffield.

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

West Riding Asylum, Scalebor Park, Burley-iu-Wharfedale, Yorks.
1906. Gilmour, Richard Withers, M.B., B.S.Durh., M.R.C.S., L.R.C.P.Lond.,
Assistant Medical Officer, St. Luke’s Hospital, E.C.

Digitized by v^ooQle

xii Members of the Association .

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

1888. Goldie-Seot, Thomas G., M.B., C.M.Edin., M.R.C.S., L.R.C.P., Junior

Assistant Physician, Royal Asylum, Gartnavel, Glasgow.

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

1889. Goodall, Edwin, M.D., B.S.Lond., F.R.C.P., Medical Superintendent,

City Asylum, Cardiff.

1899. Gordon, James Leslie, M.B., Cb.B., Tooting Bee Asylum, Tooting,
Loudon, S.W.

• Gordon, William S., M.A., M.B., T.C.D., District Asylum, Mullingar.
1906. Gordon-Munn, John Gordon, M.D., F.R.S.E., Heigham Hall, Norwich.

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

1899. Graham, Robert A. L., B.A., MB., 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, Thomas, M.D.Glasg., 8, Gartliland Place, Paisley.

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

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

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

Peckham Road, S.E.

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

County Asylum, Chester.

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

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

Whitchurch, Salop.

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

Kent.

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

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

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

Medical Officer, London County Asylum, Banstead, Surrey.

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

Officer, West Ham Borough Asylum, Goodmayes, Ilford.

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

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

Northampton County Asylum, Berry Wood, Northampton.

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

Medical Officer, Cornwall County Asylum, Bodmin.

1899. Harmer, W. A., L.S.A., Resident Superintendent and Licensee, Redlauds
Private Asylum, Tonbridge, Kent.

1904. Harper-Smith, George Hastie, M.R.C.S., L.R.C.P., B.A.Cantab., 102,

Huntingdon Road, Cambridge.

1897. Harris, William, M.D.St. And., F.R.C.S.Edin., M.R.C.P.Edin., c/o Dr.

W. T. Harris, 1, The Bourne, Bolton Gardens, High Street,
Chiswick.

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

Hall, Middleton St. George, Co. Durham.

1905. Hart, Bernard, M.B.Lond., M.R.C.S.Eug., Herts County Asylum, Hill

End, St. Albans, Herts.

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

Digitized by v^ooQle

Members of the Association . xiii

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

1891. Havelock, John Q., M.D., C.M.Edin., Physician 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., 32, Brunswick Terrace, Hove,
Sussex.

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

1905. Hector, George W. K., M.D., L.R.C.P.&S.

1908. Heffernan, Patrick, M.B., B.Ch., B.A.O., R.U.I., Rathkenny, Fethard,
co. Tipperary.

1905. Henderson, George, M.A., M.B., Medical Superintendent, Fisherton

House, Salisbury.

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

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

York.

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

Denbigh, North Wales.

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

1903. Hewitt, David Walker, M.B., B.Ch., R.U.I., Surgeon R.N.

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

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

Hayes Park Asylum, Hayes Park, Middlesex.

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

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

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

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

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

London, W.

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

ford, York.

1894. Hotchkis, Rcbert D., M.A., M.D., Renfrew Asylum, Dykebnr, N.B.

1900. Hughes, George Osborne, M.D.Virginia, M.R.C.S., L.R.C.P., Common¬
wealth Block, Market and Main Streets, Winnipeg, Canada.

1900. Hughes, Percy T., M.B., Ch.M.Edin., D.P.H.Lnnd., Medical Superinten¬
dent, Worcestershire County Asylum, Barnseley Hall, Bromsgrove.

1904. Hughes, William Stanley, M.R.C.S., L.R.C.P., Park View, Aberayron,

Cardiganshire.

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

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

1904. Hunter, Percy Douglas, M.R.C.S., L.R.C.P.Lond., 2, Chartfield Avenue,

Putney.

1905. Hutchinson, Joseph Armstrong, M.D., M.S.Durh., Northallerton, York¬

shire.

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

Road, New Beckenham, Kent.

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

burg.

Digitized by v^ooQle

xiv Membets of the Association.

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

1871. Ireland, William W., M.D.Edin., 1, Victoria Terrace, Musselburgh, N.B.
1006. Irwin, Peter Joseph. L.R.C.P.&S.I., L.M., District Asylum, Limerick.

1905. Jackson, Arthur Molyneux. M.D.Oxon., Medical Superintendent, Notts

County Asylum, Radcliffe-on-Trent.

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

1904. Jeremy, Harold Rowe, M.R.C.S.Eng., L.R.C.P.Lond., 60. Friern Road,

East Dulwich, S.E.

1906. Johnson, Smeeton, M.B.Lond., L.R.C.P., M.R.C.S., Rainhill Asylum,

near Liverpool.

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

1905. Johnston, Thomas Leonard, L.R.C.P.&S.Edin., L.F.P.S.Glas., Brace-

bridge Asylum, Lincoln.

1905. Johnstone, George A., M.B., Ch.B.Aberd., 46, Charlotte Street, South
Shields.

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

District Asylum, Melrose.

1903. Johnstone, Thomas, M.D.Edin., M.R.C.P.Lond., 32. Park Square, Leeds.
1880. Jones, D. Johnson, M.D.Edin., Medical Superintendent, Banstead Asylum,
Surrey.

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

1882. Jones, Robert, M.D.Lond., B.S., F.R.C.S., Medical Superintendent,
London County Asylum, Clay bury, Woodford, Essex. {Gfon.
Secretary from 1897 to 1906. President 1906-7.)

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., The Old Treasury

Buildings, Spring Street, Melbourne.

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

Wadsley, near Sheffield.

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

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., Tod Pedu, South Godstone,
Surrey.

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

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

District Asylum, Enuiscorthy, Wexford.

1902. Kennedy. Patrick Gabriel, L.R.C.P.&S.Editi., 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, Sliotts, N.B.

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

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

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

Medical Superintendent, Northumberland House, Finsbury Park, N.
1897 Kingdon, Wilfred Robert, M.B., B.S.Durh., 160, Goldhawk Road, W.
1905. Kingsbury, William Neave, M.R.C.S., L.R.C.P., Middlesex County
Asylum, Tooting, S.W.

Digitized by v^ooQle

Members of the Association . xv

1003. Kingsford, Arthur Beresford, M.R.C.S., L.R.C. P.Lond., D.P.H.Camb.,
19, Upper George Street, Bryanston Square, W.

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

shire.

1889. Kirwan, James St. L., B.A., M.B., B.Ch., B.A.O.Roy. Univ. Irel.,
Medical Superintendent, District Asylum, Ballinasloe, Ireland.

1903. Koogh, Edward Fitzadam, M.B., B.Ch., County Asylum, Gloucester.

1806. Labey, Julius, M.R.C.S., Medical Superintendent, Public Asylum, Jersey.
1902. Langdon-Down, Percival L., M.A., M.B., B.C.Cantab., Dizland, Hampton
Wick, Middlesex.

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

1902. Laval, Evariste, M.B., C.M.Edin., The Warneford Asylum, Oxford.

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

Canterbury.

1899. Law, Charles D., L.R.C. PAS.Edin., L.F.P.G.S., c/o Manager, Bank of

Victoria, 10, King William Street, E.C.

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

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

1906. Lawson, William Wilfred James, M.B.Aberd., Ch.B., Whitwell, Mans¬
field.

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

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

1905. Le Fanu, Hugh, M.B., C.M.Aber., County Asylum, Prestwich, Manchester
1883. Legge, Richard J., M.D., Medical Superintendent, County Asylum,

Mickleover, Derby.

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

Kent County Asylum, Maidstone.

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

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

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

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

1859. Lindsay, James Murray, M.D.St.And., F.R.C.S. and F.R.C.P.Edin<
Seacliff, St. Anbins, Jersey. (President, 1893.)

1908. Logan, Thomas Stratford, L.R.C.P. A S.Edin., L.F.P.S.Glas., Epileptic
Colony, Ewell.

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

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

1898. Lord, John R., M.B., C.M., Heath Asylum, Bexley, Kent. (Assistant
Editor of Journal since 1900.)

1906. Lowry, James Arthur, M.B., B.Ch., B.A.O., R.U.I., Assistant Medical
Officer, Middlesex County Asylum, Napsbury.

1904. Lyall, C. H. Gibson, L.R.C.P. A S.Edin., Garlands, Carlisle.

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

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

Digitized by v^ooQle

XVI

Members of the Association .

1906. Macarthur, John M.R.C.S., L.E.C.P.Lond., London County Asylum,
Claybury, Woodford Bridge, Essex.

1899. Macartney, William H. C., L.R C.P.&S.I., Riverhead House, Sevenoaks.
1880. Mac Bryan, Henry C., L.R.C.P. & S. Edin., Kings down House, Box, Wilts.
1902. M'Carthy, 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. McConagbey, John C., M.B., C.M.Edin., Parkside Asylum, Macclesfield,

Cheshire.

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

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

head, Paisley, N.B.

1884. MacDonald, Peter VV., M.D., C.M., Medical Superintendent, Dorset
County Asylum, Herrison, Dorchester. (Hon. Sec. S. W. Division
1894 to 1905.)

1905. MacDonald, William Fraser, M.B., Cli.B.Edin., Drive Lodge, Polwarth
Terrace, Edinburgh.

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

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

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

Officer, City Asylum, Newcastle.

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

1895. Macfarlane, Neil 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.

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

Asylum, Bridgend, Glam.

1906. Macllraith, Alex. Robert MacIntyre, Ayr District Asylum, Ayr.

1905. Macllraith, W. MacLaren, L.R.C.P. & S.Edin., L.F.P.S.Glasg.,
L.D.S.R.C.S.Edin., Assistant Medical Officer,Norwich City Asylum,
Hellesdon, near Norwich.

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

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

1903. Mackenzie, Theodore Charles, M.B., Ch.B.Edin., Royal Asylum,

Aberdeen.

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

1873. Macleod, Murdoch D., M.B., 48, Westwood Road, Beverley, Yorks.

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

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

1898. Macnaughton, George W. F., M.l)., F.R.C.S., 33, Lower Belgrnve Street,
Eaton Square, London, S.W.

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

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

1896. Macpherson, Charles, M.D.Glas., Deputy Commissioner in Lunacy, 193,

Brnntsfield Place, Edinburgh.

1886. Macpherson, John, M.D., F.R.C.P., 8, Darnaway Street, Edinburgh.

Digitized by v^ooQle

Members of the Association. xvii

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

Asylum, Morningside, Edinburgh.

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

M urray field, Edinburgh.

1894. Me William, Alexander, M.A., M.B., C.M.Aber., Medical Superintendent,
Odiham, Winch field, Hants.

1904. Manning, Ernest J., M.R.C.S., L.R.C.P.Lond., Broadmoor Asylum,
Crowthorne, Berks.

1885. Manning, Henry J., B.A.Lond., M.R.C.S., Laverstock House, Salisbury.
1900. Manning, Herbert C., M.R.C.S., L.R.C.P., County Asylum, Cambridge.

1903. Marnan, John, M.B., B.Ch. t Avoca, Mount Eden Road, Donuybrook,

co. Dublin.

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

Asylum, Lenxie.

1897. Marshal), John, M.B., C.M.Glasg., 66, Leamington Terrace, Edinburgh.
1906. Marshall. Robert Macnab, M.B., Ch.B., Oak lands, 21, Maxmill Drive,

Pollokshields, Glasgow.

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

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

Ferry hill, Durham.

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

County Asylum, Cheddletou, near Leek.

1891. Merrier, Charles A., M.D.Lond., F.R.C.S.Eng., Lecturer on Insanity,

Westminster Hospital; Flower House, Cat ford, 8.E.

1877. Merson, John, MJL, M DJLber., Medical Superintendent, Borough

Asylum, Hull.

1871. Mickle, William Julius, M.D., F.R.C.P.Lond., Grove HOI Asylum, Bow,
London. (Pbssidbitt, 1896-7.)

1893. Middlemass, James, M.D., C.M., B.Sc.Edin., F.R.C.P., Medical Superin.

tendent. Borough Asylum, Ryhope, Sunderland.

1888. Middlemist, George Edwyn, M.B., Keel by, Brocklesby, Lines.

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

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

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

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

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

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

intendent, County Asyinm, Cane Hill, Conltdon, Surrey.

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

1906. Moore, Francis Joseph, L.R.C.P.AS.lrel., Assistant Medical Officer,
London County Asylum, Banstead, Sutton, Surrey.

1899. Moore, Wm. D., M.D., M.Ch., Medical Superintendent, Holloway
Sanatorium, Virginia Water, Surrey.

1892. Morrison, Cuthbert S., L.R.C.P. and L.R.C.8.Ediu., Medical Super*
intendent, County and City Asylum, Bnrghil), Hereford.

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

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

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

Digitized by v^ooQle

xviii Members of the Association.

1862. Mould, George W., M,R.C.S.Eng., Oak Monnt, Colvin Bay, N. Wales.
(Pbssidsnt, 1880.)

1897. Mould, Philip G., M.R.C.S.Eng., L.B.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.

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.B.C.P.Lond., Banstead Asylum,
Sutton, Surrey.

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

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

Nash, Arthur Charles, M.R.C.S., L.R.C.P.Lond., County Asylum,
Mickleover, Derby.

Navarra, Norman, M.R.C.S., L.R.C.P., City of London Asylum, Stone,
Dartford.

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

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

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

Newington, H. Hayes, F.R.C.P.Edin., M.R.C.S.Eng., The Gables, Tice-
hurst, Sussex. (Pbbsidbnt, 1889.) (Treasurer.)

Nicholl, Robert Campbell, L.R.C.P. A S.I., Hatton Asylum, nr. Warwick.

Nicolson, David, C.B., M.D., C.M.Aber., M.R.C.P.Edin., F.S.A.Scot.,
Balgownie, Edgeborough Road, Guildford. (Pbbsidbnt, 1895-6.)

Nixon, John C., M.B., West Riding Asylum, Menston, nr. Leeds.

Nobbs, Athelstane, M.D., C.M.Edin., Layton House, Upper Richmond
Road, S.W.

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

Norman, Conolly, F.R.C.P.I., Medical Superintendent, Richmond District
Asylum, Dubliu, Ireland. (Hon. Secretary for Ireland , 1887—1894.)
(Pbbsidbnt, 1894r*5.) (Co-Editor of Journal since 1895.)

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

Waterford, Ireland.

1906. O'Brien, Mary, L.S.A., Borough Asylum, Leicester.

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

1904. O'Downey, Augustine Francis, L.R.C.P.AS. Edin., Salop and Mont¬

gomery County Asylum, Bicton Heath, nr. Shrewsbury.

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

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

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

1886. O'Neill, Edward D., M.R.C.P.I., Medical Superintendent, The Asylum,

Limerick.

1868. Orange, William, M.D.Heidelb., F.R.C.P.Lond., C.B., Oakhurst,
Godaiming, Surrey. (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, Laudel R., M.B., M.P.C., Physician Superintendent, Royal
Asylum, Gartnavel, Glasgow.

1899. Owen, Corbet W., M.B., C.M.Edin., 81, High Street, Bangor, North,
Wales.

1904.

1903.

1880.

1903.
1875.

1873.

1904.
1869.

1899.

1893.

1888.

1880.

Digitized by v^ooQle

XIX

Members of the Association .

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

1896. Parker, William Arnot, M.B., C.M., Medical Superintendent, Gartloch
Asylum, Gartcosh, N.B.

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

1901. Passmore, Wm. Edwin, L.S.A.Lond., Forest View, Woodford Bridge,
Essex.

1899. Haton, Robert N., L.R.C.P., L.R.C.S.Edin., Medical Officer, H.M. Prison,
Wormwood Scrubbs, London, W.

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

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

Officer, City of London Asylum, Dartford.

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

stone, Dorset.

1903. Pearce, Francis H., M.B., B.C.Cantab., Madeley Court, Salop.

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.,
60, Iverna Court, Kensington, W.

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

Eldon Square, Newcastle-on-Tyne.

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

Officer, London County Asylum, Banstead, Sutton, Surrey.

1905. Phillips, Norman Routh, M.D.Brux., M.R.C.S., L.R.C.P., Stone Honse,
St. Martins, Canterbury.

1891. Pierce, Bedford, M.D.Lond., F.R.C.P., Medical Superintendent, The
Retreat, York. (Hon, Sec. N. and M. Division.)

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

Dudley, Stafford.

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

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

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

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

Lunatic Asylum, Nottingham.

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

Natal, South Africa.

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

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

Radnor Asylum, Talgarth, S. Wales.

1904. Quin, Henry C. E., L.R.C.P., L.R.C.S.Edin., Camberwell House, Peck-
ham Road, S.E.

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

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

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

Asylum, Bicton Heath, Shrewsbury.

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

on-Tyne.

1889. Raw, Nathan, M.D., F.R.C.S., Mill Road Infirmary, Liverpool.

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

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

1870. Rayner, Henry, M.D. Aberd.,M.R.C.P.Edin., 16,Queen Anne Street, London,
W. (PBE8IDENT, 1884.) ( General Secretary , 1878-89.) (Co-

Editor of Journal since 1895.)

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

New Norfolk, Tasmania.

Digitized by v^ooQle

xx Members of the Association.

181)9. Rediugton, John, F.R.C.S.&L.R.C.P.I., A.M.O., Richmond Asylum,
Dublin.

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

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

Medical Superintendent, Central Criminal Asylum, Dundram,
Ireland.

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

Moor, Didsbury, Manchester.

1899. Rice, David, M.R.C.S., L.R.C.P., Cheddleton Asylum, nr. Leeks, 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.

1905. Ridley, Edward Hope, M.D.Edin., Ticehurst House, Ticehurst, Sussex.

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

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

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

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

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

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

Superintendent, District Asylum, Larbert, Stirling.

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

1905. Robertson-Milne, Capt. Charles John, M.B., C.M.Aberd., Superintendent,
Bengal Central Asylum, Berhampur, Bengal.

1900. Robinson, Harry A., M.D., Ch.B.Vict., 57, Canning Street, Liverpool.

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

1859. Rogers, Thomas Lawes, M.D.St. And., M.R.C.P.Lond., M.R.C.S.Eng.,

Eastbank, Court Road, Eltham, Kent. (President, 1874.)

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

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

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., 4, Roxburgh Terrace, West

Park Road, Dundee. (Late Son. Secretary for Scotland.)

1888. Ross, Chisholm, M.D., Lunacy Department, Sydney, New South Wales.

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

Surrey.

1899. Rotherham, Arthur, M.A., M.B., B.C.Cantab., Medical Superintendent,
Darenth Asylum, Dartford, Kent.

1902. Round, John, L.R.C.P., L.R.C.S., L.F.P.S., 30, New Cross Road, S.E.

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

Derby County Asylum, Mickleover.

1884. Rowe, Edmund L., L.R.C.P.&S.Edin., Medical Superintendent, Borough
Asylum, Ipswich.

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

I a.

Digitized by v^ooQle

Members of the Association . xxi

1902. Bows. Richard Gundry, M.D.Loud., M.K.C.S., L.R.C.P., Pathologist,
County Asylum, Lancaster.

1877. Russell, Arthur P., M.B., M.R.C.P.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 Mair, 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 J., M.B., District Asylum, Londonderry, Ireland.

1902. Sail, Ernest Frederick, M.R.C.8.Eng., L.R.C.P.Lond., Assistant Medical
Officer, West Sussex County Asylum, Chichester.

1905. Salter, Charles Edward, M.D.Loud., B.S., F.R.C.S.E., Scarborough Hos¬

pital, 34, Prince of Wales Terrace, Scarborough.

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

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

1873. Savage, Geo. H., M.D.&F.R.C.P.Lond., 26, Devonshire Place, W.
(Late Editor of Journal .) (President, 1886.)

1906. Scanbin, John, L.R.C.S.Edin., Assistant Medical Officer, Devon County

Asylum, Exminster.

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

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

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

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

Ashton-on-Ribble, Preston.

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

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

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

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

1891. Shaw, Harold B., B.A., M.B., D.P.H.Camb., Medical Superintendent,

Isle of Wight County Asylum, Whitecroft, Newport, Isle of Wight.

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

1904. Shaw, Patrick, L.R.C.P.AS.Edin., Ararat Hospital for the Insane,

Ararat, Victoria, Australia.

Shaw. T. Claye, M.D.Lond., F.R.C.P.Lond., 80, Harley Street, Loudon,

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

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

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

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

1899. Sibley, Reginald Oliver, M.B.Lond., M.R.C.S., L.R.C.P., Assistant
Medical Officer, London County Asylum, Cane Hill, Coulsdon,
Surrey.

1906. Sierwright, Henry Gates, M.R.C.S., L.R.C.P.Lond., Assistant Medical

Officer, Monmouth Asylum, Abergavenny.

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

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

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

Beverley, Yorks.

Digitized by v^ooQle

xxii Members of the Association.

1888. Sinclair, Eric, M.D.Glasg., Medical Superintendent, Qladesville Asylum,
New South Wales.

1891. Skeen, James Humphry, M.B., C.M.Aber., Medical Superintendent,
Glasgow District Asylum, Both well.

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

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

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

Asylum, Brentwood.

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

Home Office, Whitehall, S.W.

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

Surrey.

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

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

Tunbridge Wells.

1885. Smith, R. Percy, M.D., B.S., F.R.C.P., M.P.C., 36, Queen Anne Street,
Cavendish Square, W. (General Secretary t 1896-7.) (Pbbsidbnt,
1904-5.)

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

Melbourne, Victoria. f

1903. Smith, William Maule A., M.B., ChB.Edin., M.R.C.P.Edin., West Ridimr
Asylum, Wakefield, Yorks. *

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

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

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

1906. Spark, Percy Charles, M.R.C.S., L.R.C.P.Lond., London County Asylum

Hanwell, W.

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. (Pbbsidbnt, 1899-1900,
formerly Registrar.)

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

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

City of London Asylum, Stone, Dartford.

1905. Stevenson, William Edward, M.B., B.S.Durh., West Riding Asylum.

Menston, Leeds.

1905. Stewart, Frederick William, B.A., M.B., B.Ch., B.A.O.I., Keut County
Asylum, Barming Heath, near Maidstone.

1868. Stewart, James, B.A.Queen’s Univ.Irel., F.R.C.P.Edin., L.R.C.S.Irel.,
Junior Constitutional Club, Piccadilly, S.W.

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

1905. Stillwell, Henry Francis, L.R.C.P.&S.E., Barnwood House, Gloucester.
1862. Stilwell, Henry, M.D.Ediu., M.R.C.S.Eng., Moor croft 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, Peckham.

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

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

Digitized by v^ooQle

Members of the Association . xxiii

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

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

Willows, Lancashire.

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

Asylnm, Rosslynlee, N.B.

1886. Saffern, Alex. C., M.D., Medical Superintendent, Raberry Hill Asylam

near Bromsgrove, Worcestershire.

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

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

1903. Sutherland, David, M B., Ch.B.Edin., Pathologist, The Dispensary,
Worksop, Notts.

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

61, Queen Street, Edinburgh.

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

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

Asylum, HeUesdon, nr. Norwich.

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

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

1904. Tate, Robert George H., M.D., D.P.H., Lt. R.A.M.C.

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

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

L.R.C.P.Lond., Medical Superintendent, East Sussex Asylum,
Hellingly.

1904. Thompson, Alexander D., M.B., Ch.B.Qlasg., Monmouthshire Asylum,

Abergavenny.

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

Thorpe, Norfolk.

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

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

Redhill, Surrey.

1905. Thwaites, Harry, M.R.C.S., L.R.C.P.Lond., Medical Superintendent,
Lebanon Hospital, Asfuriyeb, near Bey rout, Syria.

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

1901. Tigbe, John V. G. B., M.B., B.Ch., B.A.O.Irel., North Riding Asylum,

Clifton, Yorks.

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

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

Transvaal, South Africa.

1905. Toogood, Frederick Sherman, M.D.Lond., Medical Superintendent, The
Infirmary, High Street, Lewisham.

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

Chart ham, Kent.

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

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

Parkhnrst, I. of W.

1908. Tredgold, Alfred F., M.R.C.S., L.R.C.P., 6, Dapdune Crescent, Guild¬
ford, Surrey.

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

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

1881. Tuke, Charles Molesworth, M.R.C.S.Eng., Chiswick House, Chiswick.
1888. Tuke, John Batty, jun., M.D., F.R.C.P.Edin., Resident Physician,

Saughton Hall, Edinburgh; Linden Lodge, Loanhead, Midlothian.

Digitized by v^ooQle

xxiv Members of the Association.

1885. Take, T. Seymour, M.A., M.B., B.Ch. y M.R.C.S.E., Chiswick House,
Chiswick, W.

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

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

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

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

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

Eastern Counties Asylum for Idiots, Colchester.

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

County Asylum, Brentwood.

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

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

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

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

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

St. Ann’s Asylum, Trinidad, B.W.I.

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

Asylum, near Sheffield.

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

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

Dinas Mawddwy, Merionethshire.

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

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

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

58, Parliuinent Street, Cape Town, South Africa.

1902. Watson, Frederick, M.B., C.M.Edin., The Orange, East Finchley,

London, N.

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

1885 Watson, William Riddell, L.R.C.S. and L.R.C.P.Edin., Qovan District
Asylum, Hawkhead, Paisley.

1880. Weatherly, Lionel A., M.D., M.R.C.S., Bailbrook House, Bath.

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

Asylum, Kilkenny, Ireland.

1872. Whitcombe, Edmund Bancks, M.R.C.S., Medical Superintendent, Winson
Green Asylum, Birmingham. (President, 1891.)

1884. White, Ernest William, M.B.Lond., M.R.C.P.Lond., Fcnstanton, Christ¬
church Road, Strentham Hill, S.W. (Hon. Sec. South-Eastern
Division , 1897-1900.) ( President 1903-4.)

1905. White, Robert George, M.A., M.B., B.Sc., Ch.B., Pathological Depart¬

ment, School of Medicine, Cairo, Egypt.

1903. Whittingham, George M., M.R.C.S., L.R.C.P., 77. Foxbourne Road,

Balham, S.W.

1905. Whittington, Richard, M.A., M.D., 1, Sill w ood Place, Brighton, Sussex.
1889. Whitwell, James Richard, M.D. and C.M., Medical Superintendent,
Suffolk County Asylum, Melton Woodbridge.

1903. Wigan, Charles Arthur, M.D.Durh., M.R.C.S.Eng., Deepdene, Portia-
head, Somerset.

1S83. Wiglesworth, Joseph, M.D., F.R.C.P.Lond., Rainhill Asylum, Lancashire.
(President, 1902-3.)

1895. Wilcox, Arthur William, M.D., C.M.Edin., Assistant Medical Officer,
County Asylum, Hatton, Warwick.

Digitized by v^ooQle

Members of the Association . xxv

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

Plymouth Borough Asylum, Blackadon, Ivybridge, South Devon.
1887. Will, John Kennedy, M.A., M.D., C.M., Bethnal House, Cambridge
Road, N.E.

1906. Williams, David John, M.R.C.S., L.R.C.P.Lond., Medical Superintendent
The Asylum, Kingston, Jamaica.

1901. Wilson, Albert, M.D.Edin., 1, Belsize Park, N.W.

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

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

1896. Wilson, Robert, M.B., C.M.Glasg., Kails worth, Gloucestershire.

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

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

1875. Winslow, Henry Forbes, M.D.Lond., M R.C.P.Lond., 11, Burwood Place,
Connaught Square, Hyde Park, W.

1894. Wood, Guy Mills, M.B.Durb., 49, Gordon Square, London, W.C.

1904. Wood, Martin Stanley, M.B., Ch.B.Vict., Royal Asylum, Cbeadle,

Cheshire.

1908. Wood, Maurice Dale, M.D.Durh., B.S., Assistant Medical Officer, County
Asylum, Haywards Heath, Sussex.

1869. Wood, T. Outterson, M.D., M.R.C.P.Lond., F.R.C.P., F.R.C.S.Edin.,
40, Margaret Street, Cavendish Square, W. (President, 1905-6.)
1885. Woods, J. F., M.D., M.R.C.S., 7, Harley Street, Cavendish Square, W.

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

95, Breconsfield Villas, Preston Park, Brighton.

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

Obdieaby Members . 638

Hokobaby Members . 32

CORRESPONDING MEMBERS . 15

Total. 686

Members are particularly requested to send changes of address, etc., to Dr.

C. Hubert Bond, the Honorary Secretary , 11, Chandos Street , Cavendish
Square, London, W., and in duplicate to the Printers of the Journal ,
Messrs. Adlard and Son, 221 Bartholomew Close , London, B.C.

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XX\1

List of those who have passed the Examination for the Certificate of Efficiency
in Psychological Medicine, entitling them to append M.P.C. (Med.-Psych.
Cert if.) to their names.

Adamson, Robert 0.

Adkins, Percy, R.

Ainley, Fred Shaw.

Ainslie, Williani.

Alexander, Edward H.
Anderson, A. W.

Anderson, Brace Arnold.
Anderson, John.

Andriezen, W.

Armour, E. F.

Attegalle, J. W. S.

Aveline, H. T. S.

Ballantyne, Harold S.

Barbour, William.

Barker, Alfred James GianviHe.
Bashford, 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.

Ewan, 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

xxvu

Gawn, Ernest K.

Getnmell, William.

Genney, Fred. S.

Gibson, Thomas.

Giles, A. B.

Gill, J. Macdonald.

Gilmour, John B.

Goldie, E. M.

Goldschmidt, Oscar Bernard.
Goodall, Edwin.

Graham, Dd. James.

Graham, F. B.

Grainger, Thomas.

Grant, J. Wemyss.

Grant, Lacklan.

Gray, Alex. C. E.

Griffiths, Edward H.

Hall, Harry Baker.

Halsted, H. C.

Haslam, W. A.

Haslet t, William John Hand field.
Hassell, Gray.

Hector, William.

Henderson, Jane B.

Henderson, P. J.

Hainan, George.

Hewat, Matthew L.

Hewitt, D. Walker.

Hicks, John A* jnn.

Hitching*. Robert.

Holmes, William.

Horton, James Henry.

Hotchkis, E. D.

Howdeo, 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, Darid Bartv.

King, Frederick Trnby.

Laing, C. A. Barclay.

Laing, J. H. W.

Law, Thomas Brjrden.

Leeper, Richard R.

Leslie, R. Murray.

Livesay, Arthur W. Bligh.
Livingstone, John.

Lloyd, R. H.

Low, Alexander.

McAIlum, Stewart.

Macdonald, Darid.

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

Macdonald, W. F.

Maceroy, Henry John.
McGregor, George.

Maclnnes, lan Lam out.
Mackenzie, Henry J.

Mackenzie, John Camming.
Mackenzie, William H.
Mackenzie, William L.

Mackie, George.

McLean, H. J.

Macmillan, John.

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

Macpherson, John.

Macvean, Donald A.

Mallannah, Sreenagnla.

Marr, Hamilton C.

Marsh, Ernest L.

Martin, A. A.

Martin, A. J.

Martin, Wm. Lewis.

Masson, James.

Meikle, T. Gordon.

Melville, Henry B.

Middlemass, James.

Mitchell, Alexander.

Mitchell, Charles.

Moffett, Elisabeth J.

Monteith, James,

Moore, Edward Ertkiue.

1 Mortimer, John Desmond Ernest.
M orison, 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 Farquhsr.

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.

Raunie, James.

4 Raw, Nathan.

Digitized by v^ooQle

xxvm

Reid, Matthew A.

Reutou, Robert.

Rice, P. J.

Rigden, Alan.

Ritchie, Thomas Morton.

Rivera, W. H. R.

3 Robertson, Q. M.

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

Rose, Andrew.

Rowand, Andrew.

Rudall, James Ferdinand.

Rust, James.

Rnst, Montague.
lORutherford, 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.
Syme8, G. D.

Thompson, George Matthew.
Thomson, Eric.

Thomson, George Felix.
Thorpe, Arnold E.

Trotter, Robert Samuel.
Turner, W. A.

Umney, W. F.

Walker, James.

Wallace, W. T.

Warde, Wilfred B.
Wateraton, Jane Elisabeth.
Watson, George A.

Welsh, David A.

West, J. T.

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

Williamson, A. Maxwell.

4 Wilson, G. R.

Wilson, James.

Wilson, John T.

Wilson, Robert.

Wood, David Janies.

Wright, Alexander, W. O.
Yea tea, 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.
10 To whom the Gaskell Prize (1906) was awarded.

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THE

JOURNAL OF MENTAL SCIENCE

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

No. 220 JANUARY, 1907. Vol. LIII.

Part I.—Original Articles.

The Pathological Anatomy and Pathology of Epilepsy .
By John Turner, M.B.(Aberd.), Assistant Medical
Officer Essex County Asylum.

Part I.

Introduction. Page

Thesis stated—Class of cases examined—Incidence of the lesions among
these—Intravascular clot neither the result of fits nor solely of general
inflammatory conditions—Regions of nervous system examined, methods
employed—Micro-chemical detection of phosphorus—Blood-plates . 2

Part II.

Synopsis of cases and details of microscopical examination of each . . . §

Part III.

General review of the histological findings .

(a) Brain —(1) Changes in meninges — (2) Presence of gliosis — (3) Sclerosis
and atrophy—(4) Nerve-cells : Diminution in number—Persistence of
embryonal forms—Degeneration—Swelling of nucleus—Betz cell changes
—The axonal form characteristic of congenital defect; its incidence
among all classes of the insane—Purkinje cells—(5) Vessels—Structural
alteration—Increase in perivascular and pericellular nuclei—Distension
and haemorrhage — Thrombi— (b) Spinal cord—Qb\\ changes—Tract
degenerations ............ 38

Part IV.

Evidence pointing to the efficiency of stasis or cerebral ancemia as an excitor
of convulsions—Conclusion .........

Addendum.

The coagulability of the blood in epileptics ....... 73

LIII. 1

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

PART I.

The following pages contain an account of the microscopical
examination of the central nervous systems of forty-one cases of
idiopathic epilepsy, which form the data on which I base my
thesis that epilepsy is a disease occurring in persons with a
defect of the nervous system either congenital or involutional,
and in whom also there is an abnormal state of the blood,
characterised by a special tendency to intravascular clotting,
and that the fits, whether of the nature of grand mal or petit
vial , owe their exciting cause to sudden stasis of the blood¬
stream in some (generally limited) portion of the cortex, result¬
ing from the blocking of cerebral cortical vessels by these
aforementioned intravascular clots. I have already in a paper
read at the pathological meeting of the Neurological Society in
December, 1905, and published in the British Medical Journal
March 3rd, 1906, given a short account of my views, but it was
impossible in the limit of time at my disposal when reading
the paper to deal in any but a very cursory way with many
interesting aspects of the question, nor could I then give suffi¬
cient details of the microscopical examination of the individual
cases.

With reference to material, my cases have been drawn
entirely from among the inmates of the Essex County Asylum,
and were in a great majority either idiots or imbeciles. The
term “ imbecile,” however, is very elastic and embraces, on the
one hand, those little removed from idiocy, and on the other
those whose mental capacity is very little below the average of
the class from which they are drawn. I have, therefore, roughly
classified my imbeciles into three divisions as follows :

(a) Low-grade imbeciles .—Those not far removed from
idiocy, but who, under favourable circumstances, are just
capable of adjusting themselves to simple environments (which
the idiot is not able to), and yet are not able to work.

(j 3 ) Medium-grade imbeciles .—Those who are able to attend
to themselves and do simple housework.

(y) High-grade imbeciles .—Those who are able to keep them¬
selves neat and clean, who do their simple work intelligently
and well, and in many cases, as I have just said, are not very
far below the average of intelligence of their social class. Of
my 41 cases, 8 were idiots, 10 were low-grade imbeciles, 3

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1907-]

BY JOHN TURNER, M.B.

were medium-grade, and I o high-grade ; whilst the remaining
io showed no marked mental aberration except during, or as
the result of long-continued, fits.

It would be highly desirable, of course, to compare with this
series a series from the brains of those epileptics who were not
inmates of asylums ; this, however, it was not possible for me
to do. Nevertheless, I believe we shall be able to form a fairly
correct estimate of the probable incidence of the pathological
changes which I regard as of most importance, in a series of
sane epileptics, by a comparison of the pathological incidence
in the different classes of my cases.

In the following table I have tabulated the number of
instances in which the intravascular clot, the presence of
changes in the Betz cells characteristic of imperfect develop¬
ment, and the occurrence of atrophy and sclerosis of different
parts of the brain were met with in (i ) those who, apart from
the effect of their fits, were of average intelligence ; (2) high-
grade imbeciles ; (3) low-grade imbeciles ; and (4) idiots :

Class.

Number of
cases.

Clot.

Axonal
character of
Betz cells.

Atrophy and
sclerosis.

Weak-minded

High-grade imbeciles

9 |

! 7

Low-grade imbeciles

Idiots.

From this table it will be seen that there is practically no
difference in the incidence of these pathological changes,
whatever the mental state may have been.

The objections have been raised that the occurrence of the
intravascular thrombi on which I lay so much stress is the
result of some general inflammatory condition to which the
patient succumbs, or that it is the result of the fits and not
the cause. An analysis of the relationship which the clot
bears to the immediate cause of death in my cases will, I think,
go far to remove both these objections.

Status epilepticus was the cause in nine cases, in eight of
whom intravascular thrombi were found.

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

Epilepsy—and by this I mean that the autopsy revealed no
obvious cause of death which may or may not have occurred
in or immediately after a fit—was the cause in fourteen, in ten
of whom the thrombi were found.

Some inflammatory condition (pneumonia, tubercle of lung,
peritonitis, or dysentery) was the cause in ten, in all of whom
clot was found. Disease of the kidneys (chronic) was the
cause in four, in all of whom clot was found.

Thus status epilepticus may occur without thrombi being
discovered, and the fits cannot therefore necessarily be the
cause of the copious clotting which is sometimes found in this
condition. This is still more decisively shown in those cases
which have had no fits for years before their death (29, 33,
and 36), and where abundant clotting is present.

Those dying from epilepsy, or in status epilepticus , were the
only ones that did not invariably show intra-vascular clotting.
This lends some support to the contention that general
inflammatory disorders may be factors in the production of
these clots, a supposition I am quite ready to grant, but not
that they are necessarily factors; for, as will be shown later on
(vide Case No. 12), control brains from persons who died from
acute inflammatory disease frequently failed to show any signs
of intravascular thrombi.

The regions of the nervous system examined. —In all but a
very few cases the pre-frontal sections were taken across
Wernicke’s transverse fissure—occipital across the calcarine
fissure, the cerebellum from sagittal sections through the left
lateral lobe. In all cases the ascending frontal sections were
from the apex of this convolution, at right angles to the median
line, so as to include part of the paracentral convolution.
Three levels only of the cord were examined, from the cervical
enlargement, the mid-dorsal region, and the lumbar enlarge¬
ment.

Methods employed .—The tissues from the earlier cases were
fixed in saturated sublimate solution for twenty-four hours,
then passed through graded alcohols, chloroform, imbedded in
paraffin, cut, fixed to the slide by Gulland’s method, and
stained either by toluidin blue or Unna’s polychrome blue.
Some sections were counterstained by erythrosin. Latterly I
employed absolute alcohol to fix the tissues. If they are
immersed for about twenty-four hours in this fluid, changed

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1907]

BY JOHN TURNER, M.B.

two or three times, very little shrinking occurs, and the finer
detail of the cell structure is very well shown, better than in
sublimate preparations. Sections so prepared are also suitable
for the application of micro-chemical tests.

In a few cases Beneke's methyl violet method for the
staining of glia was used. For tract degeneration pieces of the
cord, after hardening in Miilleris fluid, were treated some with
osmic acid for the detection of recent degeneration, and others
by Weigert’s method for old degeneration. For the preparation
of these sections, as well as many from the other parts of the
central nervous system, I have to thank my colleague Dr. de
Steiger, and for great assistance in many other ways in the
course of this investigation.

For the detection of phosphorus in the tissues I have
employed Macallum's phenyl-hydrazin test, slightly modified
in so far as I have not found it necessary to use a Soxhlet
apparatus to extract fats, etc. The following is my pro¬
cedure : sections fixed to the slide by Gulland’s method, after
extraction of their paraffin, are placed for eighteen hours in a
mixture made by dissolving i part pure molybdic acid in 4 parts
strong ammonia, and adding 1 5 parts of nitric acid, sp. gr. 12,
then they are rinsed in distilled water, and a freshly prepared
I to 4 per cent, solution of phenyl-hydrazin hydrochloride is
poured over them and left for a few minutes, the sections rinsed,
dehydrated, cleared in xylol and mounted in colophonium or
Canada balsam. In sections so treated the^rganic phosphorus
stains a bright green.

In the nerve-cells the nucleolus stains a bright emerald
green of greater depth than any other part; the chromatin of
the nucleus is a very pale green, and the nuclear membrane
nearly colourless. The chromatoplasm (Nissl bodies) stains
green, somewhat paler than the nucleolus, whilst the achromatic
substance is nearly or quite colourless. This reaction is exception¬
ally well shown in Betz or anterior cornual cells. Degenerated
nerve-cells stain an uniform dark green, nucleolus, nucleus,
and cytoplasm all alike; on this account they stand out
very prominently in contrast to healthy cells. Ante-mortem
(vital) thrombi stain green of various depths, darkest in the
hyaline masses met with either lining or completely filling the
lumen or as little free spheres, singly or in clusters. The
finely granular clot stains less intensely.

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

Post-mortem clot, especially that the result of alcohol fixa¬
tion, does not stain green at all.

Leucocytes stain of about the same depth as the granular
clot and the clusters of small, round granules of 1*5 to 2 /l in
diameter, which I believe to be blood-plates, stain as intensely
as the hyaline clot. Buckmaster has recently published some
experiments which almost conclusively show that these bodies
are not elements of normal blood, but are produced either by
injury to the plasma within or without the body, or to a much
smaller extent are extruded from the erythrocytes. He states
emphatically, however, that they exist in pathological blood.
Whether they are or are not independent constituents of
normal blood does not affect my views as to their role in
epilepsy. Their presence cannot be explained away, and in
all probability is closely connected with coagulation, not
necessarily massive coagulation. In the same sense as Nissl
regards the disposition of the chromatoplasm of nerve-cells as
an equivalent picture of health or disease, so here, in a series
of sections all treated precisely alike, the presence in smaller
or greater numbers of these bodies will possess some patho¬
logical significance. Buckmaster quotes Wlassow as stating
that an aggregation of these bodies seems to occur when the
endothelial lining of an artery is injured, and from this plug¬
ging tendency they have been regarded as specific agents for
inducing coagulation of the blood.

Sections from thirty-one of the cases were treated by
Macallum’s method. The coagula and blood-plates usually
show quite plainly when stained in the ordinary way with
Unna’s polychrome blue, but this stain cannot be relied on.
If it give a positive picture, well and good ; but it may give a
negative one, where the phenyl-hydrazin method has shown
that a marked amount of coagula and numbers of blood-
plates are present.

PART II.

Synopsis of Cases and Detailed Account of the
Microscopical Examination of Each.

Case i. —E. S —, female. A low-grade imbecile, depraved in habits,
restless, troublesome, and spiteful. Her fits were strong and frequent,

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1907]

occurring either singly or in batches (serial). Died in status epilepticus ,
set 18, with a temperature of 103° F.

Autopsy thirty-one hours after death. The encephalon weighed
1309 grammes and showed no special naked-eye abnormality except
atrophy and sclerosis of the right cornu ammonis. The liver on micro¬
scopic examination showed fatty degeneration and some increase of
interstitial tissue. The kidneys also showed this latter change. No
other special alterations to note. The ascending frontal convolution
and the cornu ammonis of both sides were fixed in sublimate, passed
through graded alcohols, sectioned, and stained with erythrosin and
toluidin blue.

Ascending frontal (a). —Meninges : some slight fibrous thickening in
places. Here and there are spots where marked infiltration of the
meninges with mononuclear cells is present. The infiltrating bodies
are round, oval, square, or elongated, and average 8—10 ft, but some
are 16 /x. The cytoplasm is fairly dense and homogeneous and stains
pink. The nucleus (6 fi) may be centrally placed or at one end; it is
sharply outlined, showing several chromatin spots connected by threads.
In shape it is round, bilobed, or reniform. In some cases there are
two nuclei in a cell. Practically no small lymphocytes are to be seen.
Between the pia and the surface of the cortex is a fine amorphous
epicerebral exudate.

On the surface of the convolution are little buds or excrescences,
which consist of fibres crossing in all directions and much denser in
some parts than others. Many nuclei are present, varying from 4 to 6 /x
in diameter. The smaller are very dense, but for the most part a
central nucleolus and smaller chromatin spots can be made out.
Beyond these little glial excrescences there is no sign of a band of
sclerotic tissue over the greater part of the surface, but here and there
a thin rim is seen, much less than often occurs in the brains of chronic
forms of insanity.

The whole extent of the first layer is fairly thickly strewn with small
ill-defined glia cells from 8 to 12 /*, whose nuclei is precisely similar to
those just described.

Here and there in this layer are nerve-cells, which although always
found in the new-born infant, are not found in the adult, except as an
accompaniment of defective development. They represent embryonal
nerve-cells.

The second layer is fairly well defined, the cells are numerous and of
average size. Many of their nuclei are swollen and clear or “ bladder¬
like.” The smaller and medium-sized pyramids are well formed, but
in patches here and there are groups of darkly-stained, shrunken forms.

The great majority of the Betz cells are large, with a finely granular
condition of the central chromatoplasm and with a nucleus, situated in
a very eccentric or peripheral position, but which otherwise shows a
normal structure. This form of cell is indistinguishable from an early
stage of that which has been termed reaction d distance , or (by A. Meyer)
axonal reaction. Perhaps it is the same, but, at all events, there are
facts which tend to show that it remains in this condition without
material alteration, and that it occurs in over 70 per cent . of ail imbeciles.
Very little pigment is present.

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

The nerve-cells are usually surrounded by large numbers of peri¬
cellular elements similar to those to be described around the vessels,
which often encroach upon or in some cases completely enter into the
nerve-cells.

Meynert’s striae are well marked.

Vessels .—Marked engorgement, only very few leucocytes. No struc¬
tural alteration noted. Around the capillaries in the lymph-spaces
there are considerable numbers of cells, with very scanty cytoplasm and
round and oval nuclei (6 ^), which stain uniformly but show darker
chromatin particles.

As a rule these elements adhere to the distal wall of the lymph-space,
and not to the capillary.

The subcortical nerve-cells, which usually disappear shortly after
birth in the human being, are still present in large numbers; e.g. y it is
possible to count twenty in a low power field (x ioo). The cytoplasm
of these cells is of an indefinite structure, something like frayed out
cotton-wool, but definite chromatoplasm can be detected staining blue
in contrast to the spongioplasm, which stains red. These cells rarely
exceed 20 fj. in their longest diameter.

Side (b) showed similar appearances.

Cornu ammonis .—Right (atrophied) side : The pyramidal cells were
few, shrunken, and darkly stained, especially in the nucleus fasciae
dentatae.

Many of the vessels are engorged and sometimes ruptured, but, side
by side with these, collapsed vessels lying in greatly dilated spaces are
found. These dilated perivascular spaces are occupied by a delicate
foam-like structure, which shows especially well in sections stained by
iron haematoxylin. Spider cells are not at all a prominent feature.

Left side: Shows similar appearances to the right, but scattered
about in the vessels are darkly stained spheres and mulberry-like
masses, and in one instance one of these latter has become impacted
in a vessel, and led to its rupture. On one side of this body the
vessel is distended with erythrocytes; on the other it is collapsed, and
erythrocytes are lying free in the lymph-space.

Remarks .—The localised occurrence of the intravascular
clotting should be noted ; although sections were examined
from four different regions of the brain it was only noticed in
those from the left cornu ammonis.

Case 2.— R. B —, female. A high-grade imbecile, employed in a
factory before admission. Able to converse rationally and to attend to
herself. Industrious. Had frequent single attacks of grand mal .
Very dull, heavy, and confused after fits.

She died in status epilepticus> set. 18; two years previously had an
attack of status, from which she recovered.

Autopsy thirty-one hours after death. Encephalon 1263 gr. The
cornua ammonis were not sclerosed, but in the cerebellum were
atrophied sclerosed foliae on the right side along the posterior border,

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1907.] BY JOHN TURNER, M.B. 9

and on the left side in a corresponding position was a meningeal
hemorrhage. The spinal cord was very soft. With the above excep¬
tions the viscera appeared healthy. The following parts were fixed in
sublimate and examined microscopically. Ascending frontal (both
sides). Cerebellum in the regions referred to above and spinal cord.

Ascending frontal, —Meynert’s striae not well marked, probably owing
to paucity of cells.

The meninges appeared as if glued to the surface of the cortex, and
their engorged bulging vessels were sunk in depressions of the surface.
No structural alterations noted in the vessels, but rupture of their
walls is evident by the diffused escape of erythrocytes noted between
the meninges and cortex. A considerable infiltration of large lympho¬
cytes, as described in Case No. 1, is met with in patches, also numbers
of small lymphocytes (4 — 5 /*).

The surface of the brain is undulated, owing to the pressure of the
engorged meningeal vessels. No superficial band of sclerosis nor
increase of glia-cells seen. Many ruptured capillaries noted and also
the occurrence of embryonal nerve-cells.

There appear to be few nerve-cells throughout the cortex, especially
in the second layer, which is in consequence very ill-defined. In most
cases they are shrunken, rounded, and with few branches, and lie in
dilated spaces, their nucleus in all cases being darkly and homo¬
geneously stained. Very few Betz cells seen. They vary, some ap¬
pearing dark and shrunken, others pale and ill-defined, without visible
pericellular space. The nucleus is similar to that described in the
other cells. Some of the cells are typically axonal.

Vessels. —The majority engorged, others collapsed. Walls of the
arteries slightly thickened. An inconsiderable amount of perivascular
and pericellular infiltration; in the former situation the cells tend to
adhere to the side of the lymph-space and not to the vessel.

Large numbers of sub-cortical nerve-cells.

On one side a copious amorphous epicerebral exudate was observed.
Cerebellum. —Right side : Atrophied foliae. The meninges were some¬
what thickened (fibrous), the vessels distended and ruptured. A
copious amorphous exudate on the surface of the foliaj. Very few
Purkinje cells, and those seen were densely stained. Granules very
much reduced in numbers. No appearance of Bergmann’s fibres or
other evidence of glial overgrowth.

Left side: Although not visible to the naked eye, the foliae here were
also atrophied. Same appearances as on right side, only the number
of escaped erythrocytes was much larger.

Cord. —Cervical enlargement. Atrophy of one fore-horn; its cells
are few in number, shrunken, and darkly stained, with wide pericellular
spaces. In the other horn the cells are more numerous and larger, and
have a natural appearance, except that their nucleoli are often swollen,
measuring 9 instead of 4 or 5 ft. Lumbar enlargement similar.

Sections from the ascending frontal region and cerebellum were
treated with Macallum’s phenyl-hydrazin test for phosphorus, but as
regards intra-vascular clotting gave a negative result.

Case 3.—O. D —, female. A low-grade imbecile, subject to fits since

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IO ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

nine years old, obstinate, resistive, and spiteful; dirty in habits. Violent
after fits, which were sometimes single and sometimes serial. Was found
dead after a fit at the age of nineteen, apparently in robust health the
previous day.

Autopsy four hours after death. Encephalon 1309 grammes.
Atrophy of convolutions on the right side of the first and second
temporal and lower part of ascending parietal and those of the island
of Reil. Apart from this the brain appeared natural.

Liver was in a state of fatty degeneration, and both it and the kidneys
showed increase of interstitial tissue (microscopically); the other viscera
appeared natural.

The ascending frontals, right temporal convolution, medulla oblongata,
and spinal cord were fixed in sublimate and examined after staining
with Unna’s polychrome blue or toluidin blue and erythrosin.

Ascending frontals .—Meynert’s striae not so distinct as in normal
brain, due to the paucity of nerve-cells. The meninges show slight
fibroid changes, and in places some slight infiltration with mononuclear
cells (large lymphocytes). The vessels are not unduly distended,
and there is no appearance of haemorrhage. Epicerebral exudate
present.

On the surface is a dense, reticulated rim, about 30 /x thick with
few nuclei in it, in places raised up into little buds or granulations.
Throughout the first layer fairly numerous glia cells are seen; some of
these are about 10 /x in their longest diameter, and have a dark, cloudy
cytoplasm, and a plump, clear nucleus (7—8 /x) with central nucleolus
and peripherally-arranged chromatin spots. Others show hardly any
cytoplasm, and their nucleus is small (6 /x) and darkly stained. The
second layer is ill-defined, with only few nerve-cells, and these mostly
shrunken and darkly stained, but side by side are others with large,
clear, “ bladder-like ” nucleus. The same patchy distribution of dark,
shrunken cells and those with swollen nuclei is found among the small
and medium-sized pyramids. The Betz cells are few in number, and
some of them show the congenital form, others are ill-formed and darkly
stained all over.

Vessels .—Some (veins chiefly) engorged, others (arterioles) shrunken,
somewhat tortuous, and lying in wide spaces. In the medullary portion
some of the vessels lie in great cavities, across which is a very loose
reticular structure, and in the big meshes lie masses of pigment (staining
dark green with polychrome) and a very few large lymphocytes.

There is no increase in the perivascular or pericellular elements of
the cortex. Subcortical nerve-cells numerous, and some are very large
(50 x 14 /t).

Right temporal (atrophied) convolutions . — Meninges : The arteries
and vessels generally dilated and filled with erythrocytes, among
which is a rather large proportion of leucocytes. In the pial meshes
lie infiltrated cells, arranged below according to their number.

(1) Oval or round nuclei (8 — 9 /x) with dark border, central
nucleolus, and peripheral chromatin spots. These apparently are
analagous to the nuclei of the pial fibres.

(2) Very darkly stained nuclei (4 /x) with a wisp of cytoplasm ;
small lymphocytes.

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BY JOHN TURNER, M.B.

(3) Round cells, with dull, smoky cytoplasm (8 fi) and lateral
nucleus (6 ji) which may be reniform; large lymphocytes.

(4) Polymorphonuclear leucocytes.

(5) One mast-cell noted.

In the meshes also lie extravasated erythrocytes and an amorphous
deposit.

In the most atrophied parts of the cortex all the nerve-cells have
disappeared, and the tissue consists of glia cells, with very little cyto¬
plasm but darkly-stained (crimson with erythrosin) fibres. Along the
surface of the convolution is a denser rim of glial fibres. In
places are small, rounded areas crowded with nuclei resembling small
lymphocytes.

Sometimes a vessel is seen within these infiltrated areas. The
vessels in the cortex are usually somewhat collapsed and lie in wide
spaces, in which is an amorphous deposit and a few cells, chiefly large
and small lymphocytes, one or two mast-cells noted, and a few fairly
typical plasma-cells, the cytoplasm of which does not, however, show
any clear area.

Medulla oblongata .—Small granulations on the floor of the fourth,
situated away from the centre line. No appearance of glial over¬
growth.

The hypoglossal and ambiguous nuclei cells show fairly good
stichochrome appearance ; nucleus increased in density. The cells
of the lateral and gracile nuclei show, as usual, an axonal appearance.
In other respects the appearances are similar to those seen in the brain.

Spinal cord\ only examined by NissPs method, shows appearances
very similar to those described in the brain as regards meninges and
vessels.

Anterior horn-cells have a fairly good stichochrome appearance.

Sections from the ascending frontal region tested for phosphorus
show the presence of many dark green (degenerated) nerve-cells, among
which are most of the Betz cell. Several clumps of dark-green,
stained blood-plates were seen filling up the lumen of their containing
vessel, also hyaline casts in some of the cortical capillaries.

Case 4.—E. W—, female. A high-grade imbecile, subject to
epileptic fits from age of fifteen or sixteen. Mother states that she was
previously an intelligent child. Her fits were strong and frequent, and
occurred singly or in batches (serially). Except just after fits, when
she often became maniacal, she was a quiet and industrious girl. Died
in status epilepticus y set. 21 (temp. 102° F., vasomotor paralysis).

Autopsy five and a half hours after death. The encephalon weighed
1273 grammes. No sclerosis of cornu ammonis. The viscera generally
appeared natural.

Pieces from both prefrontal and both ascending frontal lobes, the
cerebellum smd medulla oblongata were fixed in sublimate and stained
as usual.

Prefrontal (1).—No thickening of the meninges. Most of the
vessels are distended and tortuous, with slight thickening of mus-
cularis. Copious extravasation of erythrocytes, among which are seen
also clumps of polymorphs and large lymphocytes (large hyaline cells)

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12 ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

and a very few small lymphocytes. First layer contains relatively few
spider-cells, which are very small and shrunken, and no sclerosed
surface band.

Second layer of cells is not well defined owing to their sparsity.
The cells appear fairly natural except for an occasional one with a large
“ bladder-like ” nucleus.

The pyramidal cells are few in number, generally pale and with ill-
defined chromatoplasm. Here and there are groups of darkly-stained
shrunken forms lying in wide spaces. Just beneath the second layer
is the region where the cells are most sparsely scattered, and it is in
this region that the greater number of the dark, shrunken cells are met
with.

The nuclei of the spindle-cells are swollen and “ bladder-like,” often
bulging out the contour of the body. They contrast sharply with the
nuclei of the pyramids.

In places there is a considerable infiltration of nuclei in the peri¬
cellular spaces ; six or seven may be counted around one nerve-cell.

Vessels. —For the most part they are distended with erythrocytes,
and blocking up the lumen of many are masses of a hyaline material
which stains moderately dark blue with polychrome. Some of the
vessels show absolutely no lymph-space, but fit closely up against the
matrix ; others are surrounded by a wide lymph-space. Some slight
thickening of the muscularis of the arteries is noted. Very little
nuclear proliferation in the perivascular spaces. In the medullary sub¬
stance, close to the cortex, are numbers of greatly dilated veins, which
are in many cases blocked up by hyaline material or by a finely granular
deposit.

The subcortical nerve-cells are small but relatively numerous.

Prefrontal { 2).—This side does not show the empty appearance ot
the upper pyramidal region noted in the other side. Fibrin threads
and many blood-plates noted in the meningeal vessels. In other
respects similar to the first side.

Ascending frontal. —Some increase in the breadth of the meninges at
the top of the convolutions. They show a loose structure with infiltra¬
tion of mononuclear cells (large lymphocytes), more marked than in
the prefrontal regions.

Vessels distended. Extravasation of erythrocytes and epicerebral
exudate. Hyaline coagulum in some of the veins, in the clot are
imbedded erythrocytes and an occasional polymorph.

Meynert’s striae well marked, no visible sparseness of nerve-cells. No
increase of glia observed in first layer. Some embryonal nerve-cells.

Nerve-cells. —Second layer fairly well defined ; most of the nuclei are
dense and only a few large and clear. The small and medium-sized
pyramids are well-shaped but small; nucleus dense, and on the side
which shows the intra-vascular clotting often in a condition of homo¬
geneous degeneration (/. e. staining densely and homogeneously). A
good number of Betz cells are present on one side, only a few on the
other. They stain darker than usual owing to the ground substance
taking on the colour, but the chromatoplasm is well defined except in
some which show central chromatolysis. Very little pigment. The
nucleus is generally peripheral, is denser than normal, and in many

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BY JOHN TURNER, M.B.

cases its lining membrane is thickened at one side. The spindle cells
are small, with rather dense nuclei. Pericellular infiltration is a marked
feature in all the layers below the second, but chiefly around the
spindles: it takes the form of small, darkly-stained nuclei with no visible
cytoplasm.

Vessels .—The arteries, veins, and capillaries were generally filled with
erythrocytes. In some instances an artery was distended in one part
and collapsed a little further on. The veins generally showed practically
no lymph-space. A solitary mast-cell was noted.

On one side the vessels contained a considerable quantity of hyaline
clot, and on this side a small capillary haemorrnage was seen.

Sub-cortical nerve-cells occurred in large numbers. Around the
vessels of the medullary substance were clusters of pigment granules,
which stained green with the polychrome. Capillary emboli were often
observed.

Medulla oblongata. —Meninges and vessels as above. No appear¬
ance of glial overgrowth. The hypoglossal cells showed a good sticho-
chrome appearance, with somewhat dense nuclei.

Cerebellum. —Condition of meninges and the vessels similar to those
in the cerebrum. Bergmann’s fibres faintly visible in places. No
atrophy of foliae met with. Purkinje cells sparse, mostly large and
pale, with central clear nucleus (sometimes swollen), others small and
darkly stained with shrunken nucleus.

Case 5.—J. R. R—, male. A low-grade imbecile, dirty in habits,
unable to attend to himself. Had very frequent fits, and died in status
epiiepficus y aet. 22.

Autopsy seventeen hours after death. Encephalon weighed 1239
grm. The cornua ammonis were sclerosed and of almost cartilaginous
consistency. The thoracic viscera appeared natural. Some com¬
mencing cirrhosis of liver and interstitial nephritis. Portions of the
ascending frontals, the ascending parietal (of one side), the cornu
ammonis, and the cerebellum were saved for microscopical examina¬
tion. All but the cornu ammonis piece were fixed in sublimate; this
was put direct into absolute alcohol.

Ascending frontals .—Some fibrous thickening of the meninges, vessels
full and prominent A slight proliferation, chiefly in the dips of the
sulci, of lymphocytes, small and large. Amorphous epicerebral exudate.
Here and there on the zonal layer is a thick (70—130/4) surface rim of
sclerosed tissue, with few or no nuclei, but between this band and the
rest of the layer a somewhat closely set row of small glia-cells lie.
Glia-cells averaging 15/4 in diameter, with clear, plump nuclei (6 to
8 ft) are scattered throughout the layer. Not infrequently there are
two nuclei to a cell. A few embryonal nerve-cells seen. Meynert’s
striae well marked.

Nerve-cells. —The second layer is ill-defined, owing to the cells being
few in number, but they appear natural and their nucleus is not
swollen. There is a great sparseness of cells in the upper part of the
pyramidal layer, but they are of a fairly good shape, with a clear but
not swollen nucleus.

The Betz cells are few in number; they are small and their ground-

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14 ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

substance stains; the nucleus is central and clear. Very little pig¬
ment. Only a few show axonal characteristics. The spindle-cells
are not prominent; they usually have a clear nucleus.

Darkly stained, shrunken, sub-cortical nerve-cells are numerous.

No marked pericellular infiltration.

Vessels. —Show the usual condition. The venules swollen out with
erythrocytes and with no visible lymph-space; the arterioles less dis¬
tended and with more or less marked lymph-space; some of the
arteries are collapsed and tortuous, with slight thickening of the mus-
cularis. A hyaline coagulum coats the inner wall in places and some
deposition of fibrin threads.

On one side there is an appearance as though the convolutions
had become fused to one another in the sulci. (See also Case 14.)
Nothing calling for further remark in the ascending parietal section,
except a small haemorrhage (microscopic) in the cortex.

Cornu ammonis .—The main feature to note is the presence of very
shrunken, darkly-stained pyramids lying in very wide spaces. No
appearance of any active glial overgrowth.

Cerebellum. —Meninges, vessels engorged, extravasation of erythro¬
cytes, copious amorphous exudate. At the bottom of the sulci there
is a moderate infiltration of lymphocytes (large). No marked atrophy of
foliae noted, but in places the granules are manifestly decreased in number.

Bergmann’s fibres well marked. Purkinje cells few and shrunken,
with no chromatoplasm. Nucleus generally dense and distorted.

Clumps of hyaline clot and blood-plates observed in the veins.

Case 6. —T. H. S—, a married man, and a “ clerk” by profession, a
case of “acquired epilepsy.” During his residence here was noisy,
violent, and destructive, and had but few fits. Died of colitis, set. 36.

Autopsy nineteen hours after death. Encephalon weighed 1229
grm.; both cornua were sclerosed. Pieces of the ascending frontals
and ascending parietals of both sides were fixed in sublimate and
stained as usual. Slight fibroid thickening of meninges and practi¬
cally no infiltration of cells. Marked extravasation of erythrocytes
and epicerebral exudate. Maynert’s striae well defined. No increase
of glia-cells or other abnormal features in the zonal layer.

Nerve-cells .—In places the second layer is very ill-defined owing to
sparseness of cells. In some parts the individual cells have a natural
appearance, in others they are shrunken and darkly stained. There
is in places considerable diminution in the number of the pyramidal
cells in the upper part of the third layer. The cells vary, some fairly
natural, others with swollen, “bladder-like” nucleus, and others (in
groups) shrunken and darkly stained. There are a fair number of Betz
cells present, and they all show appearances similar to a somewhat
advanced condition of axonal reaction— i.e., with practically complete
disappearance of chromatoplasm, and the lateral nucleus compressed
and increased in density. In some cases they stain uniformly and
very darkly, so that all interior detail, even the nucleus, is obscured.
They contain very little pigment. The spindle-cells are in good number
and resemble the others. They are surrounded by pericellular elements
in considerable number.

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BY JOHN TURNER, M.B.

Vessels .—Several small capillary haemorrhages noted in the cortex.
The arteries are generally nearly or quite empty and very tortuous,
lying in wide lymph-spaces. The veins are tisually engorged and show
no lymph-space. Around the capillaries, lying free in the lymph
spaces, are a considerable number of small round nuclei. Two or
three mast-cells seen. Mulberry-shaped masses of hyaline clot and
spheres are met with in the vessels, together with considerable numbers
of blood-plates.

Numerous subcortical nerve-cells, as a rule small and with rather
dense nuclei.

Remarks .—Although this man must have been from the
nature of his employment of average intelligence, yet his brain
showed all the characteristics of defective development, and in
addition he had a narrow, badly-shaped palate.

Case 7.—C. C—, male. A low-grade imbecile. Bedridden for
some months before his death. His fits were single ones, and chiefly
by day, and he rarely had more than one fit in a day. He died of
pulmonary tubercle, aet. 32.

Autopsy twenty-five hours after death. Brain anaepiic; sclerosis of
left cornu ammonis; no other morbid features noted. Encephalon
1260 grammes.

Pieces from the prefrontal, ascending frontal, calcarine fissure con¬
volutions, and cornu ammonis of both sides, and cerebellum were fixed
in sublimate and stained as usual.

Prefrontal .—The meninges and the zonal layer appear normal.
Under a low-power view the Meynert’s striae are well defined, and there
appears to be no diminution in the number of nerve-cells.

The second layer is fairly defined, the individual cells are small
and darkly stained with homogeneous nuclei. The pyramidal and
spindle-cells are of the same character. No marked proliferation in the
l^ericellular spaces.

Vessels .—Some slight thickening of the arteries, which are tortuous,
nearly empty, and lie in wide spaces. The veins are engorged and
show no lymph-spaces. In many of the vessels, especially those of the
medullary substance, there are masses of hyaline and granular coagula
and blood-plates.

In sections from this region treated with Macallum’s phenyl-hydrazin
test for phosphorus numerous blood-plates (green) were visible in the
vessels, and in places these appeared to have amalgamated into a
granular substance entirely filling the lumen.

Ascending frontals .—Meninges healthy, a considerable quantity of
epicerebral amorphous exudate. Meynert’s striae well defined.

Zonal and second layer as in prefrontal region. In patches in the
upper region of the pyramidal layer (third) there is considerable dimi¬
nution in the number of nerve-cells. The majority of those present are
of normal shape and their nucleus is normal, but here and there are
groups of the dark, shrunken forms, and occasionally a cell is seen with
swollen and “ bladder-like ” nuclei.

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16 ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

Very few Betz cells seen.

A slight increase in the number of pericellular elements, chiefly in the
spindle layers. Numerous subcortical nerve-cells.

Vessels , as in the prefrontal region. Hyaline coagula, in some cases
entirely filling the lumen of a vein, are noted. In the medullary sub¬
stance there is pigment around some of the vessels, staining dark green
with polychrome.

Region of the calcarine fissure .—The meninges and cortex show a
healthy aspect; some erythrocytes are seen extravasated beneath the
pia.

Cornu ammonis (left) quite similar to that described in Case i, but
no intra-vascular clot noted. On the right side microscopic haemor¬
rhages noted in the cortex.

Cerebellum .—No atrophied foliae seen. Extravasation of erythrocytes
in meninges. In places very slight infiltration of lymphocytes.

Bergmann’s fibres not visible. Purkinje cells few in number and
similar in general appearance to the pyramidal nerve-cells.

Case 8.— J. H—, male. Probably congenitally weak-minded, but
possessed sufficient intelligence to earn his living as a hawker. Talked
coherently, and could give a good account of his past. Typical epileptic
speech. Died, set. 42, of peritonitis, the result of a perforation in the
transverse colon.

Autopsy twenty-three hours later. In the left parietal region the
meninges were opaque and nearly -J- inch thick over the sulci. On
section they appeared as a firm yellow substance. The cortex beneath
was firm and adherent to the meninges.

The left cornu ammonis was sclerosed. The brain generally was firm.

The large intestines showed extensive colitis. The liver was fatty.
>Purulent matter in the peritoneal cavity.

Pieces from the left parietal region only were fixed in sublimate, and
when sectioned were found to be quite gritty and blunted the knife.

This condition was due to numerous vitreous masses lying in the
meninges and in the most superficial layers of the cortex. On addition
of hydrochloric acid they dissolved with effervescence.

Meninges .—At the summits of the convolutions in the meshes of the
pia arachnoid are numerous small deposits of hyaline material, which
stain a rather deep blue with either toluidin or polychrome blue, and
large multi-lobulated masses of the same material, which have in part
undergone vitreous changes. In this region there is also a very marked
infiltration with cells, apparently large and small lymphocytes, chiefly
the former. In the sulci this infiltration is not marked, and here the
thickened pia consists of a densely fibrous mass. The arteriole walls
are enormously thickened, all the coats participating in the change,
especially the muscular and the inner. The walls of the veins do not
appear to be thickened. Both arteries and veins are filled with blood.

In the zonal layer there are small vitreous deposits with radial
fractures and also numerous hyaline masses, which stain deep blue
and often show a vitreous centre. There is no appearance of any glial
overgrowth.

Meynert’s striae are well defined, and the nerve-cells are numerous

Digitized by v^ooQle

Digitized by'

^!r ?mSK, Jj^F* Fa

BY JOHN TURNER, M.B.

I 7

I907.]

and of a normal shape. They all appear to be in a condition of acute
cell change (pyrexial), their nucleus somewhat angular, darkly and
uniformly stained. No marked increase of pericellular elements.

Subcortical nerve-cells small, but in fair number.

Beyond some thickening of the walls of the cortical arteries there are
no marked structural changes in the vessels. A few mast-cells were
noted about the vessels, both in cortex and meninges.

The vitreous and hyaline deposits were very numerous in the upper
portion of the third layer. From a study of transitional forms it was
possible with a considerable degree of certainty to trace their origin and
metamorphoses. Inside the vessels were hyaline spheres and tabulated
masses from 6 to 8 jx and more in diameter, which stained pale blue
with either toluidin or polychrome blue. In some places outside the
capillaries were closely ranged in the lymph-spaces rows of quite similar-
looking bodies, with here and there a larger sphere or dumb-bell-shaped
body apparently formed by fusion of the previously mentioned spheres;
some of these had undergone vitreous changes in their centre. Again,
in both the perivascular spaces and lying free in the matrix were starch¬
like bodies (21 p or more in diameter) with concentric markings (see
Fig. 1). These stained blue, except in the central parts of some which
had undergone the vitreous change. In the last stage the deposits were
much larger and more irregularly shaped; they showed a large glass¬
like centre with radial fractures, and a rim of material which still stained
blue (see Fig. 2). There is no appearance of any glia proliferation in
the cortex.

In the medullary substance there is a marked increase of nuclei,
especially alongside the capillaries. These nuclei stain very densely,
measure 4 or 5 ji, and sometimes lie two or three deep in the lymph-
spaces.

Remarks .—The chief feature of interest in this case is the
presence of the vitreous bodies, unassociated with any appear¬
ance of irritation in the cortex, and their probable derivation
from the same material, which is so frequently found in the
form of intra-vascular clots. It must be assumed, if this is
correct, that there was a transudation of the plasma substance
(nucleo-proteid) which coagulated after it had left the vessels.
I have met with a similar condition in the cerebellum of an
epileptic (1 vide Case No. 1 5), and also in the brain of a general
paralytic with a condition which was apparently an early stage
of the change, where enormous numbers of the small hyaline
spheres lined the lymph-spaces of the capillaries in a limited
region of the calcarine cortex (*).

Two epileptics (not included in this series) had gross
calcified bodies deposited—one in the cortex of the island of
Reil and the other (the size of a hazel-nut) in the pons, just
beneath the floor of the fourth ventricle.

LIII. 2

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18 ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

Possibly these bodies were of similar origin to the vitreous
bodies here described.

It may be noted that in sections treated with Macallum’s
test for phosphorus these extra-vascular deposits stained a
fairly deep green, with the exception of the large vitreous
bodies, and in their case there was generally an external rim
or band which still took on the green colour.

Case 9.—W. F —, male. An agricultural labourer; fits since birth;
was subject to batches of severe fits every two or three months, and
during these periods was violent and maniacal. He died after a severe
fit whilst suffering from typhoid fever, aet. 34.

Autopsy nine hours later. The encephalon, beyond sclerosis of both
cornua ammonis, appeared natural.

Recent pleurisy of left side.

Pieces from the prefrontal, ascending frontal (both sides), medulla
oblongata, and spinal cord were fixed in sublimate and stained in the
usual way ; pieces of the spinal cord were also fixed in osmic acid.

Prefrontal ,—The meninges are structurally natural, their vessels
engorged and containing a relatively large proportion of lymphocytes,
both large and small. Marked extravasation of erythrocytes.

The zonal layer shows in places a narrow sclerosed rim, but it
contains very few glia nuclei.

Cells ,—The second layer is ill-defined and the cells few, but Meynert’s
striae are fairly shown. The nerve-cells generally are small, darkly
stained, and with a shrunken, angular nucleus, which is often homo¬
geneous and dense. The pericellular spaces are wide, but there is
very little pericellular infiltration.

Vessels ,—As usual, veins engorged, arteries empty. Many small
vessels in the cortex have ruptured. They contain, as in the meninges,
a large number of large lymphocytes, and also numerous blood-plates,
discrete and in clusters.

Ascending frontals ,—Meninges natural. Zonal layer shows no
increase of glia-cells, except in places near the surface. In one section
there is a small glial bud. Embryonal nerve-cells noted.

Meynert’s striae well defined. Nerve-cells well shaped and not
apparently diminished in numbers. Here and there are the usual
patches of darkly stained, shrunken forms. About a half of the Betz
cells show the appearances characteristic of developmental defect. The
others are normal. Pigment in excess for his age. A considerable
proliferation of pericellular elements. Numerous subcortical cells.

Vessels ,—Precisely similar to those in prefrontal region. Some of
the veins in the medullary substance are filled up with a hyaline
coagulum.

Medulla oblongata ,—Some sclerosis of the olives, very numerous
large lymphocytes noted in the vessels, some of which have a dis¬
tinctly spindle shape. Ruptured vessels noted. The hypoglossal
cells show a fairly good stichochrome appearance, but are somewhat
shrunken.

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1907.] BY JOHN TURNER, M.B. 19

Spinal cord —Cervical and lumbar enlargement, no marked changes
in the nerve-cells and meninges. No tract degeneration visible in osmic
add preparation.

Remarks .—The large number of lymphocytes seen in the
vessels is probably a result of the typhoid fever. (See “ Rdle
of the Lymphocytes,” W. G. MacCallum, Brit . Med \ Journ .,
September 10th, 1904.)

Case 10. —M. E. L — , female, a high-grade imbecile, fits since
twenty, was excited, abusive, and spiteful, used stereotyped and
meaningless phrases. On admission her knee-jerks were exaggerated
and her pupils equal and reacted normally to light and on accommo¬
dation. Ultimately her knee-jerks were absent and her pupils nearly
rigid to light. At one time she quite lost the use of her lower limbs,
but later on regained her ability to walk. Her fits were slight and
infrequent; would go for a month or so and then have two or three.
Her eyes became fixed, she lost consciousness, frothed at the mouth,
and fell down. No convulsions of the limbs; the fit was over in
a few seconds ; they got more frequent latterly. She died of chronic
Bright's disease, aet. 32.

Autopsy twenty-seven hours after death. Encephalon = 1140 grm.
Some shrinking of the convolutions of the vertex. No sclerosis of the
cornua ammonis. The olivary bodies appeared sclerosed. Spinal cord
very firm. Microscopical examination of the liver showed thickened
capsule and marked fatty degeneration.

Pieces from the ascending frontal, ascending parietal, the cortex of
the calcarine fissure, the medulla oblongata, cerebellum, and spinal cord
were fixed in sublimate and stained as usual. Pieces from the cervical
and lumbar enlargements were hardened in Muller and stained in
osmic acid.

Ascending frontal, —Meninges and zonal layer appear normal.

Nerve-cells .—Meynert’s striae well marked. Second layer well defined,
some slight diminution in number in the outer half of the third layer.
The Betz cells are in good number, and practically all show axonal
characteristics, with some excess of yellow pigment. The usual patches
of shrunken, darkly-stained cells are met with in all the cell-layers. There
is a noteworthy increase of nuclei in the pericellular and perivascular
spaces of the capillaries and small vessels, which tend to adhere to the
wall of the space.

Vessels, —As usual, veins and capillaries engorged. Intra-vascular
dotting in the form of fibrine and hyaline masses, entirely blocking
up the lumen, is met with. (The hyaline material gave a blue colour
when tested for iron with ferrocyanide of potassium.) Subcortical nerve-
cells numerous.

Top of ascending parietal showed similar appearances. Beneath the
meninges were seen extravasated erythrocytes.

Calcarine fissure cortex. —Meninges natural. In the zonal layer
there was a slight increase of small glia-cells in patches, and a narrow
sclerosed rim.

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20 ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

The nerve-cells were numerous and of normal shape. Some of the
large cells show axonal characters. The vessels are similar in their
contents and general appearance to those described in the ascending
frontal region.

Medulla oblongata .— Foam-like exudate beneath the meninges.
Small ruptured vessels seen in the nervous substance. The hypo¬
glossal cells show a natural stichochrome appearance, but are
rather shrunken. The cells of the olives (sclerosed) were very
shrunken and darkly stained, and the matrix of these regions was
beset with small glia-cells. Vessels as in ascending frontal.

In specimens stained with osmic acid after hardening in Muller’s
fluid the whole of the olivary bodies are studded with small (i—3/4)
black spots, and the cells are heavily pigmented (light brown).. The
vessels lie in wide spaces, across which stretches a delicate foam-
like exudate, stained a very pale brown, and in its meshes are large,
empty, oval, bladder-like bodies (18 /a), with black borders. Many of
these have a crumpled-up appearance.

One or two recently degenerated fibres noted in the pyramidal tracts,
which appear otherwise normal.

Cerebellum .—Meninges natural. Bergmann’s fibres are visible over a
considerable extent of the molecular layer. The Purkinje cells are few
in number, and many are shrunken and darkly stained all over, nucleus
included. A folium, which was atrophied along one side only, was
discovered on microscopical examination, although not seen at the
autopsy.

The vessels were similar to those of the cerebrum.

Spinal cord .—Cervical enlargement. The fore-horn cells are shrunken
and darkly stained, but show a stichocrome appearance, and are not
axonal in character. Nucleus increased in density. Central canal
obliterated by proliferation of its lining endothelium. The column of
Goll stains darker with the erythrosin than Burdach’s column, and in
the former region there is a slight increase of glia nuclei. In the
lumbar enlargement the fore-horn cells are not shrunken and appear
natural. The central canal is obliterated.

The specimens stained in osmic acid show old degeneration (visible
to the naked eye after hardening in Muller’s fluid) of Goll’s columns in
both cervical and lumbar regions, and scattered thickly throughout
Goll’s and Burdach’s columns are recently degenerated fibres (Marchi
reaction). The cornu-commissural zone is practically free from de¬
generation. The crossed pyramidal tracts in both regions show a few
recently degenerated fibres.

Remarks .—The foam-like exudate which has been referred
to already, in all the cases examined, was noted long ago
(1859) by Schroeder van der Kolk, who designated it an
albuminous exudate, and laid great stress on its importance.
He further stated that it may undergo fatty degeneration.
The sections of the medulla oblongata in this case, which were
stained in osmic acid, appear to support this view, for bound

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BY JOHN TURNER, M.B.

1907 .]

up with this exudation were bodies which appeared to be of a
fatty nature. Sclerosis of the medulla oblongata was a feature
which Schroeder van der Kolk considered of great importance
in the pathology of epilepsy ; and whether this is so or not it
must be remarked that many of my cases showed this change,
more especially, as in the present case, in the region of the
olivary bodies.

Case ii. —A. T. D—, male. An idiot, does not play, sits all day,
probably not able to walk, although the notes do not say so. He had
frequent and strong fits, chiefly nocturnal Died of pulmonary tubercle,
aet 15.

Autopsy twenty-seven hours after death. The meninges were slightly
milky in the prefrontal region and along the sulci generally of the
vertex. The cortex was a slaty colour in places. The left cornu
ammonis was sclerosed.

There was a small haemorrhage and caseous deposit in the right
caudate nucleus, and a small abscess about the size of a pea in the
posterior part of the right temporal lobe. Encephalon weighed 1112
grm.

Pieces from the prefrontals, cornua ammonis, medulla oblongata,
and cerebellum were fixed in sublimate and stained as usual.

Prefrontal .—Very considerable fibroid thickening of the meninges,
and extravasation of erythrocytes beneath them. The meshes of the
pia are infiltrated with large lymphocytes in considerable numbers. A
foam-like epicerebral exudate is present. Most of the vessels contain
masses of fibrin which often enclose in their meshes erythrocytes and
lymphocytes. The zonal layer shows no increase of glia-cells or
sclerosed rim.

Nerve-cells .—The second layer is very badly defined, and in places
no cells, only empty spaces, are visible. The cells generally are shrunken
and darkly stained with small, dark, homogeneous nuclei. No marked
infiltration in the pericellular spaces. Many subcortical nerve-cells.

Vessels .—In the usual condition as regards distension. There is a
considerable amount of intra-vascular clot. The number cf blood-
plates is large. In sections treated with Macallum’s phenyl-hydrazin
test for phosphorus the clot, fibrin, hyaline and granular, and the
blood-plates take on a green colour.

Ascending frcntals .—Very considerable fibroid thickening of the
meninges over the convexity of the convolutions. In the deeper layers
some large lymphocytes are present, and there is a fairly copious
epicerebral exudate. The vessels contain a quantity of fibrin threads.

In the zonal layer there is a considerable increase of small glia-cells
and in places a sclerosed rim (40 p thick).

Nerve-cells .—Second layer ill defined, cells diminished in number,
both in this and the upper part of third layer. They are fairly well
formed*

The Betz cells are numerous, small, rather darkly stained, and show
little or no chromatoplasm; nucleus in some small and dense, in others

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

clear and natural; very often the nucleolus appears enlarged (6 or 7 /a).
All the cells show the characters of somewhat advanced axonal reac¬
tion. Not much pigment. No marked pericellular infiltration.

Vessels .—Veins not markedly engorged. Blood-plates in large
numbers.

Careful inspection with a high power shows a very common distribu¬
tion of small hyaline masses in the form of spheres of 10 /a in
diameter, which appear to have been formed by the coalescence of still
smaller bodies. In some cases the clot takes the form of long (30 ja)
cylindrical rods, completely blocking up the capillary in which they lie.

Numerous subcortical nerve-cells.

Cornua atnmonis .—It is not necessary to describe in detail the
appearances, as they are quite similar to those previously described.
In the left subiculum was a tiny patch of extravasated polynuclears,
representing in all probability the origin of a small abscess. Intra¬
vascular clot, in the form of spheres and long cylinders (90 / a ) in the
capillaries is prominent, and many blood-plates are visible in the vessels.

Medulla oblongata .—Hypoglossal cells natural. The majority of
the olivary nerve-cells are shrunken, distorted, darkly stained, and
heavily pigmented.

Extravasation of erythrocytes beneath the membranes. Occurrence
of emboli as in other parts.

Cerebellum. —Meninges as in cerebrum. No appearance of Berg-
mann’s fibres : in one spot is a minute collection of free polynuclears
(beginning of small abscess).

A small part of one folium is atrophied, and shows the characters
previously described in this condition.

Vessels .—Similar to those seen in cerebrum.

Case 12. —E. S—, female, married, second child bom day before
admission : has had epileptic fits ever since the age of seventeen,
following the birth of her first child. Addicted to excess of alcohol.
Admitted in an acutely maniacal state, which lasted for a week or two.
A great strong woman, quiet, weak-minded, and industrious, except
after her fits, which were frequent and generally at night (single fits).
Then she was quarrelsome and very violent. During the last few

months of her life her fits were more frequent, and generally of the

nature of petit mal. In her last illness she had a “strong” fit at
9.30 p.m., after which she got out of bed and walked about, spoke to
the nurse, and retched violently. The next morning, when asked if

she wished to get up, said, “ I wish to God I could.” All day she

laid huddled up and spoke very little, but recognised her mother. At
10 p.m. seemed to have another fit, with twitching of the limbs and
head. Limbs flaccid, draws up her feet when they are pricked. Tem¬
perature varied between ioo° and 103*4° F. Remained in a comatose
state for three days and then died, set. 25.

Autopsy two and a half hours later. Encephalon 1316 grm.; beyond
engorgement of the meningeal veins it showed no naked-eye lesions.

What appeared like two recent haemorrhages were found in the cord.
One, the larger, in the upper cervical region, which occupied about an
inch of the meninges, had ploughed up the posterior half of the cord

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1907-] BY JOHN TURNER, M.B. 23

in an oblique direction, leaving the right anterior cornua nearly intact
and completely destroying the left. The smaller one (4x3 mm.)
occupied the antero-lateral tract on the left side in the mid-dorsal region.

Both lungs were in a state of grey hepatisation. The liver was
congested and the kidneys natural (verified microscopically).

Pieces from the prefrontal, ascending frontals, calcarine fissure
cortex, medulla oblongata, cornu ammonis, cerebellum, and spinal
cord were fixed in alcohol and stained as usual. The cord was
hardened in Muller’s fluid.

Prefrontal .—Meninges natural, except for a slight infiltration with
large lymphocytes in places. The vessels nearly all contain abundant
fibrin, hyaline spheres, and blood-plates. Epicerebral exudate present.

The zonal layer has in places a sclerosed rim 50 to 70 /a thick.
It appears very wide, shows no marked increase of glia-cells, and is
limited internally by cells with the characteristics of those of the third
layer, and nearly all the second layer elements seem to have disappeared.
Beyond this there is no appreciable diminution in the number of the
nerve-cells, many of which contain a large, “ bladder-like ” nucleus, but
are otherwise normal. No groups of dark, shrunken cells noted. The
vessels show no structural alteration; veins engorged. Both in sections
stained in polychrome and those treated for phosphorus the amount of
intra-vascular clotting is very marked, and also the number of blood-
plates. It is chiefly in the capillaries and smaller vessels that the
thrombi are noticed in the form of long, hyaline cylinders, blocking up
the entire lumen of a vessel, single or aggregated spheres and granular
masses; and in the sections treated for phosphorus, the two former
varieties—and the blood-plates as well—stain dark green, and the latter
a paler green.

Not many subcortical nerve-cells seen.

Ascending frontals .—Meninges natural. The zonal layer shows no
sclerosed rim or increase of glia cells, and is not wide. Nerve-cells:
the second layer is fairly well marked; its cells, as well as those of the
other layers, have a natural appearance, except that in many cases the
nucleus is large and “bladder-like.” The Betz cells are numerous,
large, with well-marked central chromatoplasm and large (often swollen),
clear nucleus, and enlarged (7 ft) nucleolus. They all show axonal
characteristics. No pigment. Not many subcortical nerve-cells seen.

The vessels are similar to those in the prefrontal regions, and, as
there, intra-vascular clotting is a very marked feature.

Calcarine fissure cortex .—The section presents a normal appearance,
except for a small cortical haemorrhage and intra-vascular clotting (much
less marked than in the two preceding regions), which gives a positive
reaction when tested for phosphorus.

Cornu ammonis .—Beyond some increase in the number of glia cells
and shrinking and dark staining of the cells of the nucleus fasciae
dentatae and granule layer, there were no structural appearances calling
for remark.

Intra-vascular clotting, chiefly in the form of hyaline spheres and
lobulated masses, was a very marked feature. A small vessel in the
cortex of the subiculum had ruptured and was blocked up by a hyaline
mass which partially protruded through the ruptured wall, the peri-

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

vascular space was distended and filled with erythrocytes, and lying in
it was a hyaline thrombus, evidently in connection with that within the
vessel. One of the main nutrient arteries was found to be extensively
obstructed by a partially organised clot, which, in its deposition around
the inner wall, had reduced the lumen of the vessel in a very marked
degree.

Cerebellum .—Showed no structural alteration. The Purkinje cells
were large and numerous. Intra-vascular thrombi and blood-plates
in large amount, which gave a positive reaction when tested for
phosphorus.

Medulla oblongata .—The only structural alteration calling for notice
is, the shrunken and darkly-stained condition of the nerve-cells of the
olivary bodies. Intra-vascular thrombi as in other regions.

Spinal cord \—Upper cervical region. The lesion here was found to
be an angeioma of the meninges, which had ruptured and ploughed
up the posterior two thirds of the cord in an oblique direction, so that
whilst the greater portion of the right anterior cornu had escaped, the
entire left was destroyed. The cells which had escaped destruction in
the horns showed a fairly normal appearance.

The lesion in the mid-dorsal region was also found to be a small
angeioma, occupying the antero-lateral tract on the left side, and not
implicating the grey matter. It was composed of a number of dilated
spaces filled with erythrocytes, blood-plates, and clot, chiefly in the
form of clumps of fibrin threads. The walls of most of these spaces
were extremely thin, but sometimes they were thicker, and consisted
entirely of fibrous tissue, which occupied also the space intervening
between several of the blood cavities.

In the specimens stained with osmic acid the anterior forehom-cells
of both cervical and lumbar regions were heavily laden with a nearly
black pigment. The nucleolus in the cells of the lumbar region was
enlarged (8 /a).

There was no evidence whatever of any tract degeneration, recent
or old.

Remarks .—It might be suggested that the large amount of
the intra-vascular clot found in this case was associated with the
pneumonic condition, and had no relation to the epilepsy, but
this is rendered very improbable from the study of sections
from other cases not subject to epilepsy dying from pneumonia
— e.g., sections from the ascending frontal convolution, the
cornu ammonis, and the cerebellum from a woman set. 5 5 in
a state of acute mania, who died from lobar pneumonia, were
prepared in the same way and used as a control. In none of
these sections was intra-vascular clotting met with. In another
control case, an idiot without epilepsy, who died of broncho¬
pneumonia, there was a similarly negative appearance as to
clotting, with the exception of a small amount of fibrin in one
or two of the vessels.

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> 907 ]

BY JOHN TURNER, M.B.

Angeiomata .—I have met with twelve instances of this con¬
dition, all small (covering an area from size of split pea to a
sixpence), in the central nervous system. Zeigler states that
they are not uncommon in the meninges of the cord and the
brain, and that in the latter region they do not as a rule form
actual tumours, but merely small reddish specks. Virchow
suggested that they were of congenital origin.

The following table gives the sex, age, forms of insanity, and
the site of the lesion in my cases.

Three other cases in my knowledge, two reported by Drysdale
and one by Creite, all occurred in epileptics.

From this series it would appear as though epileptics were
especially prone to this condition ; and whilst ready to admit
that congenital defect may be a predisposing factor in their
production, their apparent rarity in imbeciles not subject to
epileptic fits points to the necessity of some exciting cause,
which, I suggest, is rise of blood-pressure due to an obstruction
in the blood-stream on the venous side of the circulation, lead¬
ing to enormous dilatation of the capillaries, etc.

!no.

Sex.

Age.

Form of insanity.

Situation.

Male

35.

about

Imbecile, epileptic

Pons.

1 2

? Epileptic

Spinal cord.

Female

Adolescent mania

Pons.

Imbecile, epileptic

Spinal cord and meninges
of cord.

”

Melancholia

Cerebral cortex(left parietal,)
pons.

Imbecile, epileptic

Pons.

Male

General paralysis

„

4 ^

Melancholia

Female

Acquired epilepsy

! 10

Male

General paralysis

' 11

Female

Congenital defect without

•1

Male

epilepsy

Imbecile; epileptic

Medulla and adjoining cor¬
tex of pre-frontal lobe.

Case 13.— \V. P. A —, male. A high-grade imbecile, restless and
troublesome, and during and after fits acutely maniacal. Frequent
fits. Died of colitis, set. 29 (temperature during his illness ranged from
102*8° to 99° F.).

Autopsy nine hours after death. Encephalon 1469 grm. Small
brown surface softenings of orbital lobes in the region of each olfactory
bulb. Marked sclerosis of left comu ammonis. Except for these

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

findings the brain appeared natural. Pieces from the orbital, ascending
frontal, cornu ammonis, medulla oblongata, cerebellum, and spinal cord
were fixed, some in alcohol and some in sublimate, and stained as
usual. The cord was placed in Muller’s fluid for subsequent treatment
with osmic acid.

Ascending frontal —Considerable fibroid thickening of the arachnoid;
no infiltration. The zonal layer shows embryonal nerve-cells, but other¬
wise is natural.

Nerve-cells .—The second layer is ill-defined, owing to the small
number of its cells, and there is some diminution in the number of
pyramids in the outer half of the third layer. The cells generally are
shrunken and darkly stained with the exception of the Betz cells,
which are numerous, large, with well-defined peripheral chromatoplasm,
and clear, laterally disposed nucleus (congenital form). Most of them
contain, for a man of his age, a large amount of yellow pigment.

In the sections treated for phosphorus the degenerated pyramids
stand out clearly in groups, staining all over (nucleus and cytoplasm) a
dark green.

Vessels as usual. A small cortical haemorrhage noted. Blood-
plates numerous, and considerable amount of intra-vascular thrombi,
which stain dark green in Macallum preparations.

Numerous sub-cortical nerve-cells.

Cornua ammonis .—On the atrophied (left) side the cells of the
dentate fascia are extremely degenerated, few and shrivelled ; on the
other side they appear fairly healthy. There is also an increase of glia-
cells in the left dentate fascia. Intra-vascular clotting as in the pre¬
viously described region.

Orbital convolution .—In the olfactory groove the meninges were
thickened, and contained a number of large brown granule-cells. The
adjacent cortex was destroyed, and granule- and glia-cells were present,
the latter in large number. The vessels for the most part were col¬
lapsed and lying in wide spaces. Not much coagulum noted.

Medulla oblongata. —Hypoglossal cells natural; olivary body cells
degenerated. Coagula as in other regions.

Cerebellum. —No special alterations to note except degeneration and
diminution in number of Purkinje cells. No Bergmann’s fibres seen.
No atrophied foliae. Clot in vessels quite a marked feature.

Spinal cord. —Meninges show fibroid thickening and extravasation
of erythrocytes. Anterior cornua cells somewhat contracted and dark,
but show a fairly good stichochrome aspect; not much pigment. The
nucleolus is often large (8—9 /1). The central canal is patent.

In sections stained with erythrosin the columns of Goll in the cervical
region are perceptibly darker than those of Burdach. Quite a large
amount of intra-vascular clot noted. In preparations stained in osmic
acid there was no evidence of any recent degeneration, and save for a
slight pallor in the middle zone of the posterior internal columns in
the lumbar region no signs of old degeneration. This pallor appeared
to be due to a paucity in the number of myeline fibres, with a corre¬
sponding increase of the connective tissue of the matrix.

Case 14 . —A. H. O —, female. An idiot (deaf, dumb, and unable to

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1907-] BY JOHN TURNER, M.B. 2J

articulate); was able to walk in a very imperfect way. Would scream for
hours together. Had a great number of fits, both single and serial, and
occasional attacks of petit mal ’ Died in status epilepticus (temperature
100*4° falling to subnormal), aet. 34.

Autopsy eight and a half hours after death. In places the cortex
of the left prefrontal and right parietal had a mottled and ill-defined
aspect General shrinking of the convolutions; sclerosis of the left
cornu ammonis and the olives. Cerebellum and cord very firm and
tough. Encephalon 945 grm.

When microscopically examined the liver and kidneys were found to
be in a state of marked fatty degeneration. Pieces from the ascending
frontals, right parietal, cornu ammonis, medulla oblongata, cerebellum,
and spinal cord were fixed, some in alcohol, and some in sublimate, and
stained as usual. The spinal cord was put into Muller’s fluid for later
examination.

Ascending frontals .—Considerable fibroid thickening of the arachnoid
and a foam-like epicerebral exudate; in places a noticeable infiltration
with large lymphocytes. The zonal layer on the left side shows a
slightly raised granulation (600/x long and 60/x deep) containing a
number of glia cells with small, dark nuclei. Elsewhere there is no
appearance of a sclerosed rim, and the glia nuclei throughout the layer
are few. Embryonal nerve-cells seen. On the right side it appears as
though there were several shallow sulci which had fused by their
adjacent surfaces, and over which the meninges pass. On both sides,
in many places, this layer appears very wide, probably owing to dis¬
appearance or absence of second layer cells. The nerve-cells on the
right side seem more numerous than on the left, and on the right side
the Meynert’s striae are not well defined. As usual, one sees single cells
or groups of degenerated, darkly stained cells, and others with a more
natural aspect or with a large clear “ bladder-like ” nucleus. The Betz
cells are few in number, contain an excess of yellow pigment, some (the
minority) are small and darkly stained, but they all show the usual
axonal character.

There is a somewhat marked proliferation of pericellular nuclei
around the spindle-cells on the right side.

Subcortical nerve-cells very numerous.

Vessels .—The walls of the arteries are thickened, the veins enor¬
mously engorged. Intra - vascular thrombi, chiefly in the form of
hyaline spheres and masses, present in large number, and, in some
places, almost every capillary contains a plug. In sections treated for
phosphorus this clot and also the degenerated nerve-cells stain dark
green.

Right parietal .—Meninges as in ascending frontal region. Extra¬
vasation of erythrocytes. The surface of the zonal layer shows a
patchy, sclerosed rim, and in places distinct buds of glia tissue
(50—150/i. deep) with numerous nuclei. In other parts there is no
appearance of increase in the glia-cells.

Meynert’s striae are quite indistinguishable, and the first layer has a
very extraordinary configuration. It apparently dips down in places
into the cortex, so that its two edges join and fuse together. And it
can be traced as a cell-free band pursuing a most serpentine course

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

throughout the entire depth of the cortex, and bordered thickly on
either side by nerve-cells indistinguishable from the ordinary cells of
the second layer. The remaining cells of the cortex are scanty and to
a large extent shrunken and degenerated.

Vessels .—There is an enormous engorgement of the veins, and cortical
haemorrhages are present, but intra-vascular clotting is not marked.

Cornua ammonis .—Meninges as in preceding region. The nerve-
cells of the pyramidal stratum show a fairly good appearance, and no
decided diminution in numbers. The granules are diminished in
number, and this layer is beset with large-bodied glia-cells.

The vessels contain a fair amount of intravascular clot. In sections
specially stained for neuroglia by Beneke’s methylene violet method

Case 14. —Showing the appearance of the right parietal cortex under a low
magnification. The dotted lines enclose the zonal layer which is con¬
tinued in a circuitous course throughout the entire depth of the grey
matter.

there is seen to be a marked proliferation of glia elements, and a
sclerosed rim to the ventricular surface in the region of the dental
nucleus. The glia cells vary in size from 60 /a to 24 /a. Their body
assumes a pale rose tint, and their branches, which are very sharply
defined, a dark red or purple.

Medulla oblongata .—The only features calling for remark were the
degenerated condition of the nerve-cells of the olivary bodies and the
increase of small glia-cells and fibres, here and in the marginal portions
of the anterior half of the medulla.

Cerebellum .—In the section examined there is general atrophy of the
foliae, with fibrillar condition of the molecular layer, disappearance of
Purkinje cells, and great diminution in the number of granules. The
meninges are thickened, and there is a considerable extravasation of
erythrocytes in them.

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1907.]

Spinal cord. — Meninges and extravasated erythrocytes as in the
cerebrum. Many of the forehom cells, especially in the lumbar
region, show an axonal character; the cells contain a considerable
amount of yellow pigment, which stains black with osmic acid. The
central canal is patent in the cervical region, obliterated in the lumbar.
In the former region a small neuroglial bud is seen projecting into the
lumen. Numerous small punctate haemorrhages into the forehorns.
There was some atrophy of the left side of the cord, associated with old
degeneration of the crossed pyramidal tract. No other tract degenera¬
tion noted.

Remarks .—I would draw attention to the fact that in the
regions specially stained for glia elements, and which showed
the proliferation of cells and fibres, a similar condition could
be seen, but not quite so distinctly, by the ordinary methods.

Case 15.—A. K—, female, a medium-grade imbecile, with dorsal
curvature and torticollis. Able to do simple household work. Had
single and serial attacks of grand mal nearly every day. Died,
set 24.

Autopsy four and a half hours later. Encephalon ni4grm. The
cerebrum appeared natural. The upper surface of each lateral lobe
of the cerebellum was sclerosed and atrophied.

There was atrophy of the right anterior horn in the upper dorsal
region (only).

No very evident cause of death was discovered. There was some
quiescent tubercular lesion of one lung. The liver and kidney were
fixed in alcohol and treated for phosphorus. The former showed
marked evidence of intravascular clotting, the latter none. Structurally
both organs were natural.

Pieces from ascending frontals, upper lobes of cerebellum and spinal
cord were fixed in alcohol and stained as usual.

Ascending frontals .—The zonal layer was bordered by a continuous
thin (30 ft) sclerosed rim, containing only glia fibres. In other parts of
the layer the glia-cells were increased.

Nerve-cells .—The second layer was ill defined, owing probably to
diminution in numbers of its elements. The striae of Meynert were
not well defined. The cells generally were either small and darkly
stained with dense nucleus, or else pale and with clear or swollen
nucleus.

The Betz cells were numerous ; all showed the usual axonal character¬
istics, and the majority were large, pale, and rather heavily pigmented,
with a clear and swollen nucleus. A few were rather darkly stained
and shrunken.

There was a noticeable increase of pericellular and perivascular
nuclei in all the layers, and erosion of the nerve-cells.

The vessels presented the usual appearance as to distension, but very
little clot was seen, which was most marked as a green, granular material
in those sections treated for phosphorus by Macallum’s reagent.

Cerebellum. — The foliae were atrophied and the Purkinje cells

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

diminished in number, but those present were generally large and
pale, with scarcely any chromatoplasm and an eccentric, clear nucleus
(axonal characters).

Bergmann’s fibres were visible. The granules were few. The larger
vessels in the white matter showed a considerable amount of granular clot.

In quite a localised region of the atrophied part—an area only a few
mm. square—in the granular layer and one of the roof nuclei there
were, as seen in unstained sections, numbers of highly refractive round
bodies, single or in clusters, looking exactly like air-bubbles. When
tested with hydrochloric acid these partially dissolve, but do not
completely disappear, even if left in the acid for twenty-four hours.
If sections which have been subjected to hydrochloric acid are
stained with erythrosin and toluidin blue, these bodies stain very
nearly black (Fig. 3), the smallest (1 fi) up to the largest alike; but
in sections not previously treated with the acid it is only the small ones
which stain darkly, the larger masses colour a pale blue and exhibit
concentric markings and sometimes radial fractures (Fig. 4). From
these appearances 1 infer that the larger masses have undergone more
or less calcareous change, which prevents them from staining till the
lime has been removed by the hydrochloric acid. In sections treated
with acid and then stained by Macallum’s method the bodies all stain
a dark green, showing that they contain phosphorus and indicating
their nucleo-proteid nature.

This material lies alongside small blood-vessels and capillaries,
forming sometimes for some distance an outer cast to a capillary.
It is probably a transudation from the blood, and seems to represent
a somewhat earlier stage of the same vitreous process that was seen in
the cortex of Case No. 8.

Spinal cord . — Anterior horn-cells show a normal stichochrome
appearance in the cervical region, but in the lumbar a fair number
(7 or 8 in each horn) show axonal characters. No pigment.
Nucleus large and clear. The central canal is patent in the upper,
nearly obliterated, and with proliferation of its lining cells in the
lower region.

There were no signs of tract degeneration, either recent or old.

Case 16. —S. M—, female, mother of eight children, became first
insane (melancholy) when thirty-four. Only subject to occasional single
epileptic fits for the last two years of her life. Between fits was a quiet,
industrious woman. Died in status epilepticus aet. 51.

Autopsy twenty-eight hours after. Encephalon 1140 grammes.
Basal vessels bulky and atheromatous. Marked atrophy of convolu¬
tions in both frontal and parietal lobes.

Some small old softenings in right thalamus, left lenticular nucleus
and a recent small softening in left caudate nucleus. Ventricles dilated.
Both cornua ammonis sclerosed, pons small and firm. The liver showed,
microscopically, increase of interstitial tissue and fatty degenera¬
tion, with marked thickening (all coats) of the arteries. The kidneys
also showed increase of interstitial tissue.

Pieces of the prefrontal, ascending frontal, and pons were fixed in
sublimate and stained in the usual way.

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1907 .]

3 1

Prefrontal. —Some fibroid thickening of the meninges in places and
slight infiltration with large lymphocytes. Well-marked, foam-like
epicerebral exudate. There is hyaline thickening of the arterial walls,
and many vessels show very marked endarteritis (signet ring form).
The zonal layer appears natural and shows no sclerosed rim.

Nerve-cells. —There appears to be in patches here and there a diminu¬
tion in the number both of the second layer-cells and the pyramids.
Many of the cells are shrunken and darkly stained, with homogeneous
degeneration of the nucleus. No swollen nuclei observed. The cells
are not rounded, but often stunted and with few branches. There is
some proliferation of pericellular nuclei.

Vessels. —No marked engorgement, no structural alterations. Quite
a large number of blood-plates and hyaline spherical thrombi.

Numerous subcortical nerve-cells.

Ascending frontals. —Meninges similar to above. Extravasation of
erythrocytes. The zonal layer shows a sclerosed rim (45 /a) and
definite granulations which seem in places to have grown into the
membranes.

The Meynert’s striae are well defined, and there is no appreciable
diminution in the number of cells. Second layer fairly well defined.

Throughout the cortex are degenerated (darkly stained) cells and
groups of cells. The Betz cells are numerous, mostly shrunken and
heavily pigmented. They stain with toluidin blue, a uniform dull
colour (no chromatoplasm), some pale, others dark. Nucleus generally
clear. They are in the condition generally termed “ pyrexial ” (although
it should be noted that this woman's temperature did not rise above
ioo° F.), or by Marinesco, coagulation necrosis.

Vessels. —Veins engorged, arteries tortuous and collapsed. No
marked evidence of intra-vascular clot.

Subcortical nerve-cells not numerous.

Medulla oblongata. —Very marked endarteritis of meningeal arteries.
Granulations on the floor of the fourth, remote from the central line.

No marked evidence of clotting. The cells of the olivary nucleus
were pigmented and degenerated.

Case 17.—M. P—, female, a high-grade imbecile, active and well-
nourished, subject to very frequent and strong fits since birth. Died in
status epilepticus, aet. 25.

Autopsy thirty hours after. Encephalon 1192 grm. Sclerosis of left
cornu ammonis, otherwise no abnormal appearances. A small recent
haemorrhagic infarct in apex of left lung, otherwise the thoracic and
abdominal organs appeared natural.

Pieces from the ascending frontals and from the region of the
calcarine fissure were fixed in sublimate and stained as usual.

Ascending frontals. —Beyond extravasation of erythrocytes and the
presence of the epicerebral exudate there was nothing calling for notice
in the meninges. A very thin sclerosed rim, and slight increase of glia-
cells in the zonal layer of one side.

Nerve-cells. —Meynert’s striae were not well defined. The cells of the
second layer appeared fairly normal, but those lying lower showed
marked pathological change. They were shrunken, distorted with a

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32 ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

wide pericellular space, and the description to be given of the Betz cells
applies to the smaller pyramids. Betz cells, distorted and degenerated,
showed no chromatoplasm ; with erythrosin and toiuidin blue the cyto¬
plasm stained a diffuse, blurred purple. There was excess of yellow
pigment. The nucleus was small, dense, and peripheral, and stained
uniformly red. In the final stage of degeneration nothing but a shape¬
less mass remained, which had a pale, hyaline centre and a dark rim.
The nucleus was solid and shrunken up, scarcely larger than its con¬
tained nucleolus. There were one or two larger and better shaped cells
which were pale, and showed Nissl granules at their edges ; these pos¬
sessed large, clear, lateral nuclei. Evidently the majority originally
showed the axonal form, but this had been masked by subsequent
pathological changes. No marked proliferation of perivascular nuclei.

Vessels .—Great engorgement of veins and capillaries, arteries col¬
lapsed and tortuous. Only a small amount of intra-vascular clot, in
the form chiefly of hyaline spheres.

The cells of the cortex in the calcarine region were very similar but
less markedly affected. No other changes calling for remark.

Case 18.—E. E. P—, female. A low-grade imbecile, active and
spiteful, unable to attend to herself. Subject to frequent and severe
fits, in one of which she died, aet. 25, having been in good health and
condition on the previous day.

Autopsy three and a quarter hours after death. Encephalon weighed
1022 grammes. The meninges were thick and opaque at the vertex,
and over the prefrontal lobes there were deeply congested areas.
Marked atrophy of the convolutions at the vertex and in prefrontal
region. Both cornua ammonis were sclerosed.

Microscopically the liver showed some increase of interstitial tissue
and slight fatty degeneration. The kidneys showed small cysts, but
apart from these their tissues appeared healthy.

Pieces from the prefrontal and both ascending frontal and medulla
oblongata were fixed in sublimate and stained as usual.

Prefrontals (from congested area noted above).—Extensive extravasa¬
tion of erythrocytes. Veins enormously engorged and contain granular
and hyaline clot. No thickening or infiltration.

There is a thin (20—30 /a) sclerosed rim to the zonal layer in places,
and a marked increase of small glia-cells and fibres. Embryonal nerve-
cells present.

Nerve-cells .—The second layer is well defined and its cells have
generally a large clear nucleus. The pyramidal cells are in fair number,
and they also usually contain a swollen “ bladder-like ” nucleus. Only
a very few darkly stained shrunken forms ; little groups of these lie
close to little groups of cells with the swollen nuclei. Some excess of
pericellular nuclei about the spindle-cells.

Vessels .—Engorgement of veins and capillaries. The latter in places
are crowded with emboli in the form of cylinders of hyaline material.
Blood-plates numerous. A small capillary haemorrhage noted.

Ascendingfrontals .—Meninges as above described. The zonal layer
shows no sclerosed rim and a fewer number of glia elements.

The nerve-cells of the second and pyramidal layers are similar to

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BY JOHN TURNER, M.B.

190/.]

those in thfc prefrontal section. Especially noticeable are the swollen
“bladder-like” nuclei. The cells in the outer part of the third layer
are few in number.

Betz cells, large and in fair number. The majority show the axonal
form and contain an excess of yellow pigment There is a marked
increase of the pericellular elements. Numerous subcortical nerve-cells.

Vessels similar to those in the prefrontal section. Numerous small
cortical haemorrhages seen. Some sections show many capillaries
blocked up and even distended by long hyaline clots, others show very
few or none.

Medulla oblongata, — Many small capillary haemorrhages in the
regions of the hypoglossal and vagi nuclei. The hypoglossal cells are
rather small and stain darkly with toluidin blue, but the stichochrome
arrangement of their chromatoplasm is still observable. The nerve-
cells of the olivary nucleus are small, distorted, darkly stained, and
pigmented.

Case 19.—J. F—, male. A high-grade imbecile, subject to very
frequent fits since four years old, sometimes as many as fifty-five a
month (day and night).

Character of fits .—If standing, generally fell backwards and kicked
up his legs, if sitting would fling his legs up and sometimes turn a
somersault over the back of the chair. Troublesome and violent.
Developed pulmonary tubercle and died aet. 22.

Autopsy twenty hours after death, head and spine only examined.
Microgyri in parts of ascending frontal, ascending parietal, and occipital
gyri. No atrophy of convolutions. Sclerosis of cornua ammonis, most
marked on the right. Encephalon weighed 1238 grm.

Pieces from the prefrontal, ascending frontal, calcarine fissure, cornu
ammonis, cerebellum and spinal cord were fixed in alcohol and stained
as usual The cord was put into Muller’s fluid for further examination.

Right prefrontal.- In one place the meninges show a marked infil¬
tration with lymphocytes, chiefly of the small variety. No engorgement
of veins seen. A foam-like epicerebral exudate is present The zonal
layer appears normal.

Nerve-cells .—The majority are darkly stained and shrunken with a
small, dark, solid nucleus with, in many cases, a clear areola between
it and the cytoplasm, (these cells stain dark green with Macallum’s
test for phosphorus,) and lie in wide spaces. They have a stunted
appearance with few branches, and are diminished in number.

Vessels .—No structural alterations to notice. Blood-plates numerous
and hyaline clots also seen, in one case blocking up a small venule as it
dips into the cortex from the membranes. Subcortical nerve-cells well
marked.

Ascending frontals .—There is some fibroid thickening of the meninges
and infiltration with lymphocytes. A thin, sclerosed rim to the zonal
layer and a minute bud of glia elements. No marked increase of glia-
cells in the rest of the layer. Embryonal nerve-cells noted.

Nerve-cells .—Meynert's striae very well defined. The cells of the
second layer are in fair number. The outer half of the pyramidal layer
is scanty, and the individual forms are stunted and with few branches.
LIII. 3

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

The majority are darkly stained and shrunken, and with a dense
irregular nucleus. They lie in wide spaces.

The Betz cells are very numerous and show axonal characteristics.
They stain uniformly, and their chromatoplasm is in dust-like particles.
They show, superadded to their congenital characteristics, the so-called
pyrexial or coagulation necrosis (Marinesco) change. The bulk are
large and pale, with a swollen “ bladder-like ” nucleus (see Fig. 5), but
intermixed with these are a good number of darkly-stained shrunken
forms, with a small dense nucleus. They contain no pigment.

Vessels, as in prefrontal sections, containing a noticeable amount of
intravascular thrombi and numerous blood-plates. Subcortical nerve-
cells numerous.

Right calcarine fissure cortex. —Convolutions small, cells as in pre¬
ceding regions. No increase of glia noticed. Vessels as just described.

Cornua ammonis .—As usual, the more pronounced rim of sclerosed
tissue and the greater exuberance of glia-cells is on the less sclerosed
and atrophied side. There is shrinking and diminution in the number
of the cells of the nucleus fasciae dentatae, both granules and pyramids.

The vessels and their contents do not differ from those in the
previously described regions.

Right lateral lobe of cerebellum (upper surface).—Fibroid thickening
of the meninges over the surface. No infiltration. Enormous engorge¬
ment of veins, and in one place one of these had ruptured. No
appearance of Bergmann’s fibres.

Purkinje cells. —Fair number, and the majority are of good size and
normal appearance, with round, clear, central nucleus. A few darkly-
stained, shrunken forms occur in groups. One small atrophied folium
observed.

Fibrin and other forms of coagulum found in abundance in the vessels.

Spinal cord. —Nothing special to notice in regard to the anterior
cornual cells. Central canal obliterated. The only tract degeneration
noted was a symmetrically-disposed oval patch divided by the posterior
fissure, which was well marked in the upper cervical and lower dorsal
regions, but not appreciable (in Weigert preparations) at the lumbar
enlargement.

Case 20.—H. P—, female. A low-grade imbecile. Fits very seldom,
but very severe. Was in bed with general dropsy for some months
prior to death. Died, set. 24, of chronic Bright’s disease.

Autopsy seventeen hours after death. Encephalon 1150 grammes.
The brain was anaemic, but otherwise showed no pathological appear¬
ances. The kidneys were small, very pale and tough, and capsules
thickened.

Microscopical examination verified the chronic Bright’s condition.
The liver showed no pathological changes microscopically.

Pieces from the prefrontals, ascending frontal, medulla oblongata, and
cerebellum were fixed in alcohol and stained as usual.

Prefrontals .—Meninges natural, except for thickening of the muscular
wall of the arteries. Zonal layer wide ; no increase of glia.

Nerve-cells. —Those of the second and outer half of the third layer
were few in number. The cytoplasm was scanty and ghost-like. The

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BY JOHN TURNER, M.B.

1907.]

nucleus small and solid-looking, but quite round; it appeared to have
shrunk from the cytoplasm, so that it was surrounded by a clear space.
Here and there were groups of very shrunken, darkly stained cells.

Vessels. —The walls of the arteries were somewhat thickened. The
veins were engorged and contained a marked amount of hyaline clot.

Ascending frontal. —No special changes in meninges or zonal layer.

There is a marked diminution in the number of nerve-cells, chiefly in
the outer half of the cortex. The individual cells are in a similar con¬
dition to those in the prefrontal region. The Betz cells are numerous,
and show the usual axonal characteristics, on which apparently have
been superimposed later pathological changes. They are large, stain
with polychrome blue an uniformly pale colour, with practically no
chromatoplasm. In many, semicircular pieces appear to have been
scooped out from their border, in the concavity of which a small,
darkly stained nucleus lies free (phagocyte).

The nucleus, which is pushed up to one side, is sometimes clear and
round, but more often very small and solid-looking. There is no
pigment in these cells.

Vessels. —As in the prefrontal section. Blood-plates numerous.

Medulla oblongata .—This region was specially stained for glia ele¬
ments by Beneke’s methyl violet process, but showed no marked
increase.

Cerebellum .—Meninges natural. No Bergmann’s fibres visible in
the molecular layer. The cells of Purkinje are probably diminished in
number. The majority are small and darkly stained.

There is a marked amount of hyaline and granular clot and numerous
blood-plates, which give the usual degrees of green colour when treated
for phosphorus.

Case 21.— M. A. S—, female. A married woman, typical epileptic
disposition. No history as to when her fits originated; was subject to
frequent and severe fits. She was resident in the asylum twelve years,
and gradually became quite demented.

Died in status epilepticus at the age of forty-six; her temperature
during the attack rose to 103*4° F., and fell to 99° F. just before death.

Autopsy three and a half hours after death. Well nourished. Ence¬
phalon 1129 grra.

Enormous (nearly half an inch) jelly-like, milky-white thickening of
the meninges, in which the engorged veins stood out nearly black.

Corresponding atrophy of the convolutions (chiefly ascending frontal
and parietal) beneath ; very little atrophy or visible change in the
membranes at the prefrontal and occipital poles; ventricles dilated.
Both comua atrophied, the left very firm.

Some stenosis of the mitral valve.

The kidneys were tough, with diminished cortex, and microscopical
examination of these organs and the liver showed extensive fatty
degeneration.

Pieces from the ascending frontal and the cerebellum were fixed in
sublimate and stained as usual.

Ascending frontal. —The thickened meninges consisted of a loose,
fibrous meshwork containing numerous large lymphocytes, chiefly lying

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

in the neighbourhood of the convolutions. The adventitial and mus¬
cular coats of the arteries were thickened. The zonal layer showed a
marked proliferation of large glia-cells, and its surface was sclerosed and
raised into granulations.

The nerve-cells generally were shrunken, distorted, and stained deeply,
and the nucleus also. The Betz cells did not show the axonal characters,
but they were so darkly stained and shrunken that it was difficult to
form a very exact idea of their original configuration.

Vessels .—There was some thickening of the arteries and tortuosity,
the usual venous engorgement and abundance of hyaline clot, which, in
many instances, was found blocking up the capillaries. Golden pigment
was deposited in some of the perivascular spaces. No marked increase
of subcortical nerve-cells.

Ce?ebellum .—The meninges were thickened over the atrophic foliae,
and showed marked infiltration, with large lymphocytes and a few
polynuclears. In other parts they appeared natural.

The tops of four of the foliae presented small, wedge-shaped atrophic
areas of degeneration, the apex of the wedge lying in the granular layer.
Here, and here only, there was a marked proliferation of glia-cells and
disappearance of the nervous elements. Compound granular corpuscles
were scattered over the affected region, especially alongside the vessels
(see Fig. 6). The cells of Purkinje were numerous, large, and pale,
with, in many cases, well-marked Nissl granules around their periphery.
The hyaloplasm of the cells had taken on the stain (polychrome). The
nucleus was rather small and crumpled, denser than normal, and pushed
up to one side (axonal form). A few scattered, darkly stained, shrunken
forms were met with. In the section with the atrophic foliae the cells
showed more advanced changes; there was here practically a total
disappearance of the chromatoplasm, and the cell was stained an uniform
dull, dark blue, colour (acute cell change; coagulation necrosis).

Deposition of hyaline clot giving a positive reaction for phosphorus
and blocking of the capillaries with the same was a marked feature,
especially in the neighbourhood of the degenerated foliae.

Remarks .—The small, well-demarcated, wedge-shaped areas
of atrophic degeneration at the summit of some of the cerebellar
foliae point strongly to their vascular origin, and the presence
of the cylindrical coagula, occluding the smaller vessels, offers
a plausible explanation as to the means whereby these areas
would be deprived of their blood-supply, and thus reduced to
the condition they were in.

Case 22. —S. H—, female, a widow, probably imbecile. Had been
subject to fits all her life, but during her residence in the asylum (over
two years) was not known to have had any. She was demented and
unable to attend to herself. Died jet. 53, of colitis.

Autopsy thirty-five hours after death. Fairly nourished. Encephalon
weighed 1133 grm. and showed no naked-eye changes. On micro¬
scopical examination the kidneys appeared fairly healthy, but the liver

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BY JOHN TURNER, M.B.

1907.]

showed marked fatty degeneration. No clot was noted in the vessels of
either viscus.

Pieces from the ascending frontals and the left cornu ammonis were
fixed in alcohol and stained as usual. The spinal cord was placed in
Muller’s fluid for further examination.

Ascending frontals .—The zonal layer appeared natural. There was
a marked deficiency of the nerve-cells in the second and the outer
half of the third layers. The majority showed no appreciable patho¬
logical changes, but scattered about were the usual groups of
degenerated cells.

The Betz cells were large and numerous, and showed the usual axonal
characteristics. They were heavily pigmented. On the left side many
were distorted, shrunken, and darkly stained.

Vessels .—The usual condition as to distension was present; although
no massive clot was seen, most of the vessels contained clusters of dark
green (phosphorus reaction) hyaline bodies, varying from 4 to 20 fi in
diameter. A cortical haemorrhage was noted.

Left cornu ammonis .—No appearance of gliosis. The nerve-cells
appeared natural Intra-vascular clot as in preceding sections and also
in the form of granular massive deposits. Some fibrin.

Spinal cord . — Naked-eye inspection of transverse sections after
hardening in Muller’s fluid, showed a pale, thin, oval area lying in
the columns of Goll over the middle half of the posterior fissure. The
fissure divided this area into two fairly symmetrical halves. In Weigert
preparations this area corresponded to a great paucity (but not complete
absence) of myelin fibres. It was visible in sections from the cervical
to the lumbar region, and occupied the same position close to the fissure
at all levels. It was not appreciable in osmic acid preparations.

Case 23.—H. P—, male. A low-grade imbecile, subject to frequent
and severe fits since 18; three or four every week, chiefly in the
daytime. Died aet. 26, of lobar pneumonia.

Autopsy four hours after death. Poorly nourished. Encephalon
1235 grm.

Beyond the pneumonic condition of the right lung the viscera
appeared healthy.

Pieces from the ascending frontals, the cornua ammonis, the cere¬
bellum, and the spinal cord were fixed in alcohol and stained as usual.
The cord was placed in Muller’s fluid for further examination.

Ascending frontals .—Meninges natural. A slight increase of glia
cells in zonal layer, no sclerosed rim. The second layer is ill-defined
with small dark cells (staining dark green when treated for phosphorus),
and the small and medium-sized pyramidal cells are of the same
character. The Betz cells are large and numerous with axonal
characteristics. They generally contain a large clear nucleus. There is
a marked increase of pericellular elements in the inner layers of the cortex.

Vessels .—A small cortical haemorrhage present. The vessels present
the usual characteristics as to distension. There is a moderate amount
of intravascular clotting, generally in the form of granular material:
sometimes this is broken up into patches, and the centre of the patches
stains dark green with the phosphorus test, whilst the border stains pale

Digitized by v^ooQle

38 ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

green. Possibly this represents a stage in the resolution of the clot.
Some fibrin masses are also present.

Cornu ammonis shows the usual shrunken and degenerated nerve-
cells. Intra-vascular clot more abundant than in the ascending frontal
sections. Blood-plates numerous. A small cortical haemorrhage. No
increase of glia.

Cerebellum. —No special pathological features noted beyond the
usual sparsity of the Purkinje cells and their shrunken, degenerated
condition. Clot as in the preceding sections.

Spinal cord. —Some fibroid thickening of the meninges and rupture
of vessels. The anterior cornual cells show a good stichochrome aspect,
contain very little pigment, and their nucleus is clear and central, some¬
times swollen. The central canal is patent.

The cord, after hardening in Muller’s fluid, showed on transverse
section a pale, oval patch in the middle of Burdach’s column, more
marked on the right side and only visible in the cervical region. There
was also some pallor of the crossed pyramidal tracts. On microscopical
examination after osmic staining, the oval patch, only visible in cervical
section, showed not only old but also recent degeneration (Marchi
reaction).

There was considerable old and recent degeneration in both crossed
pyramidal tracts, most marked in the cervical region and least in the
lumbar. In the direct cerebellar tract of (?) right side in both cervical
and dorsal regions (chiefly the latter), there was recent degeneration
shown by the usual Marchi reaction.

Case 24.—T. E—, male. A high-grade imbecile, sufficiently intelligent
to earn his living at a jute factory before his admission to the asylum.
Subject to frequent and strong fits, before and after which he was for
some time maniacal. Worked in the asylum at hair-picking, and died
jet. 35 of pulmonary tubercle.

Autopsy seven hours after death. Fairly nourished. Encephalon
weighed 1253 grm. Except for the tubercular condition of the right
lung the other viscera were apparently healthy.

Pieces from the ascending frontals and the medulla oblongata were
fixed in sublimate and stained as usual.

Ascending frontals.— Some slight fibroid thickening of the meninges
and slight thickening of the muscular wall of the arteries.

There was a marked increase of glia-cells in the zonal layer and in
places a thin sclerosed rim.

Nerve-cells. —The second layer was well marked, its cells being fairly
normal. There did not appear to be any diminution in the number of
the cells of the third layer. The prevailing type of cell-change in all
the layers is that characterised by a swollen and “ bladder-like ” nucleus.
The Betz cells are large and numerous, presenting the axonal type. A
few are darkly stained with dense nucleus. Some slight excess of
yellow pigment.

Considerable increase of nuclei in the pericellular spaces. Subcortical
nerve-cells numerous.

Vessels. —Veins and capillaries engorged ; these latter are surrounded
by an increase of perivascular nuclei. There was a very marked

Digitized by v^ooQle

1907]

BY JOHN TURNER, M.B.

amount, especially in some areas, of hyaline clot, chiefly in the form
of cylindrical emboli, blocking up the capillaries and smaller veins.
Blood-plates numerous.

Medulla oblongata. —The nerve-cells of the hypoglossal nucleus are
not axonal. They present a good stichochrome appearance, but some
are very dense. The vessels, in respect to emboli, are similar to those
of the ascending frontal region.

Case 25.—R. J —, female. Probably weak-minded from birth;
stated to have had “ sensations ” {petit tnal) for ten years. Was only
resident in the asylum a month, appeared quite demented, and was
subject to frequent attacks, both grand and petit mal. Died, aet. 57,
of granular kidneys.

Autopsy five and a half hours after death. Encephalon 1200 grm.
There was considerable atrophy of the brain, chiefly in the parietal
lobes. The lateral ventricles were dilated. No sclerosis of cornu
ammonis. Some pneumonic patches in lower lobe of right lung.
Kidneys small and granular.

Pieces from the ascending frontals, cornua ammonis, cerebellum, and
spinal cord were fixed in alcohol and stained as usual; the cord was
put into Muller’s fluid for further examination.

Ascending frontals. —Meninges. The arteries were thickened (muscular
and inner coats), and on one side there was some fibroid thickening of
the meninges and infiltration with large lymphocytes. Some slight pro¬
liferation of glia-cells in the zonal layer.

Nerve-cells. —Second layer badly defined, and in places scarcely
visible. The cells in it were in most cases very shrunken and darkly
stained (dark green when treated for phosphorus), but here and there
was a pale cell with swollen nucleus. The outer half of the third layer
consisted chiefly also of shrunken, degenerated elements. The nerve-
cells of the inner half were in a more natural condition. The Betz
cells were numerous, and the majority showed the axonal condition.
A small amount of pigment present The nucleus clear and plump.

There was a marked pericellular infiltration in the inner layers, and
also about the smaller vessels and capillaries in this region.

Vessels showed the usual appearances, with a moderate amount of
intravascular clot (granular and hyaline bodies), and accumulations of
blood-plates.

Only a few subcortical nerve-cells observed.

Cornua ammonis. —Small granulations on the ventricular surface.
The nerve-cells appeared fairly healthy, and there did not appear to be
any paucity in the number of granules or pyramids. Large glia-cells
with large (10 ft) clear nuclei were numerous in the nucleus fasciae
dentatae, and could be seen lying among the granule cells.

Vessels. —As in the preceding sections. Ruptured vessels with extra-
vasated erythrocytes seen on both sides.

Cerebellum. —Nothing special to note, except that the cells of Purkinje
were in fair number, and in many instances showed axonal character¬
istics. Contents of the vessels as in the preceding regions.

Spinal cord. —In the lumbar region, which was the only one examined
for cell detail, there was considerable fibroid thickening of the meninges,

Digitized by

Google

AN ATOM Y AND PATHOLOGY OF EPILEPSY, [Jan.,

and a copious foam-like exudate around the vessels. The central canal
was patent. The anterior horn-cells contained excess of pigment; they
presented a normal stichochrome appearance. In some cases the
nucleolus was enlarged (io /a). A large number of round hyaline
bodies (9 to 10 ft) were present in the posterior horns and in lesser
number in the anterior. They often showed a radial fracture, and in
sections treated for phosphorus they stained a distinct green colour.
Similar bodies were also observed in the cornu ammonis.

As regards tract degeneration, there was visible to the naked eye,
after hardening in Muller’s fluid, distinct pallor of Goli’s columns in both
cervical and lumbar regions. Osmic acid preparations showed that in
this situation there was a deficiency of myeline fibres. No recent
degeneration. There was also in the position of the crossed pyramidal
tracts a pallor due to deficiency of myeline fibres.

Case 26. —A. M—, male. A low-grade imbecile, has somewhat
frequent and strong fits, chiefly during the day. They occur singly.
Died set. 14, and at the autopsy no obvious cause of death was found.
He had had a strong fit four days previously, and since then his tem¬
perature had been subnormal.

Autopsy sixteen and a half hours after death. Body emaciated.
Encephalon 1104 grm.

The meninges were somewhat opaque over the sulci and at the vertex,
and at the top of the left ascending frontal there was a thick, opaque
plaque. The left ventricle was slightly dilated and the left cornu
ammonis atrophied and firm.

The thoracic and abdominal viscera appeared healthy, and the kidney
and liver were both examined microscopically but showed no patho¬
logical appearances, and were negative as to intravascular thrombi.

Pieces from the ascending frontals, the cornu ammonis, the cere¬
bellum, and the spinal cord were fixed in alcohol and stained as usual.
The cord was hardened in Muller’s fluid for further examination.

Ascending frontals .—Marked fibroid thickening of the meninges and
in places very considerable infiltration with large lymphocytes. The
zonal layer is wide and contains an increase of glia-cells but shows no
sclerosed rim.

Nerve-cells .—The second layer is ill-defined and individual cells are
shrunken and with dark angular nuclei. There is some diminution in
the number of cells in the outer half of the third layer, and the great
majority are shrunken and with darkly stained small nuclei. The Betz
cells are large and numerous, and show the usual axonal character.
They are free from pigment. In contradistinction to the dense
shrunken nuclei of the smaller cells their nuclei are swollen and clear,
and their lining membrane is in many cases invisible.

The vessels call for no remark. There is no evidence of intravascular
clotting.

The subcortical nerve-cells are few and inconspicuous.

Cornua ammonis .—Beyond the presence of small cortical haemor¬
rhages in the right, there were no pathological features noted in these
regions nor in the cerebellum , and in neither region was there any sign
of intravascular thrombi.

Digitized by v^ooQle

1907.] BY JOHN TURNER, M.B. 41

Spinal cord .—The fcrehom cells were free from pigment, and showed
a well-marked stichochrome appearance with a large clear nucleus. In
the lumbar region one or two axonal forms were noted. There was a
small haemorrhage in one cervical forehorn. The central canal was
patent in the upper part, but blocked up by proliferating endothelial
nuclei in the lower. After hardening in Muller’s fluid and making
transverse sections, a heterotopia was found occupying about three
quarters of an inch in length of the uppermost dorsal region, and at
this site there was a perceptible increase in the bulk of the cord. A
small, thin, pale area was noted between Goll and Burdach’s columns,
best seen in the cervical and upper dorsal region and not visible in the
lumbar. Microscopic examination of osmic acid preparations showed
that this pallor was due to a number of round or loculated lacunae. So
that in this area there was a diminution in the number of myeiine fibres,
without, however, any appearance of interstitial overgrowth. No other
evidence of tract degeneration.

Remarks .—I have met with six cases of heterotopia of the
spinal cord, but this is the first that I have seen in the case of
an epileptic ( 2 ). Of these six, two were general paralytics (one
male, one female), one an imbecile girl set. 5, one a girl suffering
from dementia praecox, and one a melancholic man, who died
of cerebral haemorrhage. The sixth is the present case.

Case 27.—B. D—, male. A low-grade imbecile, slow in his move¬
ments and pugnacious, subject to frequent fits. Died, aet. 31, of a low
form of pneumonia. Temperature never above ioi° F.

Autopsy twelve hours after death. Encephalon weighed 1193 grm.
To the naked eye the brain appeared natural except that the left thalamus
was slightly smaller than the right. The liver on microscopic examina¬
tion showed commencing fatty degeneration and the presence of granular
intravascular clot.

The kidney showed hyaline spherical clots in the arteries (phosphorus-
containing).

Pieces from the ascending frontals, cerebellum, and spinal cord were
fixed in alcohol and stained as usual. The cord was put into Muller’s
fluid for future examination.

Ascending frontals. —Meninges natural. There was an increase of
glia-cells in the zonal layer but no sclerosed rim.

Nerve-cells. —The second layer ill-defined and in places barely dis¬
tinguishable, owing to the small number of its elements. Meynert’s
striae were not well marked. There was a noticeable paucity of nerve-
cells in the outer half of the third layer. The individual elements in
both the layers mentioned showed generally a natural appearance, with
here and there a darkly-stained, shrunken form. The Betz cells were
numerous and showed axonal characteristics. The majority of them
stained darkly, so as often to obscure all internal detail; the nucleus
was shrunken and dense. There was very little pigment present.

There was considerable proliferation of pericellular nuclei around the

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42 ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

spindle-cells and the nerve-cells of the inner half of the cortex, and also
in the perivascular spaces around the capillaries and smaller vessels.

Subcortical nerve-cells present in fair number.

Vessels showed no marked engorgement. Intra-vascular thrombi in
the form of small hyaline spheres, single or in clusters, and which
stained bright green when treated for phosphorus, were present in
many of the veins and capillaries.

Cerebellum .—The cells of Purkinje were in fair number, many of
them exhibited axonal characters. There was the usual admixture of
darkly-stained shrunken forms.

No Bergmann’s fibres visible. Intravascular thrombi, especially in
the form of long cylindrical hyaline clots blocking the capillaries, were
a noticeable feature. In one place in the meninges there was a copious
deposit of hyaline material (staining green when treated for phosphorus),
chiefly in the form of spheres, lying outside a vessel, in the lumen of
which quite similar bodies were seen.

Spinal cord .—After hardening in Muller’s fluid, it showed some atrophy
of right anterior horn for a limited region between second and fourth
cervical segment. In Weigert and osmic acid preparations the only
sign of tract degeneration was a little oval-shaped patch in each column
of Goll in the lumbar region only, lying alongside the middle half of
posterior fissure. Here there was a great paucity of myeline fibres and
some interstitial overgrowth.

The forehorn-cells of the cervical region in Nissl preparations showed
a fair stichochrome appearance, with slight pigment deposit. The
nucleus was large and clear.

Remarks .—The presence of extravascular hyaline material
having exactly the same appearance and reaction as to phos¬
phorus as intravascular thrombi close to it, suggests strongly
that in some way there has been a transudation of material
from the blood which has subsequently clotted. This appear¬
ance should be compared with those described in Cases 8
and 15, where a substance which gave a positive reaction
for phosphorus was found deposited in the matrix of the
cortex cerebri and cortex cerebelli, and which had undergone
partial calcification.

Case 28.— J. A. N—, female. A high-grade imbecile. Neat, in¬
dustrious, and fairly intelligent. Has fits nearly every day, sometimes
single, and sometimes a series, and also attacks of petit mal. After
succession of fits becomes maniacal and spiteful for a day or two.
Died, set. 25, in a fit.

Autopsy five hours after death. Body well nourished. Encephalon
1259 grm. Beyond slight atrophy at the summit of the central con¬
volutions and sclerosis of the left cornu ammonis, the brain appeared
normal, as also the thoracic and abdominal viscera. Both the liver
and the kidney were examined microscopically; both were structurally
natural, but in the engorged vessels of the liver there was an abundance

Digitized by CjOOQle

1907.] BY JOHN TURNER, M.B. 43

of granular clot. Pieces from the ascending frontals, the cornua
ammonis, the cerebellum, and the cord were fixed in alcohol and stained
as usual The cord was put into Muller’s fluid for further examination.

Ascending frontals .—There was hyaline thickening of the meningeal
arteries.

The zonal layer presented a normal aspect.

Nerve-cells .—The second layer was ill-defined, containing few cells,
and these generally shrunken and with dark angular nucleus. The
cytoplasm of the pyramidal cells stained uniformly a pale lilac (with
polychrome blue), and there was an absence of any visible chromato-
plasm. The branches of the cells owing to this uniform staining were
well seen. The nuclei appeared solid and very dark, and generally
angular (homogeneous degeneration of Sarbo).

There was a marked diminution in the number of the nerve-cells in
the outer half of the third layer, but in spite of this Meynert’s striae
were well defined. The Betz ceils were numerous and large; they
stained all over a pale lilac in which dust-like chromatoplasmic granules
of a slightly darker colour were visible. The nucleus was very small\
but not crumpled; it was ill-defined owing to its taking on the same
colour and being of nearly the same density as the cytoplasm. The
nucleolus was large and occupied nearly the whole area of the nucleus.
There was no pigment in these cells. They did not show axonal changes.

Vessels. — No marked engorgement of the veins. Intravascular
dotting, chiefly in the form of granular material, in large masses was
seen in some of the veins of the cortex, and sticking to the lumen of
some of the vessels were masses of a hyaline nature. In the preparations
for phosphorus the granular form stained pale green, the hyaline dark
green.

The subcortical nerve-cells were large and numerous.

Cornua ammonis .—The meninges showed slight fibroid thickening,
with some slight infiltration with large lymphocytes. No granulation
noted on the ventricular surface of the horns, and no increase of
glia-cells.

The nerve-cells of the pyramidal stratum on both sides were shrunken
and degenerated, but only on the left (the sclerosed) side were the
granules affected; here they were much reduced in number and
degenerated.

Vessels .—There was marked hyaline thickening of the veins, and in
some cases their lumen was almost obliterated. Intravascular thrombi
in the form of granular clots were present on both sides.

Cerebellum .—There was atrophy of small areas in one or two foliae on
both sides. No Bergmann’s fibres seen. The cells of Purkinje were
few in number and shrunken and degenerated. Hyaline thickening of
the walls of vessels and intravascular clot as in the preceding sections.

Spinal cord .—Anterior cornual cells showed a good stichochrome
appearance with clear nuclei. No excess of pigment. The central
canal was obliterated by proliferation of its endothelial lining.

On naked-eye inspection of transverse sections of the cord, after
hardening in Muller, there was a distinct pallor of the column of Goll,
both in the lumbar and cervical regions, but neither Weigert prepara¬
tions nor osmic showed any changes except more empty spaces in these

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44 ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

columns than elsewhere. There were slight, old, degenerative changes
throughout the crossed pyramidal tracts.

Remarks .—The change in the nucleus of the nerve-cells
(Sarbo’s homogeneous degeneration) here described has given
rise to much discussion as to its pathological significance.
Many writers contend that it is merely a post-mortem change,
and there is very little doubt that post-mortem changes do in
some cases give rise to a condition of a like or closely similar
nature. But, in support of the pathological importance of the
change, it should be noted that in the present case the autopsy
was held only five hours after death, and that the nuclei of the
forehorn cells did not participate in the change. The condition
of the cytoplasm corresponds to the acute cell change of Nissl
(Marinesco’s coagulation necrosis).

Case 29. —E. M. G— , female, subject to epileptic fits from the age
of nine days up to four years. At first they were very frequent and
strong, but gradually became less frequent and severe, and for the last
six years of her life there is no record of her having had any. An idiot,
able to walk with a little assistance. Took very little notice of things.
Died aet. 10.

Autopsy twenty-five hours after death. The viscera appeared fairly
healthy.

Marked sclerosis of right cornu ammonis, cortex congested in patches.
Encephalon weighed 1124 grm.

Pieces from both ascending frontals and right cornu ammonis were
fixed in sublimate and stained as usual.

Ascending frontals .—Some fibroid thickening of the meninges and
considerable infiltration with round or oval cells (8—9 /i, a few 12 /i).
Their nucleus very dense (4—6 y) and at one side of the cell-body.
Sometimes two nuclei. The larger cells (large lymphocytes) have a
woolly cytoplasm, which often seems to be on the verge of breaking
up. Several mast-cells seen. The vessels are not markedly engorged.
Muscular coat slightly thickened.

The zonal layer shows no sclerosed rim nor increase of glia-cells; its
innermost part is loculated. Nerve-cells observed in this region.

Nerve-cells .—No marked diminution in number. The great majority
are small, dense, with dark, angular nuclei. The Betz cells contain no
pigment; nearly half of them have a good stichochrome appearance
with a clear central and normal nucleus. The others are darkly
stained and with dense nucleus. On both sides several specimens
showing an advanced stage of the axonal reaction are seen.

Vessels .—The arteries are thickened and somewhat tortuous, the
veins engorged and fitting closely against the brain matrix. In both
varieties one sees an abundance of spherical thrombi and also a
homogeneous or granular material adhering to the inner side of the
lumen.

Digitized by v^ooQle

1907.] BY JOHN TURNER, M.B. 45

Right cornu ammonis .— Meninges similar to those in the preceding
region; its vessels contain an abundance of blood-plates, many of
which appear to be disintegrated and broken up into smaller particles.

Small granulations noted on the ventricular surface, no marked
sclerosed rim. Many small glia-cells with small dark nuclei.

The nerve-cells are similar to those in the preceding region. In the
sclerosed part (the fascia dentata) the vessels generally, both arteries
and veins, are collapsed and lie in wide spaces, across which stretches
a foam-like exudate; some of these vessels appear mere threads with
scarcely any lumen to be seen. In the non-sclerosed part the veins
are somewhat engorged, and there is a small cortical haemorrhage, in
which is seen a ruptured vessel occupied by a collection of small
spherical thrombi. These stain a dark green with Macallurn’s test for
phosphorus.

There is all over the sections abundant evidence of intravascular
dotting in all its usual forms, and, as is always the case, the homo¬
geneous variety stains a deeper green, when treated for phosphorus,
than the granular variety.

Remarks .—In spite of the fact that this child had no fits for
five or six years before death abundant evidence of intravascular
clotting was met with. This shows conclusively that in her case
this clotting was not, as has been suggested, the result of fits.
But it will be asked, Why in this case did not the thrombi pro¬
duce convulsions ? I would suggest that the explanation is,
that the nerve-cells were not in a condition to respond to the
stimulus of the cortical stasis, owing to their advanced state of
degeneration.

Case 30.—A. J. M —, male. An idiot, blind and unable to stand or
sit erect, admitted in good condition, but a year before death began to
waste and became anaemic and feeble. Eleven days before death had
a series of fits; when tested a little time after a fit the Babinski and
Oppenheim phenomena were present in the left foot, the Babinski, but
not the Oppenheim, in the right foot. He died aet 11.

Autopsy twenty-four hours after death. No obvious cause of death
found in the viscera. Both liver and kidney were examined micro¬
scopically and showed no pathological changes, except thickening of
the muscularis and adventitia of the kidney vessels. The liver con¬
tained a quantity of finely granular clot in the blood-vessels (phos¬
phorus-containing). The brain was tough; no special sclerosis of the
cornua ammonis. The right thalamus was slightly smaller than the left
The encephalon weighed 995 grm. The cord was small and firm.

Ascending frontal *.—The zonal layers showed an increase of small
glia-cells, and in places on the surface a thin, sclerosed rim. In places
the upper or outer half of the cortex, above the layer of Betz cells, is

Digitized by v^ooQle

4 6

ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

almost denuded of nerve-cells, the few remaining being very darkly
stained and shrunken.

The Betz ceils are large, pale, and all show the axonal condition.
No swollen nuclei observed. The subcortical nerve-cells are numerous
and large.

Vessels. —Small haemorrhages seen. In the vessels are abundance of
blood-plates and finely granular clot and some hyaline spheres. The
clot gives the usual green reaction with Macalium’s reagent. In the
inner half of the cortex there is some slight infiltration in the peri¬
vascular and pericellular spaces, chiefly small (4—5/4), dark nuclei.

In the cornua atnmonis the only points to call attention to are the
patchy degeneration of the cells of the stratum pyramidalum, and the
usual small granulations on the ventricular surface.

The cerebellum showed no intravascular clot, no sclerosis, and no
appearance of Bergmann’s fibres. The Purkinje cells were axonal, very
often with a small crenated or reniform nucleus. There was abundance
of foam-like exudate around the vessels.

The spinal cord showed an entire absence of any tract degeneration,
old or recent. There was a well-marked rim of sclerosis surrounding it.

The central canal was patent in the cervical region but obliterated in
the dorsal and lumbar.

The forehorn cells contained well-marked Nissl bodies; they stained
densely and were not pigmented.

Remarks .—The only point I wish to draw attention to is
that in spite of the presence of the Babinski phenomena in
both feet and the Oppenheim sign in one, there was no de¬
generation observed in either pyramidal tract.

Case 31.—E. P—, male, an idiot, unable to walk owing to con¬
traction of legs. Has his fits chiefly at night. They occur singly and
very occasionally. Died aet. 12.

Autopsy thirteen and a half hours after death. Body emaciated. No
obvious cause of death discovered by naked-eye examination. The
brain was firm and there was some sclerosis of both cornua ammonis
and of the upper surface of the left lobe of the cerebellum. No one¬
sided atrophy of thalamus. Encephalon weighed 1067 grm.

Pieces from both ascending frontals, the cornu ammonis, the cere¬
bellum, and the spinal cord were fixed in alcohol and stained as usual.
The cord was placed in Muller’s fluid for further examination.

Ascending frontals. —Slight fibroid thickening of the meninges; no
cellular infiltration.

The zonal layer showed no increase of glia-cells and no sclerosed rim.

Meynert’s striae well defined. The nerve-cells of the second layer were
shrunken, darkly stained, and slightly diminished in number, their
nucleus small, dark, and solid. No manifest sparseness of pyramidal
cells; the cells of the outer layers were more shrunken and degenerated
than those of the inner. The spindle-cells appeared least affected.

The Betz cells showed the usual axonal form. The nucleus appeared

Digitized by v^ooQle

1907.] by JOHN TURNER, M.B. 47

natural. They contained no pigment. The subcortical nerve-cells
were numerous and large.

Vessels. —The veins were well filled. There was no engorgement of
arteries or capillaries or visible alteration in their walls. Numerous
blood-plates and transitional forms between, on the one hand, blood-
plates, and on the other spherical clots, shown best in preparations
treated by Macallum’s phenyl-hydrazin reagent. Granular and spherical
thrombi and fibrin also met with. In the perivascular and pericellular
spaces in the inner half of the cortex there was a moderate infiltration
of cells with very scant cytoplasm and dark, round, or oval nuclei
5—6 ft, in diameter.

Cornu ammonis. —The only points noted were batches of degenerated
pyramidal cells (dark green with Macallum’s test), numerous blood-
plates in the vessels, and the presence in fair amount of phosphorus-
containing granular clot and spherical thrombi, also a small cortical
haemorrhage.

Cerebellum (sclerosed region). — The meninges appeared natural.
Bergmann’s fibres were visible, the cells of Purkinje few and degene¬
rated, the granules diminished in number.

Spinal cord. —Three levels examined, cervical and lumbar enlarge¬
ment and mid-dorsal. No tract degeneration, old or recent. Central
canal patent. Very little pigment (dark brown with osmic acid) in
the forehorn-cells. Some homogeneous, brown-stained (with osmic
acid) exudate around the vessels.

Case 32. —E. S—, female. A high-grade imbecile, capable of useful
household employment. Subject to frequent single fits (grand mal)
with no warning. Also has frequent attacks of petit mal. Found dead
in the airing-court lying on one side, probably succumbed to a fit, aet. 60.

Autopsy three hours after death. Fairly nourished. The heart was
infiltrated with fat, the aorta atheromatous, and the coronary arteries
rigid. The liver was tough, but on microscopical examination appeared
fairly healthy. There was a large amount of granular (phosphorus-con¬
taining) clot in the vessels. The kidneys were cystic, and on micro¬
scopical examination showed very marked endarteritis but no interstitial
changes, and no granular clot in the vessels. The brain showed no
marked changes: it weighed 1142 grm.

Pieces from both ascending frontals, the cornu ammonis, the pons,
cerebellum, and spinal cord were fixed in alcohol and stained as usual.
The cord was placed in Muller for further examination.

Ascending frontals .—Except thickening of the muscularis no marked
changes in the meninges. The zonal layer was narrow, showed some
slight increase of glia nuclei, but no sclerosed rim. Embryonal nerve-
cells present

Nerve-cells .—MeynerPs striae fairly well defined; the cells of the
second layer were scanty, shrunken, and with dense angular nuclei.
The majority of the small and medium-sized pyramids were small,
angular, darkly stained, and with a small, dense nucleus, but inter¬
spaced with these were larger, paler, and more healthy-looking speci¬
mens. There was some diminution in the number, chiefly in the outer
region. The Betz cells were not axonal; they presented a fairly normal

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

stichochrome appearance with a large, clear nucleus and very small
nucleolus. There was some excess of yellow pigment, but not out of
proportion to age. The subcortical nerve-cells were small and numerous.

Vessels .—No marked structural changes noted. A small cortical
haemorrhage seen. Very little intra-vascular clot. Considerable pro¬
liferation of perivascular and pericellular cells. These showed a scanty
cytoplasm, and clearly defined round or oval nucleus (4—6 ft) with
central nucleolus.

Cornu ammonis .—The main pathological features noted were promi¬
nent granulations on the ventricular surface, but no increase of glia
elsewhere. Some patchy degeneration and diminution in number of
the pyramidal cells of nucleus fasciae dentatae, but no marked changes
in the cells of the stratum granulosum. Hyaline degeneration, with
thickening and nearly total obliteration of the lumen of some of the
cortical and medullary vessels, and in some of the dilated perivascular
spaces and their immediate neighbourhood large numbers of round
colloid bodies varying in size from 3 to 12 /x. Endarteritis of the anterior
choroidal artery. Numerous small cortical haemorrhages.

The vessels contained a fair amount of both granular and hyaline
thrombi, which gave the usual reaction for phosphorus when treated by
Macallum’s test.

Cerebellum .—Meninges fairly healthy, except for hyaline thickening
of some of the vessels. No atrophied foliae observed, no Bergmann’s
fibres. The cells of Purkinje were pale, fairly numerous, and many
showed an axonal character. There was a large amount of granular
clot in the vessels.

Pons .—Lateral granulations on the floor of the fourth ventricle. The
cells of the hypoglossal nucleus and olivary body showed no marked
changes. There was hyaline thickening of the vessels, and a small
haemorrhage in the region of the hypoglossal nucleus. Intra-vascular clot
as in other regions.

Spinal cord .—Cervical enlargement. Meninges unaffected. Fore-
horn cells showed a natural stichochrome appearance with a large
clear nucleus and some excess of yellow pigment. Central canal
obliterated by proliferation of its lining endothelium. Large numbers
of round colloid bodies in the white matter, chiefly of the posterior
columns. Granular clot observed sticking to the sides of the lumen of
the vessels. In the lumbar enlargement the appearances were similar.
In the forehorns were, however, sharply defined groups of very darkly
stained shrunken cells, lying in wide spaces, interspersed with others
showing a normal appearance.

Weigert and osmic acid preparations showed no localised tract
degeneration, but in the lumbar region only there was a peripheral zone
with a paucity of myeline fibres and increase of connective-tissue
elements.

Case 33.— A. H—, male. An idiot, unable to walk. His fits began
when he was quite a baby, and were frequent and severe until he was
three years old; then they gradually ceased, and for the last twenty-two
months of his life he had none at all. He developed lobar pneumonia
with a temperature between 104 8° and ioi’2° F., and died set. 7.

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1907.]

BY JOHN TURNER, M.B.

Autopsy five and a half hours after death. Ill-nourished. Pneumonic
patch in left upper lobe. Brain-convolutions broad and simple, no
sclerosis of cornu ammonis. Encephalon weighed 1125 grm.

Pieces of both ascending frontals, both cornua ammonis, the cere¬
bellum, and spinal cord were fixed in alcohol and stained as usual. The
cord was placed in Muller’s fluid for further examination.

Ascending frontals —Meninges show some slight infiltration with
lymphocytes. Fibroid thickening of some of the vessels and haemorrhage.
The zonal layer appears unaffected, no increase of glia-cells.

Nerve-cells .—The second layer is ill-defined owing to paucity of cells,
which in some cases have small, dark, in others clear nuclei. There is
a great sparsity of cells generally; the pyramids in most cases contain a
swollen, clear nucleus (ligation type); a few only of the cells are dark
and shrunken. On the right side a few rudimentary Betz cells are
present; on the left none at all are seen. A feature in these sections is
the enormous number of well-developed subcortical nerve-cells, generally
containing a swollen “ bladder-like ” nucleus.

Vessels .—The veins are dilated and in places have ruptured. The
vessels contain a very large amount of clot in the form of granular
masses and hyaline spheres, both of which give the green colour indica¬
tive of phosphorus with Macallum’s test, the latter (the spheres) a
darker green than the former.

Cornua ammonis show no increase of glia and no granulations on the
ventricular surface. The ceils of the stratum pyramidalum are similar
to those above described, having generally a dilated nucleus. The
cells of the stratum granulosum are not diminished in number and
appear fairly healthy.

Vessels .—Veins engorged. The vessels show no structural alteration,
but contain an abundance of granular clot which in some cases com¬
pletely blocks up the lumen. There are also many spherical thrombi.
In a section treated for phosphorus a dilated vein is seen full of pale
green finely granular dlMs f among which are bright green blood-plates,
and erythrocytes which are nearly colourless, and appear to consist of
empty cases somewhat shrunken and broken up. The finely granular
debris in this case has the appearance of resulting from the disintegra¬
tion of erythrocytes.

Spinal cord \—In Nissl preparations the forehom cells show a fairly
good stichochrome appearance, without pigment, and their nucleus is
frequently dense. Many of the cells appear shrunken. Small haemor¬
rhages noted in both the forehoms and the white matter. The central
canal is patent in some sections, obliterated in others. The vessels
contain an abundance of hyaline and granular clot.

There is old-standing degeneration of both crossed pyramidal tracts,
most marked in the cervical region and not visible in the lumbar.

Case 34.—E. P—, male. An idiot with unsteady gait and inco-
ordinated movements. Subject to occasional strong fits, generally
single. He died of pulmonary tubercle, set. 16.

Autopsy eleven hours after death. The brain appeared natural.
There was no sclerosis of the cornua ammonis. Encephalon 1192 grm.
Pieces from both ascending frontals, both cornua ammonis, the pons,
L1II. 4

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SO ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

cerebellum, and spinal cord were fixed in alcohol and stained as usual.
The cord was placed in Muller’s fluid for further examination.

Ascending frontals .—Meninges, some fibroid thickening and in
places pial proliferation, with small, darkly stained nuclei.

The zonal layer showed no sclerosed rim and appeared natural.

Nerve-cells. —Meynert’s striae not well marked. Second layer ill-
defined, owing to the scanty number of cells. There was a marked
paucity of nerve-cells in the third layer also, and indeed in some
areas here they were almost absent. Groups of darkly stained, shrunken
forms seen. The nuclei of the nerve-cells generally were dark, small,
and angular. The Betz cells showed the usual imbecile type (axonal) ;
they contained no pigment and their nucleus was small and of slightly
increased density.

The subcortical nerve-cells were small but in fair number.

Vessels. —No special structural alterations noted. They contained
numerous masses of finely granular clot and small hyaline spheres,
giving the usual positive reaction for phosphorus. Small cortical
haemorrhage.

Cornua ammonis. —Some fibroid thickening of the meninges. Thick¬
ening of the muscularis of the arteries and endarteritis. No infiltration.
Excess of polynuclears, which often fill the whole lumen of fairly large
veins. This was observed in the veins of the cortex as well. No
granulation nor increase of glia-cells.

Nerve-cells. —The cells of the stratum pyramidalum were diminished in
number and degenerated. Those of the stratum granulosum appeared
undiminished and natural.

Intravascular clot in large amount, chiefly the granular variety.
Several small haemorrhages noted.

Cerebellum .—Meninges unaffected. There was a small area of atrophy
involving several foliae. Except here, no Bergmann’s fibres were visible.

The cells of Purkinje were degenerated and scanty. 'There was a
# large amount of clot (chiefly granular) in the vessels.

Pons .—Several capillary haemorrhages, in the neighbourhood of the
hypoglossal nuclei, and distended veins completely blocked with
granular clot.

The hypoglossal cells showed scanty chromatoplasm and contained
round, solid nuclei which stained uniformly with erythrosin (homo¬
geneous degeneration of Sarbo).

There were no granulations on the surface of the fourth ventricle.

Spinal cord. —After hardening in Muller showed to the naked eye in
cross sections marked pallor of Goll’s columns in the cervical region.
This pallor was less marked and extensive in the dorsal and scarcely
visible in the lumbar region. Microscopically the degeneration, for the
most part old-standing, but mixed with a slight amount of recent Marchi
reaction, was limited to Goll’s columns. In this degenerated area were
many large lacunae, and very slight increase of interstitial tissue.

The forehorn cells showed no marked changes, except that in the
cervical region there were a few and in the lumbar many axonal forms.

The central canal was patent. Clot was present in the vessels and
the meninges appeared to be unchanged.

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1 907-]

BY JOHN TURNER, M.B.

Case 35. —O. W. G—, female. An idiot, subject to fits since the age
of three years. Had been operated on for them at the age of seven years
(trephine mark, 2 in. in diameter, on the left side just above the ear).
Her fits were frequent and severe (serial). Twice during her residence
here was in status epilepticus , temperature rising to 105° F., and suc¬
cumbed to the second of these attacks set. 16.

Autopsy nine hours after death. Broncho pneumonia was found to
be the immediate cause of death. The kidneys (examined micro¬
scopically) were healthy.

Brain .—There was a cyst with some thickening of the walls in the
pia-arachnoid under the trephine hole, over Broca’s area. General
atrophy, most marked on the left. Consistency normal in frontal
areas, tough in occipital. Pons very firm. Cerebellum firm.
Encephalon 1016 grm.

Pieces from both ascending frontal and both occipital regions were
fixed in sublimate and stained as usual.

Ascending frontals .—Meninges, slight fibroid thickening and slight
lymphocyte invasion. Abundant epicerebral foam-like exudate.
Numerous blood-plates in the meningeal vessels. The zonal layer
shows a moderate proliferation of glia-cells and in places a narrow,
sclerosed rim.

Nerve-cells. —The second layer is fairly well defined. There are
many degenerated cells and many with a swollen nucleus. The Betz
cells vary, some being darkly-stained and shrunken, others with a large,
clear nucleus. They contain an excess of pigment. Only a few show
axonal characteristics.

Subcortical nerve-cells in fair number.

Vessels. —A black pigment is deposited in the perivascular sheath of
some of the medullary vessels. Intravascular clot in all its forms
present in fair amount. Some of the smaller vessels and capillaries
are quite blocked up. Blood-plates numerous. The clot, when tested
for phosphorus, gives the usual positive result.

Occipital regions. —Very slight evidence of glia-cell proliferation in
the zonal layer; a narrow, sclerosed rim. The nerve-cells stain darkly
and do not show a swollen nucleus. Intra-vascular clotting in large
amount, especially on the right side, many capillaries entirely blocked
with it. On the right side only, small cortical haemorrhages met with.

Case 36.—M. D—, female. A medium-grade imbecile. Subject to
fits from infancy, which gradually became less frequent, and for some
years prior to death ceased entirely. Infantile paralysis of right arm.
Died set. 47, of chronic Bright’s disease.

Autopsy twenty-four hours after death. Atrophy of left hemisphere.
The convolutions on this side were represented only by the surfaces of
the gyri, as in a bogus book-case showing only the backs of the books.
Scarcely any white matter. The right hemisphere contained a small,
white, sclerosed patch in the prefrontal lobe. The whole cerebrum
(especially the left side) was firm, but there was no special sclerosis of
the cornua ammonis. The left lobe of the cerebellum was the smaller,
and weighed 7 grm. less than the right. There was on its upper sur-

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52 ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

face a sclerosed patch. There was a difference of 150 grm. between
the weight of the two cerebral lobes. Encephalon 917 grm.

Recent infarcts in both lungs. The liver (examined microscopically)
showed merely congestion. There was a well-marked quantity of
granular and hyaline clot and fibrin. Kidneys (examined microscopi¬
cally) small and granular, with marked endarteritis.

Pieces from the prefrontal, ascending frontals, cerebellum, and spinal
cord were fixed in alcohol and stained as usual. The cord was
hardened in Muller for further examination.

Prefrontal —Meninges, fibroid thickening. Marked diminution in
the number of nerve-cells, and many were shrunken and degenerated.
Blood-plates, small hyaline spheres and cylinders, the latter lying in
capillaries, were present in considerable quantity. They gave the usual
positive reaction when tested for phosphorus.

Ascending frontals. —Meninges, considerable fibroid thickening. The
zonal layer appeared natural. Nerve-cells: Meynert’s striae not well
marked ; there was a great diminution in number of the cells of all the
layers, chiefly in the left side (atrophied). The cells of the two sides
showed marked differences—those on the left shrunken and darkly-
stained, those on the right were larger and did not stain darkly, and
their nucleus was larger and only slightly increased in density.

The Betz cells on the left were heavily pigmented, shrunken, and
darkly stained; their nucleus was contracted and dense and frequently
surrounded by a clear halo. The Betz cells on the right were much
larger, not so heavily pigmented, and with a large and fairly clear
nucleus. Several showed well-marked peripheral chromatolysis, only a
small area surrounding the nucleus containing any chromatoplasm. On
both sides the great majority showed axonal features. Vortex condition
of ceils present.

Very few subcortical nerve-cells seen.

Vessels. —Hyaline degeneration. In some cases the lumen was
nearly obliterated. Very little clot noticed. The veins in many cases
were enormously engorged.

Cerebellum. —Purkinje ceils few and degenerated. An atrophied
folium.

The intravascular clot was in fair amount and similar in form to that
found in the prefrontal sections.

Spinal cord. —Cervical enlargement. Anterior horn-cells shrunken,
but retaining a fair stichochrome appearance, nucleus increased in
density. No excess of pigment. The central canal was patent, but
showed some proliferation of cells around it. There was hyaline
degeneration of the blood-vessels.

Lumbar enlargement. —The anterior horn-cells were large, contained
no excess of pigment. They presented a good stichochrome appear¬
ance. The nucleus was large and generally of slightly increased
density. Several axonal forms noted. The central canal was dilated.

In sections stained by Meynert’s method and in osmic acid there
was found to be very marked old degeneration of one crossed pyramidal
tract and the opposite direct tract in the cervical region. This con¬
dition of degeneration was less marked in the dorsal region and least
n the lumbar. No signs of any recent degeneration. In the osmic

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BY JOHN TURNER, M.B.

190 ;.]

acid preparation the anterior horn-cells, especially in the lumbar region,
contained a quantity of black-stained (fatty) granules.

Case 37. —W. J. W—, male. A gardener, no history as to how
long subject to fits. Probably of average intelligence. Only under
observation five months. Had strong fits every two or three days, and
after each attack was maniacal. Died in a fit set. 24.

Autopsy seven hours after death. The basal membranes were bound
together by old adhesions. There was very slight atrophy of left
thalamus ; no sclerosis of cornua ammonis. The encephalon weighed
1567 grm. The cord was large and firm.

Lungs .—Old pleural adhesions on both sides. Kidneys (examined
microscopically) healthy, some hyaline spherical clots seen in the
vessels.

Spleen (examined microscopically) contained two large infarcts;
it was much enlarged (215 grm.). Liver (microscopically examined)
healthy.

Pieces from both ascending frontals, both sides of cerebellum, and
spinal cord were fixed in alcohol and stained as usual. The cord was
placed in Muller's fluid for further examination.

Ascending frontals .—A marked difference between the two sides.
In both the meninges were unaffected and the subcortical nerve-cells
fairly numerous. The vessels showed no structural changes and there
was some increase both of perivascular and pericellular nuclei.

On the left side there was some increase in the glia-cells of the zonal
layer but no surface rim of sclerosis. The cells were natural and not
diminished in number. The Betz cells were not axonal and contained
no pigment.

On the right side there was no marked increase of glia in the zonal
layer. The nerve-cells of the second and outer part of the third were
markedly few. The Betz cells were axonal and the nucleus of all forms
often swollen and bladder-like.

In sections treated for phosphorus there were practically no de¬
generated (dark green) nerve-cells. Clumps of blood-plates and small
spherical clots were seen, and there was a small amount of hyaline clot
adhering to the sides of the lumina of some of the vessels.

Cerebellum .—Meninges natural, except for a small meningeal haemor¬
rhage and abundance of foam-like exudate. No signs of gliosis. The
cells of Purkinje were fairly healthy. There was hyaline thickening of
some of the veins, and the vessels contained clusters of blood-plates
and (5 to 7 /*) hyaline spherical clots in greater number than in the
ascending frontal sections.

Spinal cord .—Cervical enlargement. The forehorn cells showed a
fairly good stichochrome appearance, their nucleus was increased in
density. The central canal was patent.

In the lumbar enlargement the forehorn-ceiis were similar. The
central canal was blocked by proliferation of its endothelial lining cells.
There was some hyaline thickening of the small vessels.

In osmic preparations the nerve-cells contained a central clump of
nearly black pigment (? fatty). There was a copious foam-like exudate
in the dilated perivascular spaces, which stained pale brown, and lying

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

in it were clusters of crumpled black-bordered spheres, probably repre¬
senting the product of fatty changes in this exudate.

In neither osmic acid preparations nor Weigert’s was any tract-
degeneration seen.

Case 38.—A. H—, female. A low-grade imbecile. Paralysed on
left side, knees contracted, but could walk. Had frequent fits. Became
very helpless and feeble, with swollen, cyanosed extremities, and died
of pulmonary tubercle set. 20.

Autopsy twenty-three hours after death. Brain small, microgyri in
occipital and parietal regions, mostly on the right side. Sclerosis of
both cornua ammonis. Encephalon weighed 988 grm. Tubercular
deposits and caseous masses in both lungs. Tubercular ulcers of
intestines. Liver (microscopically examined) showed advanced fatty
degeneration. Blood-plates and granular clot in the bigger vessels in large
amount. Kidneys (microscopically examined) fairly healthy, with
exception of slight endarteritis. No clot. Spleen (microscopically
examined) lardaceous. Pieces from both ascending frontals, the
atrophied convolutions of right side, the cornua ammonis, and spinal
cord were fixed in alcohol and stained as usual. The cord was placed
in Muller’s fluid for further examination.

Ascending frontals .—Meninges natural. Zonal layer natural. The
only cells which appeared diminished in number were the Betz. The
second layer cells and pyramids appeared healthy, but here and there
were groups of darkly stained shrunken forms. The Betz cells did
not show an axonal character. No marked excess of subcortical
nerve-cells.

Vessels .—No structural alterations noticed. Dark green (with poly¬
chrome) pigment around the small vessels. Fibrin, granular clot, and
spheres, giving a positive reaction for phosphorus, were in fair amount.

The only points calling for notice in the atrophied convolution were
disappearance and shrinking of the nerve-cells. It is to be noticed,
however—a common feature with atrophic convolutions—that there
was a remarkable persistence of second layer cells, so that this layer
was distinctly demarcated even in places where nearly all the deeper
lying ceils had perished. No increase of glia noted.

The cornu ammonis showed degeneration of nerve-cells in the
nucleus fasciae dentatae, and was negative as regards clot.

Spinal cord .—Cervical enlargement. Anterior horn-cells degenerated,
very little pigment. Central canal patent. Blood-plates, fibrin, and
granular clot seen in the vessels.

Lumbar enlargement. Cells as above. Central canal patent, some
proliferation of endothelial cells around it.

The only degeneration noted was in one crossed pyramidal tract, and
this was only visible in the cervical region and was entirely of old
standing.

Case 39.—J. C—, male, labourer. His intelligence was up to the
average of his class. Subject to occasional single and severe fits, after
which he was liable to become maniacal or very vicious and dangerous.
Died aet. 44 of epilepsy.

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*907-]

BY JOHN TURNER, M.B.

Autopsy eight hours after death. Well-nourished brain. The meninges
were very injected over the prefrontal lobes (especially the left). No
difference in size between the two halves of the thalamus, no sclerosis
of cornua ammonis. The encephalon weighed 1374 grm. The liver
(microscopically examined) showed marked fatty degeneration and some
increase of interstitial tissue, negative as to clot. Kidneys (microscopically
examined) showed marked increase of interstitial tissue and destruction of
glomeruli. Spleen also showed on microscopical examination an increase
of interstitial tissue. Other viscera appeared healthy.

Pieces from the prefrontals, ascending frontals, cerebellum, and
spinal cord were fixed in alcohol and stained as usual. The cord was
placed in Muller’s fluid for further examination.

Prefrontal .—Meninges, extensive haemorrhage, otherwise no marked
structural changes. The zonal layer appeared unaffected. There was
no noticeable diminution in number of the nerve-cells, and the majority
appeared natural, with the exception of one or two small patches in
which they were shrunken and darkly stained. The vessels showed no
structural alteration and contained no clot. The veins were engorged
and a small cortical haemorrhage was seen.

Ascending frontal. —Meninges unaffected. The zonal layer showed
no external rim of sclerosis, but there was a very considerable increase
of glia nuclei; an embryonal cell noted. The nerve-cells did not appear
diminished in number, and were well formed; they were all in an early
stage of acute cell change, their cytoplasm staining uniformly a pale lilac
colour (with polychrome), and their nucleus clear and natural.

Only a few Betz cells were seen; they also showed the acute change
and were not axonal. Only an occasional solitary, degenerated, darkly-
stained nerve-cell seen. Large numbers of subcortical nerve-cells.

Vessels. —No structural alterations and no clot observed. The veins
were engorged and one ruptured. The arteries were collapsed and sur¬
rounded by wide spaces.

There was a considerable increase of perivascular and pericellular
elements, mainly confined to the inner layers of the cortex and the
medulla.

Cerebellum .—Meninges unaltered. No appearance of Bergmann’s
fibres. The cells of Purkinje were not diminished in number, and
showed the same acute changes as the cells of the cerebrum. Practi¬
cally no dark, shrunken forms. Vessels as in the cerebrum. No haemor¬
rhage seen.

Spinal cord. —Cervical enlargement. The anterior forehorn-cells
contained an excess of yellow pigment and their nucleus was increased
in density. They appeared to be in an early stage of the acute change
and still retained some of their chromatoplasm. The central canal was
obliterated by proliferation of its endothelial cells.

Lumbar enlargement .—Anterior horn-cells more shrunken and darkly
stained ; excess of pigment. Central canal as in cervical region.

There was no appearance of tract degeneration, either recent or old.

Case 40.—E. M—, female. A high-grade imbecile, subject to fits
since the age of fifteen \ generally has two or three daily (day and

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

night), and is often maniacal after them or spiteful and disagreeable.
Died suddenly aet. 42.

Autopsy twenty-four hours after death.

Brain .—Sclerosis of both cornua ammonis, more marked on the left.
Pons and cerebellum very firm. There was a small angeioma in the
upper part of the pons, on the left side, lying between the posterior
corpora quadrigemina and the reticular substance. No other notice¬
able changes.

The encephalon weighed 1462 grm. With the exception of adherent
capsules and a small infarct (?) in the kidney, the other organs appeared
natural.

Microscopically the liver contained a quantity of intravascular and
hyaline clot and the kidney showed some destruction of glandular
epithelium and casts in the tubes.

Pieces from ascending frontals, cornu ammonis, pons, and spinal
cord were fixed in alcohol and stained as usual. The cord was placed
in Muller’s fluid for further examination.

Ascending frontals .—Marked fibroid thickening of the meninges, no
infiltration. In the zonal layer there was considerable increase of glia-
cells in patches and a thin, sclerosed surface rim.

Nerve-cells .—In places there was a diminution in the number of the
cells of the second layer, and nearly all were much shrunken and darkly
stained. The cells of the third layer, especially in its outer half, were
similar in character. The Betz cells were heavily pigmented; they
showed the usual axonal characters; some were large and pale and
others darkly stained and shrunken. No marked increase of sub¬
cortical nerve-cells.

Vessels .—Showed no structural changes; the veins were engorged
and there was marked increase in the number of both perivascular and
pericellular nuclei.

In preparations treated for phosphorus large numbers of degenerated
(dark green) nerve-cells were seen, scattered thickly and fairly uniformly
throughout the cortex. In the vessels were frequently seen clusters of
blood-plates and, but not to a large extent, small hyaline (dark green)
spheres singly or in groups of two or three.

Cornu ammonis .—Meninges slightly thickened, and in places there
was slight infiltration with cells. Some thickening of the muscularis
and slight endarteritis of the vessels. No increase of glia-cells noted,
no granulations.

The pyramidal cells were extremely degenerated, but the cells of the
stratum granulosum did not appear to be affected.

Vessels .—Small haemorrhages into cortex, some hyaline thickening
of the small veins. Blood-plates and small spherical clots as in the
ascending frontal convolutions.

Pons .—The small angeiomatous patch showed a cluster of closely set,
enormously distended capillaries and venules. The walls of most of
these were thickened and hyaline. Many of the distended vessels were
completely filled with blood-plates. In some they lined the wall only.
Fibrin threads and collections of poiynuclears seen. The arterioles
were tortuous and their walls thickened, but they were not dilated. No
spider-cells seen in the vicinity. The neighbouring nerve-cells were

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BY JOHN TURNER, M.B.

1907.]

either large, pale, and contained a large “bladder-like” nucleus, or else
shrunken, darkly stained, and heavily pigmented. They showed axonal
characteristics.

Spinal cord .—Only the lumbar enlargement examined for cell
changes, which were found to take the form in many instances of the
axonal. The nuclei were homogeneous but not shrunken. There was
a large amount of yellow pigment. The central canal was obliterated
by proliferation of its lining-cells. Some of the vessels showed hyaline
changes.

There was no tract degeneration, old or recent.

Remarks .—Some sections from the right and left prefrontal
region, the other cornu ammonis, and the calcarine fissure
region, stained by my methylene blue and peroxide of hydrogen
method showed marked zonal gliosis, in the prefrontal and
occipital sections, and patchy increase of glia-cells in the cornu
ammonis.

Case 41.—E. S—, female. A medium-grade imbecile, married.
Subject to frequent and severe fits; she died aet. 39.

Autopsy six hours after death. Her thoracic and abdominal viscera
appeared natural; the only morbid appearance noted was an cedematous
and very swollen condition of the right fold of the glottis.

The liver, kidney, and spleen were microscopically examined, but
with the exception of small haemorrhagic areas in the spleen they
showed no marked changes.

Brain appeared natural, with the exception of sclerosis of both cornua
ammonis (chiefly the right) and a sclerosed and atrophied patch in the
centre of the upper surface of the cerebellum. The encephalon weighed
1055 grm.

Pieces from both ascending frontals, the right cornu ammonis, the
cerebellum, and spinal cord were fixed in alcohol and stained as usual.
The cord was placed in Muller’s fluid for further examination.

Ascending frontals .—Meninges and zonal layer were unchanged.

Nerve-cells. —Meynert’s striae well marked. No diminution in the
number of nerve-cells, and they showed no morbid changes, with the
exception that the nucleus in many cases was swollen and bladder-like.
The Betz cells were large and numerous, and all showed axonal character¬
istics, with clear, plump, sometimes swollen, nucleus and very little pig¬
ment

The subcortical nerve-cells were small and not very numerous.

Vessels .—No structural changes noted ; some engorgement of veins
and varicose condition of those in the white matter, with deposits of
dark blue-green (with polychrome) pigment around them.

In the sections treated for phosphorus no degenerated (dark green)
nerve-cells were seen. The right side did not show any clot or blood-
plates, whilst the left contained an abundance of both. Nearly all the
capillaries and small vessels contained blood-plates (stained dark green),
sometimes solitary, sometimes clustered thickly together and entirely
filling up the lumen. These blood-plates measured 1*5 /*. When

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5 8 ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

aggregated together so as to fill up entirely a vessel those at the peri¬
phery appear to have fused into a hyaline mass.

Larger spheres were met with, some scarcely bigger than a blood-plate,
others 7 or 9 ft in diameter. The capillaries were often blocked up by
long cylinders, evidently the result also of fused blood-plates.

Right cornu ammonis showed no increase of glia or granulations ; the
majority of the nerve-cells appeared natural. Some of the vessels were
shrunken and looked like strings with no visible lumen, lying in wide
lymph-spaces. Sections treated for phosphorus showed a large amount
of clot and numerous blood-plates.

Cerebellum .—Meninges showed no marked changes. In the atrophied
foliae the molecular layer was thin but did not show Bergmann’s fibres,
the cells of Purkinje had disappeared, and only a few granules remained.
Blood-plates and intra-vascular thrombi as in other regions.

Spinal cord ’—Cervical enlargement. The anterior horn-cells were
darkly stained and shrunken, but still retained their Nissl bodies ;
nucleus dense. Very little pigment. The central canal was patent,
but there was some proliferation of its endothelial lining cells.

Lumbar enlargement .—Nerve-cells as in cervical region ; more pig¬
ment. One or two axonal forms. Central canal obliterated by pro¬
liferation of endothelial cells.

In sections treated with osmic acid no recent tract degeneration was
seen; the pigment in the nerve-cells stained brown. The central canal
was dilated in the mid-dorsal region. In Weigert preparations of
the cervical region there was old degeneration, or at least marked
deficiency of myeline fibres in the columns of Goll. This was well
seen also in the mid-dorsal region, but here at the surface end of Goll’s
columns was a small triangular or wedge-shaped area, extending on
each side of the posterior fissure, and bounded posteriorly by the
border of the columns, in which no degeneration was visible. In
the lumbar region the degeneration was scarcely noticeable. No
other tract degeneration.

Remarks .—Notice that the presence of thrombi was localised,
for whilst they were plentiful in the vessels of the left ascending
frontal, none were seen in the right ascending frontal. Sections
from the prefrontal region and the neighbourhood of the calcarine
fissure, stained by methylene blue and peroxide of hydrogen
method, showed no increase of glia-cplls in the zonal layer or
elsewhere.

PART III.

General Review of the Histological Findings.

(a) Brain (i) Meninges . — Although to the naked eye
they generally appear unaffected, except for congestion in

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I907-] BY JOHN TURNER, M.B. 59

those dying in status epilepticus , on microscopical examination
changes, slight but distinct, can often be detected. These are:
a fibroid thickening, cellular infiltration, and extravasation of
erythrocytes. These changes, as in most, if not all, the cerebral
lesions associated with epilepsy, are local, so that whilst one
region escapes, another suffers, or, indeed, one part of a section
may show the changes and not the other.

In twenty-one out of thirty-six cases in which the meninges
were examined fibroid thickening was noted, and in nineteen out
of thirty-six there was some slight cellular infiltration in the
meshes of the pia, the cells having generally the characters of
large lymphocytes. Of course the patchy character of the affec¬
tions makes it probable that a more extended examination
would have revealed these changes in an even larger number,
perhaps all. A certain amount of extravasation of red corpuscles
from rupture of meningeal vessels is practically a constant feature.
The thickening was only considerable in one of my cases.
No. 21 ; here it reached a depth of 7 mm. in hardened speci¬
mens from the ascending frontal region. In this case it was
not a dense fibroid thickening, but a loosely-meshed structure
comprised of wavy fibrils and branched fibroblasts, and there
was very little infiltration of lymphocytes or other free-lying
cells in the meshes. Structural alterations, generally of the
nature of thickening of the middle or inner coats of the
arteries, or else hyaline degeneration, occur in much the same
proportion as they do in the vessels in the brain, and will be
more fully discussed later on.

(2) Gliosis .—Except in a very few cases (where Beneke’s
method was used) no special methods have been employed to
show increase of glia. I believe that for pathological purposes
they are not only not necessary, but often misleading. With
ordinary methods the normal glia does not show in its entirety,
but only the nuclei and a general reticulum which cannot be
specially associated with any particular nucleus ; when, how¬
ever, the tissue begins to proliferate and undergo pathological
changes then the cells become clearly manifest, so that for the
determination whether the glia is increased the information
given by ordinary methods is at once precise and reliable.
All the special methods that I am acquainted with require for
their success very stringent conditions, not feasible for a general
pathological review, and when successful they show such a wealth

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

of detail that in many cases it is difficult to determine whether
one is in the presence of a normal or a pathologically pro¬
liferating glia.

Let me premise that practically in none of my cases has the
increase of glia been considerable. I mean that it was not
more than can usually be seen in any brains from cases of
chronic insanity. In twenty-four cases there wa£ an increase
of glia, generally in the zonal layer (seventeen cases), alone or
associated with increase elsewhere. The thickened surface rim
of sclerosed tissue on which Bleuler lays such stress, even to
the extent of regarding it and its glia connections as the
essential factor in the pathology of epilepsy, is not greater
than I have been accustomed to see in many brains from those
dying of chronic insanity. Sometimes it forms definite little
buds or granulations on the surface. The ventricular free
surface of the cornu ammonis shows also commonly a sclerosed
rim, and in this situation surface granulations are rarely absent;
but this, again, is by no means peculiar to epilepsy.

In the seven cases (out of twenty-two examined) where
there was an increase in the glia-cells in the substance of the
cornu ammonis, this increase was inconsiderable ; and generally
in those cases with unilateral atrophy and sclerosis of the horns
it was the mw-atrophied horn alone which showed it.

The cerebellum was examined in twenty-seven cases, in six
only of which Bergmann’s fibres were visible.

Both as to amount and locality the increase of glia met with
in my cases presented no feature characteristic of epilepsy, and
appears to me to be quite inadequate as a factor in the etiology
of the disease. Its increase can, I think, be more reasonably
accounted for as the expression of a general perversion of the
metabolism which tends to the over-production of simple (con¬
nective) tissues at the expense of the more complex and
elaborate ones (nervous, glandular, etc.) and is to be associated
with a general tendency to connective-tissue increase such as
is found in other viscera, more especially the kidneys.

(3) Sclerosis and atrophy ,—The brain of an epileptic is very
often found to have small areas in the convolutions sclerosed
and atrophied. The consistency of the affected parts may be
only slightly firmer than the bulk of the convolutions, or they
may reach an almost cartilaginous hardness, and the degree of
atrophy varies likewise. The most common sites for these

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1907 .] BY JOHN TURNER, M.B. 61

changes are the cornu ammonis, the cerebellum, and the
parietal or occipital lobes. Microscopical examination fails to
show any increase of glia in the affected parts ; the moderate
amount of gliosis is not more than is often met with in regions
where neither sclerosis nor atrophy is present.

It should be remarked that the brains of certain idiots,
whether epileptic or not, do sometimes show patches of sclerosis
associated with a genuine gliosis, in which giant spider cells
occur, but this is a very unusual circumstance ; it was not
present in any of my forty-two cases, and does not appear to
be in any sense a special characteristic of idiopathic epilepsy.

The cornua ammonis is the part most frequently selected for
sclerosis.

In nineteen of this series (45 per cent.) it was present, and
in the larger series (108) of cases which I referred to in my
paper in the British Medical Journal , March 3rd, 1906, I found
it to occur in the proportion of 48 per cent. The left, when
only one side is affected, is nearly twice as often sclerosed as
the right. According to my experience, and so far as I know
of all who have made a special study of it, this lesion is very
highly characteristic of epilepsy (Pfleger, Worcester, Bratz,
Weber). The microscopical appearances are chiefly of a
negative character: there is no increase of glia, the nerve-cells
are few in number, and those present are generally degenerated,
the vessels lie in wide lymph-spaces and are collapsed and
atrophied, or may have undergone hyaline degeneration. Small
haemorrhages are generally found in the cortex.

Atrophy of limited regions of the cerebellar cortex are very
often detected at the autopsy in epileptics, but more often,
where only a single folium or a part of one is affected, it is only
after microscopical inspection of sections that it is discovered,
and considering the very small portion of the whole organ which
is submitted to a microscopical examination, the probabilities
are overwhelming that these small atrophies occur in a very
much larger proportion than I give below.

The cerebellum was examined in twenty-seven cases, and
localised atrophies found in twelve (44 per cent.). As in the
case of the cornua ammonis, the microscopical appearances are
largely of a negative nature, disappearance of the cells of
Purkinje and the granules, general shrinking of the tissues,
and very rarely any appearance of active glial overgrowth.

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

I maintain that the essential nature of these changes,
whether in the cornua ammonis or cerebellum or elsewhere, is
a starvation of the tissues, due to a diminution or deprivation
of their blood-supply, and it is in connection with what I
believe to be the cause of this alteration in the blood-supply
that these atrophies and scleroses have such great significance
in the pathology of epilepsy.

I submit that the varied site of the lesion, its preference in
the cornua ammonis for the left side, its localised and sharply
demarcated character, and the nature of the pathological
changes observed microscopically can only be satisfactorily
accounted for on the supposition that they have a vascular
origin; and in the intravascular thrombi which I here show
can be demonstrated in 90 per cent . of epileptics’ brains I
believe we have the means whereby the blood-stream to these
parts is diminished or cut off.

By the deposition of hyaline or other forms of thrombi on
the inner wall of the main artery supplying the parts its calibre
may be so reduced that the vessel is unable to convey an
adequate supply of blood to the parts. A reference to Case 1 2
will show that such a state of affairs is no mere hypothesis, but
can sometimes be actually demonstrated. Very often I believe
the obstruction occurs in the small arteries of the cortex, and
that spherical thrombi becoming impacted therein lead to a
gradual degeneration of all the tissues which these vessels
normally supply, the final result being atrophy and hardening.
The absence of necrosis and softening may, perhaps, be referred
to the dilated lymph-spaces, which still provide a certain,
although inadequate, supply of nourishment to the affected
parts ( 3 ).

B. Onuf has drawn attention to unilateral atrophy of the
thalamus in epileptics. I have examined several of my cases
on this point. In three I found a very slight atrophy—once on
the right side and twice on the left.

(4) NERVE-CELLS (a) Number .—All observers have referred to
a diminution in number, chiefly in the second and outer half of
the third layers. I found this in twenty-nine of my forty-one
cases ; in many this sparseness was not evenly distributed, but
here and there were small patches nearly devoid of cells, whilst
in other places they were in good numbers. As was only to
be expected, the twelve who showed no decrease were in most

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1907-]

BY JOHN TURNER, M.B.

cases persons of nearly average intellect (four cases) and high-
grade imbeciles (three cases). I do not think, however, that the
sparseness is altogether due to a congenital absence of cells, there
are several points which militate against this supposition ; the
fact just mentioned of the patchy distribution of the change is
one, and another is the fact that numbers of cells are found
showing different grades of change up to total degeneration.
These degenerated (dead) cells I presume are in course of dis¬
appearing entirely, and would, if time had permitted, have ulti¬
mately done so, leaving the bare patches just referred to. The
greater liability of the smaller nerve-cells to succumb to adverse
circumstances probably accounts for the decrease usually showing
itself in these layers.

(b) Persistence of subcortical nerve-cells .—This condition is a
stigma of defective nervous development, a sign of immaturity,
and was first called attention to in the brains of epileptics by
Roncoroni. These cells are present in new-born infants, but
after a few years only a few remain. In the lower animals
they persist throughout life. Although their axon but rarely,
if ever, can be seen, their nervous nature is indicated by the
characters of their nucleus, and the presence and arrangement
of their chromatoplasm.

Twenty-seven out of thirty-six of my cases showed this con¬
dition, in nine epileptics of average intellect it was found in six
and in nine high-grade imbeciles it was present in eight.

Another sign of immaturity is the persistence of nerve-cells
in the zonal layer. In new-born infants quite a large number
can generally be found, but at the adult stage, in persons whose
nervous system is well developed, it is rare to find any by the
ordinary methods of staining.

(c) Degeneration .—It is easy to recognise degenerated and
probably dead nerve-cells by any ordinary method of staining ;
they appear shrunken, distorted, and with thin, spirally disposed
branches, they stain all over darkly, and their nucleus is small,
angular, dark, and homogeneous. In preparations treated by
Macallum’s method for the detection of phosphorus they show
as dark green bodies, contrasting very markedly with the pale
green undegenerated cells {vide Part I).

In all but five of my cases degeneration was detected, not
as an uniform change but affecting single cells, or little groups
of cells, chiefly in the second and third layers of the cortex.

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6 4

ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

(d) Swelling of nucleus .—I believe this to be an early stage
in the downward grade towards degeneration. Cells charac¬
terised by an abnormally large clear nucleus were noted in
eighteen cases. This change also affects single cells and little
groups of cells, and groups of cells with swollen nuclei and
groups of shrunken darkly-stained cells are often met with in
the immediate neighbourhood of each other.

I attach considerable importance to these changes, for I
believe that their localised occurrence can most reasonably be
explained by the assumption that there has been some inter¬
ference with the normal blood-supply of the affected cells; and
I further believe that this interference is caused by the impac¬
tion of minute emboli in the capillaries supplying them. The
swollen nucleus stage is particularly interesting because it has
been found experimentally that by ligature of the cerebral
vessels in the dog just such an alteration is produced in the
nucleus of its cortical cells (Mott).

In many cases I have noticed a distinct enlargement of the
nucleolus.

(e) Betz cells .—These cells occurring only in a very limited
region of the cortex are by their size and the definite arrange¬
ment of their chromatoplasm peculiarly adapted for demon¬
strating alterations in cell-structure. I shall not dwell, how¬
ever, on the changes with which we are familiar as the result
of definite toxic or other morbid excitants, for although such
changes are, of course, met with among epileptics, they do not
in my opinion constitute any characteristic of the disease, but
are merely an accidental accompaniment. The form of Betz
cell to be considered is one which, as I shall show, appertains
to defectively developed brains ; it is an immature form. It is
found normally in some of the lower animals and in young
cells (Lugaro, van Bervliet), and, as I pointed out some years
ago in this journal, is commonly found in imbeciles. As the
form is identical in appearance with that which characterises
the early stage of reaction a distance , or axonal reaction, there
will be no necessity to more fully describe it.

I will here briefly give the results of an examination of a
large number of brains from all forms of insanity in respect to
this axonal character of the Betz cells. These results clearly
show its importance as a stigma of defective development. In
303 cases of insanity in whom the ascending frontal region

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BY JOHN TURNER, M.B.

1907.]

of the brain was examined the Betz cells were of an axonal
character in 106 (35 per cent).

When these cases were classified there was found to be a
great difference in the incidence of the change in different
classes; at one extreme came the congenitally defective (idiots
and imbeciles) with 67 per cent., at the other the general para¬
lytics with only 19 per cent. Amongst cases in whom per¬
sistent melancholia was a feature the incidence was practically
the same as with imbeciles (66 per cent), whilst in all the
remaining classes together it was 3 8 per cent. I do not wish
to imply that an immature form of Betz cell is necessarily
synonymous with defective intellect, merely that those with
defective Betz cells will be more likely to possess other defects
of nerve-structure which do immediately subserve intellectual
functions. Certainly in the population of this asylum, and
probably in most public asylums, the general paralytics as a
class are far above the other patients intellectually, and it is,
therefore, interesting to notice the comparatively small propor¬
tion of cases with axonal cells amongst them.

To return to the epileptics, in all but twelve of my forty
cases (in one the ascending frontal region was not examined)
the axonal form of Betz cell was met with (70 per cent) and
the proportion of cases amongst those of average intellect in
whom this change occurred was very slightly below the general
average—in six out of nine, or 66*6 per cent .

(/) Purkinje cells were apparently diminished in number, and
groups of degenerating cells were very commonly met with. In
only six cases (22 per cent) did they show an axonal character.

From the preceding account of the changes in the nerve-cells
of epileptics it will be observed that there are two distinct
varieties found. The first is a change indicating defective
development This was what might have been anticipated con¬
sidering the large proportion of idiots and imbeciles included
in these cases, but it should be noticed that the cases in whom
the intellect was nearly or quite of the average showed stigmata
of degeneration in almost as large a proportion as those of very
low intelligence. The defect shown does not seem necessarily
to imply defect of those parts which immediately subserve
intellectual function. The second is a degenerative change
which at first manifests itself in an acute form by swelling of
the nucleus, then by degeneration and death of the nerve-cells,

LIU. S

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

and finally by their total disappearance, leaving areas quite
devoid of cells. This sequence I believe follows an obstruction
to the blood-supply, caused by impaction of intra-vascular
thrombi in the capillaries or small nutrient vessels of the parts
affected.

(5) Vessels .— (a) Structural alteration was, as a rule, an
inconspicuous feature. In sixteen cases thickening generally
of the muscularis was noted, but in all except one or two this
was slight; hyaline degeneration, accompanied by thickening,
was present in four, in one of these to a marked extent in the
veins of the cornu ammonis (Case 27), endarteritis in three.

(b) An increase of the perivascular (and pericellular) elements,
although not to a marked extent, was generally present. By
the method of staining which has been used in this investiga¬
tion, these elements appear as free nuclei measuring 4 — 6/1,
and staining intensely, or they may show a minute trace of
cytoplasm. They tend to adhere to the distal wall of the
lymph-space, and not, as plasma-cells do, to the vascular. I
believe that some light is shed on the true nature of these
bodies, which has for long been a matter of dispute, by the
observations I recorded in the Review of Neurology and
Psychiatry , December, 1905, of the appearance they some¬
times present when stained by my pseudo-vital method.
Under some conditions not yet understood this stain occa¬
sionally picks out these elements, and it can be seen that they
are really small cells with delicate branches, investing the
nerve-cell or vessel by which they lie, and that they appear
similar to the elements which Ford Robertson has described as
mesoglia-cells.

(r) Distension and haemorrhage .—The arteries of the cortex
are usually collapsed and tortuous, lying in somewhat dilated
lymph-spaces, the veins distended with blood and fitting closely
their lymph-spaces. A varicose condition of the veins was
noted in several cases. Haemorrhages into the meninges or
small capillary haemorrhages of the cortex were practically a
constant feature.

id') Morbid appearances within the vessels. —The presence of
large numbers of blood-plates and various forms of thrombi
are, I believe, of prime importance in the pathology of epilepsy.
The blood-plates usually form clusters of exceedingly small
round granules, about i’5 /i in diameter; they stain intensely

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JOURNAL OF MENTAL SCIENCE, JANUARY, 1907.

Fir,. 7.

Fia. 8.

Fig. 9.

To illustrate Or. John Turner's paper.

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1907 .]

BY JOHN TURNER, M.B.

with polychrome blue, and, in fact, react to different stains
exactly as blood-plates do in films. When treated with
Macallum’s method they assume a dark green, showing that
they are rich in phosphorus and indicating their nucleo-proteid
nature. Crowds of these bodies may fill up entirely a small vessel
or capillary, or they may form isolated groups surrounded by
erythrocytes. Somewhat larger spherical bodies can generally
be seen in the groups apparently formed by coalescence of
several blood-plates (Fig. 7) and specimens showing all
grades in size from a blood-plate to the largest spherical
thrombus can be readily obtained. The larger spherical
thrombi often amalgamate into cylindrical masses, filling up
entirely the lumen of a capillary or bigger vessel. Some¬
times, again, these thrombi deposit themselves around the
lumen of a vessel and partially obstruct it. The above-men¬
tioned clots, which are of a hyaline or homogeneous character,
react to stains and to Macallum’s phosphorus test precisely as
the blood-plates, and in all probably they are caused by a
fusion of these little bodies (Fig. 8).

Another kind of clot takes the form of a finely granular
material, which although it gives a positive reaction to phos¬
phorus, stains a much paler green than the blood-plates. It is
found often in large masses, either completely obstructing
vessels or adhering to their inner wall. I am not certain
whence this clot originates ; possibly in some cases it is from
the disintegration of erythrocytes which Paul Masoin has
shown are extensively destroyed before fits, and in this respect
it may be noted that it assumes the same intensity of green as
the erythrocytes with the phenyl-hydrazin test ; possibly in
other cases it represents a stage in the resolution of the
hyaline clot (Fig. 9).

With reference to the ultimate fate of the clot, probably
small masses which have blocked a capillary may after a time
be washed into the general blood-stream, or may lie so firmly
impacted as to remain fixed, in which case the parts deprived
of their blood-supply suffer permanent impairment as already
pointed out Probably in many cases the larger masses undergo
a process of resolution and disappear (vide Case 23).

I have shown elsewhere (Review of Neurology and Psychiatry,
February, 1905) that this phosphorus-containing clot is the
result of a vital process and not a post-mortem phenomenon ;

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

and the fact that blocked vessels are so often greatly distended
on one side indicates that the coagulation is not merely a
moribund phenomenon, but occurs at a time when the circula¬
tion is still active.

In all but four of my forty-one cases these thrombi were
met with (90 per cent.), and as it has been shown (Cases 1 and
41) that these depositions may be restricted to very localised
sites in the brain, it is quite possible that they were also present
in the negative cases, though I failed to demonstrate them.

Before leaving the subject of thrombi there are a few remarks
to be made on extra-vascular clot. In two cases (Nos. 8 and
15) vitreous and hyaline material were found deposited outside
the vessels, which, although they presented different appearances
to intra-vascular thrombi, were shown in one case (No. 15) to
be of a nucleo-proteid nature. In a third case (No. 27) the
material outside the vessel in the lymph-space reacted both to
ordinary stains and to the phenyl-hydrazin test in a similar
way, and was unquestionably of the same nature as the clot
quite close to it inside the vessel. It would seem as if under
certain conditions there may be a transudation from the blood¬
vessels of a phosphorised material which subsequently clots
and undergoes calcareous changes.

(b) Spinal cord was examined in twenty-five of the cases.

The character of the lesions found was similar to those in
the brain, but the changes in the cells and the amount of clot
were less marked.

The cells of the anterior horns appeared natural in ten,
their condition was not mentioned in three, and in twelve
they were affected. The changes noted were as follows: In
seven, shrinking and staining of the ground-substance, so that
the Nissl bodies, although present, were obscured. The nucleus
was increased in density, and more or less darkly stained also.
In four cases only an axonal character of some of the cells was
noted, and in three of these it was most marked in the lumbar
sections. In one case the cells at all three levels appeared
extensively degenerated. Occasionally where sections stained
by polychrome blue for Nissl characters showed no pigment in
the cells, the sections from the same case stained by osmic
acid showed a clump of very nearly black pigment situated
around the nucleus, which in all probability represented a fatty
pigment. This must be differentiated from the usual yellow

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I907-]

BY JOHN TURNER, M.B.

pigment, which is generally situated at one end of the cell, and
stains brown with osmic. This fatty pigment was specially
noted in Cases 12, 14, 36, and 37.

Punctate haemorrhages in the grey and white matter were
noted in two cases (26, 33), atrophy of one forehom in two
cases (2, 27), heterotopia spinalis in one (26).

An interesting feature was the great frequency with which
degeneration or (? congenital) deficiency of medullated fibres
was met with in the posterior columns. In twenty-four cases
examined in this respect it was found in ten (43 per cent .), and
it was not only in the idiots and low-grade imbeciles, but
among high-grade imbeciles and persons of fairly normal
intelligence and free from bodily deformity (Cases 13,
22, 25).

It was the columns of Goll which were affected as a rule,
and in only two cases (10 and 23) were recently degenerated
(Marchi) fibres seen. Sometimes the whole columns from the
lumbar to the cervical regions were affected ; in other cases
(19, 22, 27) the deficiency of myelinated fibres lay alongside
the posterior fissure only, as a thin strip tending to bulge out
in the middle and here occupying about the site of the oval
tract of Flechsig (probably a descending endogenous tract).

When the cord, after being hardened in Muller's fluid, was
cut transversely a pale area limited to Golfs columns could
often be detected by the naked eye, and sometimes when
sections from these cases came to be stained by osmic acid or
by Weigert's method, no changes whatever could be detected,
and in other cases, although there did not appear to be any
increase of interstitial tissue, large empty spaces or lacunae were
observed, indicating, I believe, a congenital absence of fibres.
If the changes met with in the posterior columns represented
a breaking down of previously existing medullated fibres, the
Marchi reaction would probably have been met with more
often.

Is there any connection between the changes observed in the
posterior columns of the spinal cord, a path by which afferent
impulses are conveyed to the brain, and the condition of the
Betz cells ? It has been shown that after section of the pos¬
terior roots certain cells in the anterior horns are found in an
axonal condition, and W. B. Warrington has suggested that
they acquire this condition owing to a deprivation of the afferent

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

impulses which normally impinge upon them. One is tempted
to assume that the reason, at any rate in some cases, why the
Betz cells remain in an immature state in imbeciles may be
because they do not receive an adequate supply of afferent
impulses.

Degeneration of the pyramidal tracts was only met with in
seven cases, and in three of these the Marchi reaction indicating
recently degenerated fibres occurred. This lesion represents
in all probability changes secondary to degeneration of the
nerve-cells of the brain, especially the Betz cells.

PART IV.

Conclusion.

I will now briefly state the evidence showing the efficiency of
stasis or cerebral anaemia as an excitor of convulsions.

(1) Ligature of cerebral arteries in animals .—Astley Cooper
tied both carotids in a rabbit and compressed both the vertebral
arteries, and spasm immediately resulted. In 1857 Kussmaul
and Tenner showed that if the left subclavian and innominate
arteries in rabbits be suddenly tied, general convulsions began
in from three to forty-five seconds after.

There is no essential difference in the symptoms whether the
arterial supply is cut off or the venous output is blocked up.
Hermann and Esher ligatured the superior vena cava and
azygos veins, the veins of the spinal cord and the vertebral canal,
and obtained a typical spasm, occurring, however, after a more
prolonged interval. Ferrari injected wax into the venous
sinuses, and when every sinus was blocked an epileptic fit
occurred.

Leonard Hill states that he has repeated Kussmaul and
Tenners experiments and finds that nearly all the rabbits die
exactly in the manner described by these authors, and in cats
about 40 per cent . die in exactly the same way.

(2) Compression of carotids in man. —Kussmaul and Tenner
compressed both carotids in six men. In two only—and
both these , they state, were of weak intellect —general spasms
resulted and all the phenomena of a slight epileptic fit.

Schiff by compression of his own carotid produced spasms

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1907.] by JOHN TURNER, M.B. 71

on the opposite side of his body, preceded by a sense of numb¬
ness and formication.

L. Hill twice produced clonic spasm in himself by compres¬
sion of one carotid artery, and he states that “ sudden occlusion
of one carotid can in some men produce a march of epileptic
spasm preceded by an aura.”

(3) Intravenous injection of oily substances .—For many years
it has been known that intravenous injection of absinthe
produces epileptiform seizures.

L. Pierce Clark states that Joffroy was able to produce con¬
vulsions in rabbits by the injection of furfurol, but of ninety-
seven rabbits so injected only sixty-nine developed convulsions.

I have seen epileptiform convulsions produced in a rabbit
two days after an intravenous injection of clove-oil.

These experiments show that convulsions simulating epileptic
can be produced by sudden stasis of the cerebral circulation,
but they also indicate the necessity of some other factor
beyond stasis, otherwise all and not only two of Kussmaul and
Tenner’s cases of carotid compression, and all, not only 71 per
cent,, of Joffroy’s rabbits, should have been convulsed. This
other factor is, I believe, a suitable condition of nerve-cell and
in all probability one of highly unstable equilibrium, such as
we should expect to find in an immature form.

I claim to have shown that among my cases 70 per cent .
showed defective structure, and 90 per cent, showed in the
form of thrombi a blood state capable of acting as an excitor
of convulsions. Granting for the moment that my supposition
is correct, then a number of hitherto isolated and apparently
unrelated phenomena are brought into line and are capable of
being grouped under one cause. Impaction of thrombi in capil¬
laries would account for the patchy degeneration of the nerve-
cells. Impaction of thrombi in small vessels, or obstruction of
large vessels by the same means would account for the isolated
areas of sclerosis and atrophy, and I believe that venous obstruc¬
tion might result in the formation of angeiomata, and clinically
that the condition of the blood which results in this tendency
to rapid clotting (not a massive clotting) would account for the
great facility with which wounds in epileptics heal.

The varied phenomena which sometimes replace the con¬
vulsive-seizure, attacks of petit mal and what are termed psychic
equivalents of a fit offer no serious objection to my supposition

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

In attempting to account for these, through the agency of intra¬
vascular thrombi, we must bear in mind several conditions having
reciprocal relations to each other. First, the locality in which
a clot is lodged—whether the site happens to correspond to a
silent or explosive area of the cortex. If in the first region it
is conceivable that the resulting phenomena will partake of the
nature of an attack of petit mat or represent a psychic equi¬
valent. Second, the strength of the stimulus, and its rapidity
of application, for it is not to be supposed that a minute
thrombus affecting only a very limited capillary cortical area
will produce, other things being equal, such marked effects as
a larger thrombus cutting off the blood-supply from a larger
area of cortex ; and coagula deposited so as only to obstruct
a vessel will produce less marked effects than those which by
entirely blocking vessels, completely and suddenly cut off
the blood-supply. Third, and probably most important of
all, the degree of initial defect of cerebral structure must be
reckoned with, according to which the equilibrium of the nerve-
cells will vary in such a way that some will be more liable than
others to respond explosively to the stimulus. It is quite pos¬
sible also in connection with this factor that at certain times in
individual cases the nerve-cells will be in a more irritable con¬
dition than at others, so that while at one time the stasis causes
only a single fit, at another it may cause a series or even the
status epilepticus .

Except in cases complicated by general inflammatory dis¬
eases or general paralysis, it is my experience that thrombi of
the nature I have described in epileptics are not commonly
met with in other forms of insanity. They do occur sometimes
in large amount, especially in imbeciles not known to be subject
to epilepsy.

With reference to the unfavourable aspect which this fact
may be supposed to bear against my thesis, the question arises
if, and to what extent, every lunatic is a potential epileptic. In
my opinion a very large number, more especially of those
with congenital defect, come under this category in so much
that they contain within themselves certain but not all the
factors required for the production of epilepsy ; sometimes they
may lack the necessary condition of the nervous system, some¬
times the necessary qualities of the blood.

My experience, probably shared by all who have much

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1907.]

By JOHN TURNER, M.B.

acquaintance with the congenitally defective, is that one of
this class not previously known to have had fits may at any
time develop them ; some may reach middle life before they do
so, or some during the whole course of their lives may only
have one fit or a single batch of fits.

It is also quite a common occurrence for the aged insane to
develop epilepsy. These cases are interesting in so much as
the mechanism of their convulsive attacks, I believe, resolves
itself into two factors of the same nature as in idiopathic
epilepsy; these are (1) an unstable condition of nerve-cells,
senile dissolution of the nervous system, and (2) a condition
of stasis or cerebral anaemia, resulting from arterial disease.
In all such cases coming to an autopsy—and I have met with
several—endarteritis obliterans has been found.

ADDENDUM.

The Coagulability of the Blood in Epileptics.

The method employed was that introduced by Sir A. E.
Wright and Dr. Paramore, and fully described by them in the
Lancet\ October 14th, 1905.

The calibrated capillary tube with an attached indiarubber
teat was so arranged by means of a mercury piston that it
would suck up a definite quantity of the blood which occupied
a definite length of the tube. The blood was taken from a
prick on the finger. The tube was then placed in water
at blood heat (37° C.) and tested at short intervals to find
when fibrin first appeared. This was done by taking the tube
out of the water and gently squeezing the teat, and allowing a
portion of the blood to come upon blotting-paper. So soon as
fibrin formed fluid blood no longer came away, but a long, con¬
tinuous thread of fibrin. The authors speak of shreds of fibrin
forming before a continuous thread ; but I was not able to detect
these, and I took as the coagulation point that time required
for the formation of a definite fibrin thread, such as, on gentle
pressure of the teat, could be seen stretching from the blotting-
paper to the end of the capillary tube, when the latter was
withdrawn a short distance from the blotting-paper.

On account of the diversity in the time of coagulation of
different samples from the same subject taken at one sitting, I

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

took in all cases at least three and sometimes five samples and
selected the one which clotted in the shortest time.

As Buckmaster observes, different observers using different
methods have arrived at very conflicting results, and on this
account it is difficult, if not impossible, to state the exact
coagulation-time of healthy blood. Again, coagulation is
influenced by a variety of conditions, many of which are
imperfectly understood ; thus the admixture of lymph, muscle-
juice, or blister fluid (Delezenne, Wright) seems to accelerate
coagulation, and Arthus has shown the influence which is
excited by a wound on the rate of coagulation, and the short
coagulation-time of a mixture of blood and lymph from a
squeezed superficial puncture, contrasted with the much longer
time when the blood issues freely from a deeper puncture. In
the case of successive bleedings the blood has been noted
to clot more rapidly.

The above remarks, extracted from Buckmaster’s book on
The Morphology of Normal and Pathological Bloody will serve
to give some idea of the difficulties in the way of a com¬
parison between the coagulation-rate in epileptics and non¬
epileptics. I soon found that no absolute statements could be
made regarding the coagulation-time of the blood in epileptics
or other cases of insanity, for there is sometimes a difference
of over sixty seconds between different samples of blood taken
at one sitting from the same case, and in the great majority
of cases there is a difference varying between fifteen and
thirty seconds.

There is another point to be noticed, which is, that the
coagulation of the blood, as determined by the method used,
depends upon the formation of fibrin. Now, this is the least
characteristic form of thrombosis found in epilepsy. I draw
attention to this because I at first thought that the rapidity
with which wounds heal in epileptics might be accounted for
by decrease in the time of coagulation of their blood, which
would seal the injury and prevent the ingress of micro-organ¬
isms ; but although I found some decrease in these cases
during fits, it was not sufficient to support the idea as first
formulated. Some observations made by Dekhuyzen, however,
indicate that one of the functions of the blood-plates is to stick
together and close wounded vessels, a phenomenon entirely
different from a massive coagulation of the blood, and in the

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1907]

BY JOHN TURNER, M.B.

light of these observations it seems to me quite probable that
the epileptic's facility for healing depends on rapid closure of
wounds by local coagula, although Wright and Paramore’s
method does not enable one to show this.

It might seem, in face of the various drawbacks mentioned,
that an investigation into the coagulability of the blood of
epileptics would not be of much value; still, I am of opinion
that the following observations made under similar conditions,
so far as possible, and at the same time of day, are of interest,
as they show that in most cases there was, at or about the time
of fits, a distinct acceleration of coagulation, and this occurred
too often, I think, to have been a mere coincidence.

Between eleven and noon the blood from twenty-eight
female epileptics was examined on 135 occasions in the
months of January to April of last year.

The mean coagulation - time in these was 120 seconds;
under similar conditions the mean coagulation-time in thirteen
cases of insanity of various forms and about the same ages as
the epileptics examined on thirty-eight occasions was 136
seconds.

Only twenty-three of the cases had fits whilst under ob¬
servation, and in eighteen of these (78 per cent.) the coagulation¬
time was shortened at or about the time of fits. Sometimes a
single fit was associated with an appreciable shortening of the
coagulation-time, sometimes it was not.

The following is a synopsis of the eighteen positive cases.
The coagulation-time in every case is given in seconds:

Case 1.—Shortly after a batch of fits her coagulation-time
was 60; twenty-four hours later it had risen to 90 ; no further
fits in between.

Case 2.—No fits for some days ; coagulation-time was 120.
Between January 30th and February 4th, during which period
she had four fits, it was respectively 60 and 100.

On February 19th, when she had been free from fits for four
days, it was 165. On February 23rd, forty-eight hours after
two fits, it was 120.

Case 3.—On January 31st, whilst having fits, her coagulation¬
time was 75. On February 19th, when she had been free from
fits for three days (nor did she have any for three days subse¬
quently), it had risen to 150.

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76 ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

Case 4.—Only subject to single fits, and had not had any for
several months when her blood was examined on February 1st,
the coagulation-time being 150. On February 9th, a few hours
after a fit, it was 60.

Case 5.—On July 1st, whilst having a number of fits, her
coagulation-time was 60. Then, again, during a period from
the 16th to the 26th, whilst she had four fits, it ranged between
105 and 115. On March 3rd, when she had not had any fits
for two days previously and did not for two days subsequently,
it rose to 180.

Case 6.—On February 3rd, just two hours after a strong fit,
her coagulation-time was 75. On February 18th it was 105.
She had had several fits the day before and one this day. On
the 21 st it rose to 135; she had had no fit this day, nor for
two days previously, and did not have any for several days after.

Case 7.—The appended chart gives in graphic form the
record of her fits and coagulation-time:

Case 8.—On February 5th, when free from fits, her coagula¬
tion-time was 180. On the 7th, the day after a strong fit, it
was 130.

Case 9.—February 20th. On this day she had a fit, her
coagulation-time was 120. On the 23rd, when she had been
free from fits for two days, it rose to 165 ; on the 25th, after
a fit, it fell to 145.

Case 10.—February 8th, having fits while the blood was
taken, her coagulation-time was 90, the next day 75. On the
17th, when free from fits for a week, it rose to 105 ; she had
no fits also for a week subsequently.

Case 11.—On February 8th, lying in a dazed condition, the
result of four strong fits during the night, her coagulation-time
was 60. On the 10th, able to walk and free from fits, it rose
to 120 and next day to 140. On March 10th, again when
having fits, it was 120.

Case 12 .—On February 9th her coagulation-time was 6$ ;
she had five fits twenty-four hours previously. On the 16th,
about twelve hours after a fit, it was 145 ; on the 17th, no
further fits, it was 155. Again, on February 23rd, during a

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Cask 7.—The continuous line records the coagulation time, the dotted line the number of fits in the twenty-four hours.

7 8

ANATOMY AND PATHOLOGY OF EPILEPSY, [JaiL,

“ fitty ” period, it fell to 95 and on the 25 th, when free from
fits, rose to 165.

Case 13.—On February 10th and I2th, during a period of
fits, her coagulation-time was respectively 60 and 120. On
February 26th, 28th, and March 1st, when free from fits it
was respectively 105, 180, and 130.

Case 14.—On February 12th, one hour after a strong fit,
her coagulation-time was 105. On the 16th, no further
fits, it had risen to 145.

Case 15.—On February 12th, four hours after a fit, her
coagulation-time was 135. On March 8th, when free from
fits, it rose to 160.

Case 16.—She had a succession of fits on February I ith and
12th, and on the 13th her coagulation-time was 135. The
next day, no further fits, it had risen to 210.

Case 17.—On February 2ist, in status epilepticus , her
coagulation-time was 135. On the 24th, when recovered
and free from fits, it was 150, and on March 8th, when free
from fits, it was 165.

Case 18.—On March 27th, in status epilepticus , her coagula¬
tion-time was 95. The next day, fits having ceased for nearly
twenty-four hours, it was 135 and the next 170.

Case 19.—I have only had the opportunity of testing a
single case in which the fits were entirely of the petit ntal type.
Observations were made on a dozen occasions, and I was not
able to determine any marked difference, in the coagulation¬
time, in blood drawn at or about the time of attacks and that
drawn when she was free from attacks.

On the whole the evidence seems to me to favour the idea
that serial or even single fits are associated with an increased
tendency of the blood to coagulate.

In the following table are given the dates when examined,
the coagulation-time in seconds, and the incidence of fits, of the
nineteen epileptics previously referred to :

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BY JOHN TURNER, M.B.

1907.]

Cue.

Date.

Coagula¬

tion-time

Jan. 30

(seconds).

» 3i

Feb. 15

» 22

» 24

120

Mch. 4

*35

» 6

130

„ 8

105

Average

107

Jan. 29

120

» 30

Feb. 4

100

» 15

140

,» 19

1^5

» 23

120

» 25

125

» 27

120

Average

”9

Jan. 31

Feb. 19

I 5 °

Average

I 12

Feb. 1

ISO

» 9

Average

xo 5

Feb. 1

> » 9

,, 16

„ 20

» 22

ii5

» 24

115

u 26

105

Mch. 1

140

»> 3

180

„ 6

155

Average

Remark*.

Another sample did not coagulate until 120;

recently had a number of fits.

No further fits.

One fit on the 12th, one on the 16th, one on
the 17th.

One fit on the 23rd.

Two fits on March 3rd, one on the 4th.

One fit in the morning.

No fits.

No fits for several days.

On Feb. 2nd had one fit, on 3rd had three
fits.

Two fits during the day.

No fits since the 15th.

Two fits on the 21st

Another sample did not clot until 170; no
further fits.

Another sample did not clot until 180; no
further fits.

Having fits.

No fits, nor for three days previously and
three days subsequently.

Has had no fits for several months; only has
single fits.

A fit this morning.

Having a number of fits, and for several days
No fit for five days.

One fit this morning, first for five days.

One fit yesterday, none to-day.

No fit
One fit.

One fit yesterday.

No fits to-day or yesterday.

One fit yesterday.

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

Coagula-

Case. Date. tion-time
(seconds).

6 Feb. 3 75

„ 18 105

» 21 135

Remarks.

Strong fit two hours previously.

One fit to-day and several yesterday.

No fit to-day, and none for two days previously
and several days after.

Average 105

Feb. 3

Taken during a period when she was having
several fits daily (two on day of observation).

» *5

“5

Ditto (three fits).

» 17

i 35

Only one fit to-day.

„ 19

130

Two fits to-day.

„ 22

Two fits to-day, four yesterday.

„ 24

130

Three fits to-day.

„ 27

120

Four fits to-day.

„ 28

”5

Three fits to-day.

Mch. 1

130

Two fits to-day.

„ 2

130

Three fits to-day.

» 3

120

Two fits to-day.

„ 4

120

Three fits before examination, three fits in the
night after.

» 5

One fit.

.. 6

120

» 9

i°S

Average

U 5

Feb. 5

180

Not having fits.

,1 7

130

Strong fit yesterday.

Average

*55

Feb. 6

120

Just after a fit, had two in the afternoon.

» IS

105

No fits.

„ 20

120

One fit.

» 23

165

No fit.

» 25

145

One fit.

Average

131

10 Feb. 8

Having fits whilst sample is taken.

» 10

Lying dazed on the floor, only able to walk
with assistance. No fits since yesterday, but
several then.

„ 17

105

No fits for a week before, nor on the day, or
for the week following.

Average 90

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BY JOHN TURNER, M.B. 8 1

Case.

Coagula-
Date. tion-time

(seconds).

Remarks.

Feb. 8

Had four strong fits last night. Is lying in a

dazed condition, unable to stand.

„ IO

120

No more fits; much better; able to walk.

» ii

140

No more fits ; much better.

Mch. io

120

For the last week has had two or three fits

each night.

Average

Feb. 9

Five fits the night before last; none since.

„ 16

*45

One fit yesterday, none to-day.

» i 7

*55

No further fits.

» 23

„ 2 5

165

For the last four nights having fits (3, 3, 2, 1).
No fit since the 22nd, but one the night

following.

» 27

**5

Two fits each night for the last two nights.

Mch. 7

120

Several fits in the last three nights (2, 5, 2).

Average

124

Feb. 10

One fit yesterday afternoon,-j D ri riod of

•SZJZT* fits coagulation-

„ 12

120

Four fits yesterday. ime 9 °’

n 26

105

No fits recently. \ During period when free

„ 28

l8o

„ „ f from fits coagulation-time

Mch. 2

130

Average

119

Feb. 12

*°5

Strong fit one hour previously.

„ 16

*45

No more fits.

Average

125

Feb. 12

135

One fit four hours previously.

Mch. 9

160

No fits for some time.

Average

147

Feb. 13

135

Succession of fits on the nth and 12th; none

to-day.

„ 14

210

No more fits.

» 21

I IO

No fits since the 18th, on which date she had

one.

» 23

IOO

No fits.

» 25

135

»»

135

Average

*37

LIII.

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ANATOMY AND PATHOLOGY OF EPILEPSY, [Jan.,

Coagula-

Case. Date. tion-time
(seconds).

17 Feb. 21 135

„ 24 150

Mch. 8 165

Average 150

18 Mch. 17 95

„ 18 135

„ 19 170

„ 20 140

„ 21 150

Two attacks yesterday afternoon and one in
the night.

No further attacks noted.

One attack last night.

Three attacks last night, and two in the after¬
noon about 3 p.m.

No further attacks.

>» >1

One attack last night and one in the afternoon.

Just after attack.

Two attacks in the night.

One attack yesterday at 10 a.m. and one in the
afternoon.

No attack since the 14th.

Average 141

FIGURES.

Fig. 1.— x 400. Case No. 8: Rounded and dumb-bell-shaped bodies with
concentric markings, lying in the cortex of the brain. The outer rim of these
stains bright blue with toluidin blue ; the centre is nearly colourless. They repre¬
sent an earlier stage of the deposits shown in the next figure.

Fig. 2.— x 300. Case No. 8 : Vitreous masses lying in the cortex and show,
ing radial fractures. They still possess an outer rim which stains with toluidin
blue, but their centre is colourless and glass-like. Notice the absence of any glial
overgrowth in the vicinity of the deposits.

Fig. 3.— x 400. Case No. 15 : Deposits lying around and alongside capillaries
in a roof nucleus of the cerebellum. The section had first been treated with
hydrochloric acid, subsequently stained with erythrosin and toluidin blue.

Fig. 4.— x 600. Case No. 15 : Section not treated with hydrochloric acid.
Vitreous deposits in the granule layer of the cerebellum. In the lower part of the

Average

138

Mch. 31

170

April 3

155

„ 4

i6 5

„ 6

i 35

„ 7

140

„ 8

120

„ 9

*35

„ 10

l 5 °

„ 11

120

„ 12

r 3 °

„ 14

I2 5

„ 16

i 55

In status.

No fits since yesterday; in bed but quite
active and cheerful.

Up and in usual health ; no fits.

»j » >>

i) » )>

Remarks.

A few hours after status , in bed conscious but
dazed.

No further fits.

11 11

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1907.]

BY JOHN TURNER, M.B.

«3

figure, lying around a capillary, are masses of a waxy-looking material, which take
00 a very pale tint with toluidin blue and are of the same nature as the deposits
shown in Fig- 3 -

Fig. 5.— x 600. Case No. 19: A Betz cell with swollen, bladder-like nucleus.
The cell may also be used to illustrate an advanced state of the form which is
met with in 70 per cent, of imbeciles, and which is indistinguishable from the
axonal condition.

Fig. 6 . — x (about) 100. Case 21 : A wedge-shaped atrophic patch in the top
of one of the foliae of the cerebellum. The larger, dark, isolated bodies are granular
corpuscles. Note the entire absence of granules in the atrophic region and the
overgrowth of glia, especially in the position where the molecular and granular
layers join.

Fig. 7.— x 600. Case No. 41: Cortical vessel containing a mass of blood-
plates, which in places have fused together to form larger spheres.

Fig. 8.— x 400. Case No. 12: Hyaline spherical thrombi lying in a vein in
the granular layer of the cerebellum.

Fig. 9.— x 400. Case No. 33 : An arteriole and venule in the cornu ammonis;
the former is plugged in its lower part by finely granular clot, which stains a paler
green than the blood-plates, the small, round, darker bodies lying within the
granular clot. In the venule is a hyaline spherical clot.

Figs. 7, 8, 9 were from photographs of preparations, prepared by Macallum's
method for the detection of phosphorus.

References.

Bleuler. — Munch, med. Woch., 1895.

Bratz.— Arch. f. Psych. , xxx, I, 3.

Buckmaster, S. A.— Morphology of Normal and Pathological Blood. London,
1906.

Crkite. — Munch, med. Woch ., 1903.

Drysdale, J. H.— Path. Soc. Trans. , 1904.

Clark, L. Pierce. — Amer. Journ. of Insanity, April, 1900.

Hill, L.— The Cerebral Circulation. London, 1896.

Kolk, S. van der. — New Sydenham Society. London, 1859.

Kussmaul and Tenner. —New Sydenham Society. London, 1859.

Masoin, P. — Arch. Intern, de Pharmac. et de Thtrap., 1904.

Mott, F. W. —Croonian Lectures. London, 1900.

Oxuf, B. — Journ. Amer. Med. Assoc., April, 1905.

Pfleger. — Allge. Zeit.f. Psych., xxvi.

Roxcoroni. — Arch, di Psich., 1896.

Turner, I.— Journ. Mental Science, 1903; Ibid., Review of Neurology and
Psychiatry, February, 1905, and December, 1905; British Medical Journal , March
3rd, 1906.

Weber, L. W.— Beit. b. Path. u. Pathol. Anat. d. Epilepsie, 1901.

Worcester, W. L.— Journ. of Nervous and Mental Dis., 1897.

Ziegler. — Pathological Anatomy. London, 1896.

( l ) And since this was in print with another case, an epileptic, in whom there
•ere extensive vitreous deposits in the cortex and meninges in sclerosed areas of
each parietal lobe. This case was of interest, as it showed appearances supporting
the view that the deposit originates from the blood. Masses of a waxy-looking
material, in some places partly vitreous, which gave a positive reaction for phos¬
phorus, were deposited in large amount in the muscular and adventitial coats of
the meningeal arteries in these regions. Pick ( Neurolog. Centralblatt, No. 16,
1903), who has drawn attention to the frequency with which the finer and finest
vessels in the brain are calcified in tetany, states that the deposit sometimes con-

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AMENTIA AND DEMENTIA,

[Jan.,

tains iron.—( : ) Since this was written, by the kindness of Dr. D. Hunter, of
Goodmayes Asylum, I have had the opportunity of examining the nervous system
of an epileptic idiot act. 13, in whom also a heterotopia spinalis was observed,
with two central canals.—(*) The Lancet (November 24th, 1906) records a case of
Bilharzia reported by Drs. Tsunoda and Shimamura, in which the patient suffered
from Jacksonian epilepsy, and at the autopsy amongst other lesions a number of
wedge-shaped areas of sclerosis were found in the brain. On histological ex¬
amination these areas were found to contain ova in considerable number, which
had doubtless produced embolism of the arteries. I quote these observations to
support the view that cutting off the blood-supply of small areas of the brain
does not necessarily result in softening.

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

PART III.—DEMENTIA ( continued ).

PAGE

[Introduction ..... ...... LU. 22IJ

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

the cerebrum .......... LU. 224]

[Mental confusion and dementia ........ LU. 428]

[Varieties of dementia . Lll. 711]

[Group I—Primarily neuronic dementia ...... Lit. 716]

[fa) Senile or “ worn-out” dementia .LU. 717]

(b) PresenUe or " climacteric ” dementia .84

(1) Mania with dementia. 90

(2) Melancholia with dementia.93

(3) Insanity with dementia.

(4) Simple dementia.

[(d) Premature dementia (dementia prcecox) .j

[Group II—Progressive and secondary dementia ...... ]

[Group III—Special varieties of dementia ....']

Group I.—Primarily Neuronic Dementia.

Class (B).

PresenUe or “ Climacteric ” Dementia .

THisclass contains sixty-five cases of presenile dementia — i.e., of
insanity ending in dementia, and occurring between the periods
of maturity and of senility. Of the 728 cases of insanity under

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*9070

BY JOSEPH SHAW BOLTON, M.D.

consideration, the present class, therefore, includes 9 per cent .,
and of the 445 cases of dementia 14*6 per cent . Though atten¬
tion has already been drawn to the distinction which is
necessarily made between “ presenility,” an age-period in all
individuals, and “ prematurely induced senility,” it is perhaps
permissible to remark here that cases of the latter type have
been included in the class of “ senile or ‘ worn-out ’ dementia,”
which was described and illustrated in the last section of this
paper.

The present description is, therefore, concerned solely with
such cases of dementia as occur at the presenile period of life
and do not present indications of the premature onset of senility.
These cases, at any rate when of the female sex, are, as a rule,
referred to as “ climacteric,” and, as a considerable proportion
of them exhibit some type of melancholia as the prominent
symptom-complex, they are commonly referred to as examples of
“climacteric melancholia.” Kraepelin, in fact, appears to limit
the term “ melancholia ” to the symptom-complex presented by
cases of “ climacteric ” depression.

Under the present class the writer has included, not simply
melancholias, but all the cases which he considers to be
examples of involution of the cortical neurones at a date prior
to the age-period at which this process may normally occur,
but after these neurones have successfully resisted the maximum
“stress” which necessarily accompanies their mature activity.

It is probable that in many patients of the female sex the
grave metabolic disorders which occur at the “ climacteric ”
may largely contribute to the onset of the process of neuronic
involution. This is rendered the more likely owing to the
occurrence in both sexes of similar metabolic disorders during
puberty and adolescence, which at these periods undoubtedly
influence profoundly—and in some instances directly preci¬
pitate—the development of premature involution of the cortical
neurones. The generative organs, in fact, attain to func¬
tional activity later than the other organs of bodily function,
and, at any rate in the female sex, normally retrogress earlier
than these; and during their development and retrogression
they induce general metabolic disorders, which necessarily
often exert serious strain on such highly evolved and unstable
elements as the neurones of the cortex cerebri.

Whilst it is not desirable to lay too great a stress on the

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AMENTIA AND DEMENTIA,

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necessary influence of retrogression of the generative system
over the onset and course of presenile involution of the cere¬
brum, this factor is undoubtedly an important one in many
cases, and probably more commonly exerts a causative or con¬
tributory influence than do any of the other varieties of “ stress”
to which post-mature cortical neurones are subjected.

From the general argument with reference to the physical
basis and nature of amentia and dementia, which has been so
far elaborated in this paper, it is only to be expected that many
types of case should be included in a class of presenile
dementia. These types, however, readily fall, as a practical
working basis, into the following four sub-classes:

(1) Presenile mania with dementia

(2) Presenile melancholia with dementia

(3) Presenile insanity with dementia

(4) Simple presenile dementia

M. F. Total.

. 7 12 19

. 6 20 26

. I II 12

.448

Total

. 18 47 65

Of these sub-classes the second, that of “ presenile melan¬
cholia with dementia,” predominates, but not unduly when the
numerous types of symptomatology which are associated with
mental depression are taken into consideration.

Though the number of cases (65 only) in this class is not
large enough to justify elaborate statistical deductions, certain
interesting details are readily elicited by an analysis of the data
at the disposal of the writer, and these will now be briefly
considered.

Age .—The average age, on the approximate date of onset
of symptoms, in the 65 cases is forty-seven years, and it varies
little either in the sexes or in the sub-classes into which the
cases are divided. This is shown in the following table:

M. F. Total.

(1) Mania with dementia .

• 45'5

. 46

(2) Melancholia with dementia .

• 47'5

■ 47‘5

(3) Insanity with dementia

• 47’3

• 47

(4) Simple dementia .

506

. 46

. 48

Total .

. 46-8

• 47

It will thus be seen that the writer, whilst employing a

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BY JOSEPH SHAW BOLTON, M.D.

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1907 .]

clinical basis for selection, has included in the pre-senile class
cases of a fairly corresponding age in both sexes, and has not,
according to common usage, taken an artificial male “climac¬
teric” about ten years in advance of the female. He feels justified
in this course as he is not aware that the average duration of life
in males is correspondingly longer than that in females, or that
senility ensues in civilised races several years earlier in females
than in males.

That females arrive at sexual maturity at an earlier age than
males and that the capacity of procreation ceases in the
former at a much earlier period of life than in the latter does
not appear to him to justify the assumption that the pre-
senile and the senile periods of life differ markedly in the two
sexes. He prefers rather to associate the greater frequency of
female pre-senile (in the sense here understood) cases with the
grave metabolic disorders which occur at the female “ climac¬
teric,” and hence he employs the term “pre-senile” (rather
than “ climacteric ”) to describe the cases here referred to.

The average duration of residence in an asylum does not differ
markedly in the two sexes, being 5 years in the case of the
males and 6*5 years in the females. The common average
duration of residence is 6*2 years, and the individual duration
in the case of the males varies from one to nineteen years, and
in that of the females from one to twenty-three years.

Previous attacks .—The percentage of cases with previous
attacks is 24*6, and these are distributed through the several
sub-classes as follows:

(1) Mania with dementia .

(2) Melancholia with dementia

(3) Insanity with dementia

(4) Simple dementia

Per cent.

5'2

34'6

16-6

50*0

Without attaching undue importance to these figures it
seems permissible to suggest that the percentages perhaps
represent to some extent the respective facility with which the
friends of the different classes of patient would be able to
obtain their discharge from the asylum. This seems probable,
because in only six instances was the interval between the
attacks sufficiently long (7, 9, 10, 20, 22, and 24 years) to be
evidence of actual “recovery.” In all the other cases the
interval was two years or less.

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AMENTIA AND DEMENTIA,

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Degree of dementia .—The cases fall readily into two types, as
regards the existing degree of dementia, about two thirds of the
patients suffering from mild and slowly progressing dementia
and about one third from a more marked but still only moderate
grade.

When considered from the point of view of the incidence of
dementia in the four sub-classes, the following interesting

result is obtained.

Mild.

Moderate.

Total.

(i) Mania with dementia

(2) Melancholia with dementia

(3) Insanity with dementia

(4) Simple dementia

Total

In other words, in the first three sub-classes three quarters
of the cases exhibit mild dementia only, whereas in the fourth
sub-class three quarters of the cases exhibit moderately severe
dementia.

Considered as a part of the general argument which has been
developed throughout this paper, this result is only to be
expected, as the cases in the first three sub-classes should
possess a distinctly greater degree of degeneracy and a relatively
less proneness to the development of dementia than those in the
fourth sub-class, in which obvious symptoms of “ insanity ” are
replaced by those of “ loss of mind.” These last cases should,
on the thesis already elaborated, have been precipitated by
definite extraneous (primarily toxic) causes of undue severity,
or should not have become insane at all. Such a cause is only
too readily revealed by a study of the personal histories of the
cases included in the four sub-classes, for ascertained intem¬
perance in alcohol existed to the following extent:

(1) Mania with dementia

Per cent.

10-5

(2) Melancholia with dementia

(3) Insanity with dementia .

16-6

(4) Simple dementia .

37'5

Total .

i 3’8

It is therefore likely that both the actual existence of the
sub-class of “ simple dementia,” and the higher grade of

1907.] BY JOSEPH SHAW BOLTON, M.D. 89

dementia occurring in it, are associated with this high percen¬
tage of ascertained alcoholic excess in the included cases.

Capacity for work .—The percentage of actual and potential
( i.e ., patients who refuse to work) workers agrees with what
would be expected from the above remarks on the comparative
grades of dementia in the different sub-classes. It is as

follows:

Per cent.

(1) Mania with dementia.79

(2) Melancholia with dementia 73

(3) Insanity with dementia .... 75

(4) Simple dementia.62*5

Total ... 74

Social state .—An estimate of the percentage of unmarried
persons in the four sub-classes reveals the following interesting

differences.

Unmarried.
Per cent.

(1) Mania with dementia.30

(2) Melancholia with dementia .... 12*5

(3) Insanity with dementia .... 63-6

(4) Simple dementia.42*8

Total.30*6

No explanation of these differences is attempted beyond
the obvious one that the cases of melancholia were perhaps
by normal temperament and general conduct more likely to
obtain partners than were the members of the other three
sub-classes.

Heredity of insanity .—The percentage of ascertained heredity
of insanity in the sixty-five cases is 33*8. It is distributed as
follows in the four sub-clauses:

Per cent.

(1) Mania with dementia.31-6

(2) Melancholia with dementia . . . 42*6

(3) Insanity with dementia .... 25*0

(4) Simple dementia.25*0

As in many of the sixty-five instances no family history was
available, these figures hardly possess even a relative value.
It may be here remarked that a history of heredity of insanity

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AMENTIA AND DEMENTIA,

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is always unsatisfactory, as family and social conditions so
largely decide whether a person should be sent to an asylum
or not. The equally and often most important evidence of
family or parental degeneracy is frequently not available and
is usually not easy to obtain.

The writer has, however, thought it worth while to insert
the above figures, although he is personally indisposed, except
in the case of families which possess a number of well-marked
examples of high- or low-grade amentia, to attach undue
importance to an ascertained heredity of insanity.

He thinks it more probable that isolated cases of insanity'
arise from the intermarriage of ill-assorted couples and mild
degenerates, and that the severer grades of family degeneracy
follow the intermarriage of definite degenerates, rather than
that isolated examples of insanity in either parental stock will
be followed by insanity in the offspring.

He would, in other words, place the percentage of heredity
at ioo, with regard to the offspring of either degenerate or
“ normal ** individuals, and, without going so far as to say
that non-traumatic cerebral under-development or dissolution
cannot occur in the absence of hereditary causes, would empha¬
tically express his doubts with regard to its occurrence with
any degree of frequency.

Sub-class (i). Presenile Mania with Dementia .

This sub-class contains nineteen cases, of whom seven are
males and twelve are females.

The dementia present is of mild grade in fourteen of the
cases and of moderate in the remaining five. The general
symptomatology is variable, and comprises one or more of the
usual symptoms of mania— e.g., instability, excitement, restless¬
ness, exaltation, garrulity, and incoherence, combined usually
with unsystematised or partially systematised delusions of a
religious, grandiose, or persecutory character, and in some
examples with hallucinatory phenomena. In the more complex
cases, therefore, the process of neuronic retrogression involves
not only the centre of higher association but also the centres
of lower association.

The average age of onset of the attack is 46 years, being 48
in the case of the males and 45*5 in that of the females.

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1907 .]

BY JOSEPH SHAW BOLTON, M.D.

The average duration of residence is 6 years, and varies from
1 to 7 (average 3*5) in the case of the males, and 1 to 19
(average 8) in that of the females.

Only one case, a married female, had suffered from a previous
attack. This occurred at the age of 51, the present and final
attack commencing at the age of 53, and the duration of this,
when the case came under observation, being 9 years. Previous
attacks are therefore rare in the present sub-class, as the pre¬
sence cases as a whole show a percentage of previous attacks
which amounts to 24*6.

Of the nineteen cases, ten were workers (six good, one
ordinary, and three poor), five refused to work, and four were
incapable of work. The proportion of actual and potential
workers is thus slightly above that in the presenile class as
a whole.

The following four cases are inserted for the purpose of
illustration:

Presenile Mania , with Religious Delusions and Mild Dementia;
certified two years.

Case 408.—T. G. A—, male, married, bricklayer, aet. 55 ; certified
two years and has shown symptoms since the age of 51.

A lively and intelligent man who, whilst I am examining other patients
in the ward, answers questions for and calls out information about them.
He gives his name and says he was bom in 1847, which year is probably
correct He knows where he is, and mentions a number of names of
places in the neighbourhood. He states where he has come from, and says
that he had resided in that asylum since three years on the 23rd of next
February. (Correct.) He knows the day and the date. He is married
and volunteers the exact date of his marriage, and adds that he has no
family. When I ask if his wife is dead, he replies “ God gave His only
begotten Son that whosoever believeth on Him shall not perish, but shall
have everlasting life; so she can’t be dead.” His mode of speech leads
me to ask whether he is a preacher, when he states that he is not, but
that he knows a bit about the Bible. He is a “ bricklayer and a sanitary
engineer.” He used at his previous asylum to pour out the tea, to
spread the bread and butter, and to oil the floors. He is lively and
excited, and garrulous, and during conversation repeatedly brings up
religious matters. He states that his mother looks after him, and when
I suggest that she is dead he excitedly repeats the above text. He used
to go round with the Salvation Army, but “ missed my chance, as I was
offered conversion ; still, God is the same yesterday, to-day, and for ever.”
All his life he has lived amongst people who told lies. He thought that
he was telling the truth when he spoke to the different gentlemen for
whom he worked, so as to be different from his father and “ shame the
devil and tell the truth.” He hopes to get out of the asylum so as to

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AMENTIA AND DEMENTIA,

[Jan.,

get converted by the Salvation Army. “ I have the sin of a hasty temper
and don’t know of anything else. I once struck my missus, and she got
a poker and struck me and made the blood fly.” He is excitable, jovial,
and exuberant; and garrulous, self-centred, and introspective.

Whilst under observation he was excitable, quarrelsome, and fond of
airing his religious views and indulging in stump oratory, and he
persistently refused to work.

Presenile Mania, with Mild Dementia ; Partial Incoherence ; Delusions
of Persecution ; certified seven years.

Case 409.—J. P. C—, male, single, seaman, set. 50; certified seven
years. Cause stated to be “ sunstroke.” Aunt insane.

Skin coarse, eyes sunken, marked horizontal wrinkles on forehead.
Palate high and deep in front. Reflexes all exaggerated. Much
muscular tremor and marked tremor of tongue. Left testicle atrophied
and only partially descended. During examination of the last the patient
remarks, “Your closets have served it with his devils and apes and
f-g matches.”

Patient gives his name and says his age is 54, and that he was born
on March 14th, 1854. (The latter is probably correct, and the former
should then be 50.) He knows where he is, where he has come from,
and when he came, also the day and the month and year, but not the
date, but “ I doesn’t keep count of dates.” He was at his previous
asylum three and a half years, and was before that at H— asylum

“ keeping dungeon, when your first b-y good keeping b-y in

Christ started their b-y in Christ lunatic asylum.” He says they put

women in their beds, “ packs of b-y God bucks and Christ bucks,

and not of women round H-shire, and clever God Lord Christs, and

devils, and going about to murder, liars, murderers, and reptiles.” He
hears these people talking “ I know well enough how many times.” He
is garrulous and excited, and most of his language consists of stereotyped
and inconsequent repetitions of persecutory words and phrases. He
intends in the next life “ to give something strong to people for every
minute I’ve been robbed in the dens . . . and every hound of you

concerned in it.”

Whilst under observation patient was excitable, unstable, and at times
troublesome, and was very little use as a worker.

Presenile Mania , with Delusions of Persecution and Mild Dementia ;
certified five years.

Case 411.—A. O—, male, married, retired ship’s steward, aet. 59;
certified five years, and has shown symptoms since the age of 51.

A dull-looking man of florid complexion, who tries to see what I am
writing. He gives his name and states that his age is 60 next March.
He knows where he is and where he has come from and when he came,
and also the present day and the approximate date. He is “ right in
every way and as straight as a man can be. I wish to earn my living.
My forehead is very tender.” He was at his previous asylum five years,
and was twenty-three years in the L.&B.S.C. Service. He is very
garrulous with reference to the persecution from which he suffers. He

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I907.] BY JOSEPH SHAW BOLTON, M.D. 93

says that he was attacked by a patient just before coming here, and since
then has been badly attacked by and undressed by two attendants. He
also complains of the dirty clothes he has to wear. He has had his face
all smashed to pieces by people in the asylum, and his eyes have been
filled with blood many times. He boasts of his cleanliness of body and
mind “ I wouldn’t be in such a place so long if I hadn’t enemies.
There’s something hanging me up that shouldn’t be here.” He suffers
from auditory hallucinations. “ Filthy rattle and chirrup that disturbs
people’s rest. Them that does the harm should suffer if there’s any
penalty.” He hears women “ talking in good part in jokes.” He has
“never harmed a woman or given any chance to a woman to harm me.’*
He is very garrulous, excitable, and querulous.

Whilst under observation patient was restless, excitable, and quarrel¬
some. He constantly complained of persecution and ill-usage, and
persistently refused to work.

Presenile Mania; Inconsequence; Sham Deafness; Mild Dementia;
certified twelve years.

Case 424. —C. E. R—, female, married, housewife, aet. 63 ; certified
twelve years, and has shown symptoms since the age of 47. Cousin
insane.

A wrinkled old woman who at once shows me her husband’s address
on a letter, and says that she lives “ on the estate.” She gives her name
and tells me that her husband didn’t put her away, but that she was
brought away and stripped of all her possessions. She is very anxious
for me to read the addresses on a number of letters. She informs me
that “all people are not Jews, but I know you are one.” “ I got deafer
since I came away but I know the meaning of the world.” She states
that her husband’s employer is cousin to the old Marquis of Salisbury
who is dead. She talks on rapidly and inconsequently about this peer,
the “young lord,” etc., and becomes very excited. Eventually she
remarks that the secretary of the Marquis was a Jew, and then becomes
still more inconsequent, and her association of ideas becomes very
rapid and difficult to follow. Accidentally using the word “ son ” she
says “ sun, moon, and stars, frost and dew ; it proceeds from our mothers
and fathers. That’s what the world is.” She still, however, inserts such
phrases as “ Some of the Jews was but to think they done such things”
and “ There’s no craziness in me.” These suggest ideas of persecu¬
tion. She pretends to be quite deaf, but as I somehow suspect that
this is not so I repeat quietly “ I’ll swear you’ve stolen those letters,”
with reference to the bundle of letters in her hand. She then at once
looks up, says “ You’re a liar! you work underground, you do,” and gets
violently excited and abuses me roundly.

Whilst under observation she was excitable and unstable, and at times
garrulous, but she was a good and useful worker.

Sub-class (2). Presenile Melancholia with Dementia.

This sub-class contains twenty-six cases, of whom six are
males and twenty are females.

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94 AMENTIA AND DEMENTIA. [Jail.,

The degree of dementia is mild in nineteen cases and moderate
in the remaining seven. The general symptomatology is that
commonly described as “ melancholia 99 or “ climacteric melan¬
cholia,” and all the usual types of hypochondriasis and
melancholia are represented. In many, in fact in the majority,
of the cases the centres of lower association are more or less
involved in the process of neuronic dissolution, this in some
instances extending even to the simpler grades— e.g. f in certain
cases of hypochondriasis.

The average age of onset of the attack is 47*5 years, and it
differs little in the two sexes.

The average duration of residence is 5 years, varying from 1
to 16 (average 7) in the case of the males, and from 1 to 13
(average 4) in that of the females.

In marked contrast to the rare incidence of these in the
previous sub-class, no less than nine of the twenty-six cases
had suffered from previous attacks, and this is considerably
above the average frequency in the presenile class as a whole.

The interval between the attacks was, in six of the cases,
from one to two years. Of the remaining three cases, in the
first the patient was insane at the age of 25, and the present
attack began at the age of 47; in the second the previous
attack occurred at the age of 42, and the present at the age of
51; and in the third the patient was insane at the age of 21
and then at the age of 45, the present and final attack begin¬
ning at the age of 46.

As regards social state, the cases in this sub-class differ from
those of the other types of presenile case in including only
12*5 per cent . of unmarried persons, whereas the average for
the whole class is 30*6 per cent.

Of the twenty-six cases, fourteen were workers (eleven good,
two ordinary, and one poor), five refused to work, and seven
were unable to work.

Owing to the great variety and interesting nature of the
included types it has been thought desirable to insert a larger
number of illustrative cases than usual. It is worthy of note
that two of these, No. 433 and No. 434, are sisters.

Presenile Hypochondriasis with Mild Dementia ; certified sixteen years.

Case 426.— J. H —, male, married, aet. 64 ; certified since the age of
48. Nephew insane.

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I907-] BY JOSEPH SHAW BOLTON, M.D. 95

A moderately healthy man with a large epithelioma of the left cheek.
Face congested.

He speaks rather thickly owing to his deformity, but quite intelligently.
He gives his name, and states when he came here and where he came
from, and he knows approximately where he is. He gives the day and can
reckon out the exact date. His age is 63, and he was at his previous
asylum fifteen years. He has had his face bad for six or seven years.
It was originally inside the cheek, and grew through the skin. At his
previous asylum he has done work at bed-making and dusting up to
about a month ago, and since then has not felt so well. When asked
about voices he replies “ I don’t think I have very much.” Before he
went to his previous asylum he “ took some medicine, and it sealed
down tight and exploded through my head, and caused a drain off in
my face. When the medicine exploded it broke my left arm, and this
arm is off now.” (Untrue.) " My legs have been out of place, not very
much. Sometimes it works off my bowels when an extra lot of it comes
off. I was quite coated with it and it is dropping off by littles. It was
taken as medicine. I was cured at the time with it, but it laid all on
me and takes some time to ripen and fall off by littles. I can feel it
now coated on my heart and lungs. That that leaves the heart and
lungs is the strongest and physics me the most. I can smell that which
comes from my heart.”

Whilst under observation patient was dull and apathetic, and at times
somewhat depressed. He was a moderately useful worker, but was very
willing to do what he could.

Presenile Hypochondriasis; “ Pseudo hallucinations ” ; Mild Dementia ;
certified eight years.

Cask 427. —D. B. D—, male, married, photographer, aet. 54; certified
eight years, and also a year previously at the age of 45. Paternal aunt
insane.

A vacant-looking and phlegmatic man, who, when I ask whether it is
morning or afternoon, says “ Well, I hardly know.” He says that he
has been told the name of this place, but doesn’t know where it is. He
came “from G—, I know that.” He cannot say how long he was there
as “ I feel in a dirty idiotic state, nasty and wet, and day and night is a
terror.” He hears filthy, indecent, and obscene words very frequently,
and “ It comes to me and makes me perfectly rotten.” The words come
into his mind , and it is not as if anyone was speaking—they Ufise in his
mind day and night. He doesn’t know whether his appearance is altered
or not (in reply to a leading question), for he has never thought of it
like that. He has been married, but doesn’t know whether his wife is
alive. He doesn’t know the day or date, but knows the month and
year. “I look at the paper from time to time to see the date. I have
not looked lately and so do not know it.” His “ insides feel rotten, and
brain all rotten, all rattle, rattle, rattle. Cannot think of anything—all
jumbled up.” He owns to fairly frequent masturbation, which habit he
explains by saying that it was the common thing at G— to find people
in bed doing it, and so he did the same. “ Feeling got so strong seeing

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AMENTIA AND DEMENTIA,

[Jan.,

’em all at it, and nothing to do, that I did it. Of course it’s a shameful
thing to say, but there you are. I did it everywhere, in waterclosets,
bedrooms, and outside and all over the place.”

Whilst under observation he was hypochondriacal, and at times very
worried and depressed. He was irritable and if not left alone was
quarrelsome and impulsive. If, however, he was not interfered with he
was a willing and useful worker, and he was very amenable to discipline
when treated kindly.

Presenile Melancholia , with Moderate Dementia ; certified four years ;

sister of Case 434.

Case 433.—H. C—, female, single, laundry-hand, aet. 54; certified
since the age of 50, and previously between the ages of 48 and 50.
Sister of Case 434.

A dull and somewhat depressed woman, whose face is covered with
fenestrated scar-tissue from former confluent small-pox. Palate very
high, narrow, and deep in front. Knee-jerks absent. She gives her
name, and knows where she is, and where she has come from, also the
day on which she came, and the present day, the month, and the year.
She has no idea as to the date, although it is only the second of the
month. She thinks her age is 52 or 53. She cannot say how long she
was in her previous asylum, but was certainly there several weeks
(four years). Before going to work in the laundry she kept house for
her brother. Whilst in her previous asylum she did a little county
needlework. She cannot give any clear account of herself, and is very
dull and slow in replying to questions. She owns to at times being
depressed, but denies ever having thought of injuring herself.

Whilst under observation patient continued dull and quiet, was at
times depressed, and did not occupy herself in any way.

Presenile Melancholia , with Moderate Dementia ; certified seven years ;

sister of Case 433.

Case 434. —F. M—, female, married, housekeeper, aet. 49 ; certified
since the age of 42. Sister of Case 433.

A dull and phlegmatic woman, with many fine horizontal wrinkles on
an otherwise perfectly smooth forehead. Palate high, and becomes
narrow anteriorly. Finger-nails bitten into the quicks. Patient gives
her name, and knows where she is, where she has come from, when
she came, and the day to-day. She had been at her previous asylum
some three or four years (nearly seven). Her age is 56. She is married,
and has a son and two daughters. She cannot remember the year in
which she was married, and when asked the colour of her wedding-
dress she states that she knows but that it doesn't matter now. She is
very slow indeed in replying to questions. She remembers going to her
previous asylum, and thinks she must have been low and depressed
when she went there. She was only in two wards during her residence
in that institution. She did a little needlework there, but not much
as her eye sight has become so bad. She is better able to give informa-

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1907.]

lion about herself than her sister is, but she is, if anything, still more
slow in replying to questions.

Whilst under observation she was as a rule mildly depressed, and was
very dull and apathetic. She at times did a little work, but was not of
much use.

Presenile Melancholia ; Apprehensive ness; Mild Dementia ; certified

two years.

Case 436.—S. P—, female, married, housewife, aet. 56; certified two
years. Paternal uncle insane.

A dull-looking woman, with much loss of facial expression. She has
a habit of almost constantly biting her finger-nails. She gives her name,
and says she thinks her age is “57 or perhaps 56 next September.”
She knows the present day, and when she came, and the approximate
date. She is doubtful about the year, but at last answers correctly.
She knows where she is, and where she has come from, and thinks she
was there about two years. When asked when she went there, she
replies, “If this is 1903” (and she seems very doubtful in spite of re¬
assurance), “it must have been 1901.” In her previous asylum she
did what the nurses told her. “ I have been willing but would not say
useful." She felt very miserable whilst there, and has done wrong in
many things. The recollection of her fancied wrong-doing makes her
look very depressed. “ I have not done my duty,” and that sums up
the whole of her offences, including those with regard to her husband.
She in consequence thought of making away with herself by getting out
of the window. She tried to do this, but her husband stopped her.
Her worst trouble now is that her husband thought her last asylum was
a “ proper lunatic asylum,” but it was not, and “ I hardly know what
name to give it. It was worse than an asylum. They treated them
unkindly.” She is very apprehensive, and is especially afraid of being
sent back to the asylum from which she has come.

Six months later patient was stouter, but very dull and depressed.
Her age is 55 to 60, and she is married, and her husband is alive. (A
short time previously I informed her myself that he was dead.) She does
not know the date, but can give the month and the day of the week,
and the month in which she came here. She hesitates over the name
of the charge nurse, whom of course she ought to know, but at once
gives that of the head nurse. When I ask who I am, she replies, “ I
don’t know quite who you are,” but after an interval gives my name
correctly. Her finger-nails are bitten into the quicks, and she is constantly
nibbling at them, and especially so when agitated. She is solitary in
her habits, but a hard and useful worker at either ward or needlework.
When examined at bed-time by the nurse she is always afraid that she
is to be hurt. She once asked what the poison bottles in the cupboard
were for. When her work is done she sits quietly, never talks to any¬
one, and never reads or writes. At times she is rather contrary, and
she often tries to stay in bed in the morning, but she is never either
troublesome or spiteful.

UII. 7

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[Jan.,

Presenile Melancholia ; “ Resistive Stupor ” ; Apprehensiveness; certified
upwards of a year .

Case 440.—E. A—, female, married, housewife, aet. 53. Certified
upwards of a year.

A restless, fidgety woman who objects to sit down. She is unable to
attend to herself, she has to be washed and dressed, and is wet and
dirty in habits. She is on mince diet and feeds herself, which is
practically the only thing she does. She strongly and violently resists
examination and eventually says “ Don't, don’t do that! ” She notices
what is going on around her, and at times looks round. She will not
reply to questions or give any account of herself. She is quiet, except
for restlessness, if left alone, but if interfered with in any way she at
once becomes resistive and struggles.

Patient continued unchanged whilst under observation.

Presenile Melancholia Agitata with Mild Dementia; symptoms for at

least ten years .

Case 441—F. J. M. F. B—, female, widow, formerly housewife, aet. 62.
Symptoms for at least ten years.

A very depressed old woman who when in bed is continually rocking
herself from side to side, and whenever she has a chance gets out of
bed and wanders about. The hair on the vertex is nearly all rubbed
off owing to constant friction, and patient spends a good deal of her
time picking and biting her finger-nails into the quicks. She is never
still a moment and will not sit down. Her face is at times blank, but
usually wears a very woebegone aspect. Patient talks readily and
gives a fairly good account of herself and her illness. “ Twenty-four
years ago or more I had a very serious illness; there was a gas
explosion when the youngest child was born ; and I became very con¬
vinced of sin, and ever since then I have had more or less of
bromide. Dr. T— gave me bromide for ten years ” (she has been
under treatment for this time) “ and I haven’t slept for a minute without.
I have done all kinds of things wrong. I don’t know that there is any
exception." She thinks that she has committed nearly every sin, and
when asked about murder says “ Well, no, but I’ve destroyed my body
and lost my soul.” (Secret sins?) “God knows.” When I suggest
that she has been a good wife she admits “ I suppose I was at one
time.” With reference to self-injury, she says that she stumbled and
hit her jaw against something in the dark, “ against the sharp edge of
a shelf.” “ Someone said I did it myself but I didn’t.” (Tried to harm
yourself?) “ Well, not with any intention . . . Well, I walked into some
shallow water once, but I was under some drug, I believe, not Dr. T —’s,
but some other doctor’s, I think morphia.” She has, however, “ though
not of that kind, done lots of worse things, sins." She begs me to give
her a draught as she is “ so restless and cannot rest at all. Dr. T—
gave me bromide in the day," and she gets extremely agitated.
She knows where she is as she has “ seen the name on something or
other, and it’s very awful to be here.” (Day ?) “ Wednesday or Tuesday,

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BY JOSEPH SHAW BOLTON, M.D.

1907 .]

yes, Tuesday , I think.” (Correct.) She knows the date approximately,
and when she came, etc., etc.

Whilst under observation she was for some months quite unchanged,
very troublesome, and never appeared to sleep day or night except
when given a sedative. Later she became somewhat quieter and
slept better, though she showed little or no actual mental change.

Pnscnile Hypochondriasis with Delusions of Persecution and
Moderate Dementia \ certified nine years .

Case 442.—E. M. B—, female, married, housewife, set. 56. Certified
since the age of 47, and previously certified at the age of 25. Grand¬
father committed suicide.

A nervous woman with a constant frown and numerous fine
horizontal wrinkles on her forehead. Her lips are pursed up and her
eyelids occasionally blink. Hands flat and spade-like, and skin of
extremities shining and atrophous. Patient gives her name and her
age as 46. She knows where she has come from, and was in that
asylum a few years. She knows the day and the month, but neither
the date nor the year. She is extremely slow in answering questions.
She states that of late she has done bed-making and cleaning (her
hands negative this statement), and could sew if her arms were not so
affected by machinery. It seems like “ train-work,” and she compares
it to “ the chain between the buffers of railway “carriages.” She does
not know who works it as she “ wasn’t an engine-driver’s wife at any
time.” Her legs are not painful this morning, but sometimes it draws
them up. It makes her head ache very much sometimes. It is the
machinery that has made her bones so conspicuous (she is thin).
It has never been in her stomach. One of her sons is suffering at H—.
He always seems to be crying, and has been there four or five years (as
far as can be made out, this is a hallucination). Yesterday patient
was very excited and hysterical for a short time, probably in conse¬
quence of her transfer here.

Whilst under observation patient continued mentally unchanged, she
frequently complained of the torture she suffered, and she did not
employ herself.

Presenile Melancholia with Mild Dementia \ certified one year 9 and
also twice previously .

Case 445.—C. E. T—, female, married, housewife, aet. 47 years.
Certified one year. Previously certified at the ages of 45 and 21.
Grandfather and cousin (paternal and maternal) insane.

A dull-looking woman, with Mephistophelian eyebrows and a surly
expression. She gives her name and age, and knows when she came,
and the day, the date, the month, and the year. She knows where she
has come from and was there eleven months. She did no work at
that asylum, as she thinks she is “ lost, and it makes me feel so
wretched that I can’t work. I feel that I’m eternally lost. Something
tells me inwardly, my heart says that I’m lost for ever.” The feeling came

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IOO AMENTIA AND DEMENTIA, [Jan.,

on her eighteen months ago quite suddenly (it is two and a half years
since she went to the asylum for the second time, and a few days under
a year since she was certified this time). She was in business with her
husband, who is a butcher, and “ it came to me in the night that I was
lost for ever. I feel in a dreadful state. I don’t know how to sit still.
Such a dreadful feeling within. I can’t read or anything. If I’d done
anything I could have confessed it and got it off my mind, but I don’t
know what I’ve done.”

From the time of her admission patient was obviously a chronic
case. Whilst under observation she continued unchanged, and she
persistently refused to work, at any rate continuously. She became
rather more dull, and her depression and its expression became more
mechanical.

Presentle Melancholia Agitata with Mild Dementia; certified four years.

Case 446.—S. H—, female, married, housewife, aet. 47. Certified
four years. Mother and maternal cousin insane.

A very restless and depressed woman, who pays no attention to
questions, but, in a state of uncontrollable agitation, rapidly makes such
statements as the following : “ Oh ! my God 1 will they burn me ? Oh,
dear! Oh, dear ! I took the Sacrament wrongfully when I was thirteen
years old, and I must be burned.” . . . “Oh ! my God ! my God ! Don't
think anyone should be burned, do you ? They shouldn’t throw a cat
on the fire. I was first-hand dressmaker in B — thirteen years.” . . .
“ My mother was in H— three times.” . . . “ I think to be burned
must be dreadful. I used to make Miss B— fourteen yards of lace at
a time like that ” (showing me some). . . . “Oh, dear! If they bum
me ! My God ! my God ! Oh ! my God ! My God ! Oh, dear ! ”

After a time she settles down a little, and tells me where she is,
when she came, where she came from, the day, the month, etc. The
last fact causes her to add that she was married in the month of
October (the same month), and has a husband 6 ft. 2 in. in height and
17^ st. in weight. Her agitation continues during her replies to questions.

Whilst under observation she, during the first few months, spent
most of her time wandering to and fro restlessly, and loudly bemoaning
her fate, whilst all the time she was engaged with almost inconceivable
rapidity in making lace. Later, after several methods of treatment
had been adopted in order to decrease the nuisance she caused, but
without success, and after she had been tried in nearly every ward in
the asylum, she was placed on bromide. She shortly afterwards
became quiet and feverishly industrious, and developed into a useful
sewing-room worker, though she was still somewhat unstable and liable
to restlessness, but rarely to noisiness. She was then well-behaved
and very useful, but somewhat childish.

Presenile Melancholia with Mild Dementia ; much Emotional Instability
and Apprehensiveness ; certified one year.

Case 449.—M. R— , female, married, housewife, aet. 47. Certified
one year, and first showed symptoms at home some four years previously
at the age of 42 ; brother insane.

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1907.] BY JOSEPH SHAW BOLTON, M.D. IOI

A restless woman, who has just pulled her bed to pieces. The only
noticeable features in her appearance are her red and expressionless
face, and her plain, monkey-like and lobuleless ears. She sits up with
a finger in her mouth, turns shyly away and grins inanely. She
refuses to reply to questions, and laughs in a silly manner when spoken
to. Eventually she gives her name and says, “If you please I wish to
go home.” She gives her age as 47, and says that she was at her
previous asylum two or three months, and that it is “shameful how
Fve been treated if this is H—” (her previous asylum). She insists
that she has been here two or three months, but under three (two days
only). (Day ?) “ No, sir, I wish to go home; you’ve not any right to

detain me here.” She knows neither the day nor the date. As she
talks on she becomes gradually depressed, and remarks: “ Everyone
troubles me; I’ve been put on the hunt ever since I came here or a
fortnight after.” She has heard someone reading at night, and thinks
it was “the nurses down at C— Place.” She remarks that she is “ not
suffering from delusions.” She obviously has fears of sexual inter¬
ference, as she remarks: “ Respectable made woman! I won’t be
treated in this way ”; and during examination of her abdomen she
resists violently and tries to pull up the sheet. She then becomes very
depressed, and her eyes suffuse and she says: “ I’m not here for any
offence, my husband pays so much a week for me.”

Some months later the condition of this patient had changed very
little. She repeatedly remarks: “ Oh, I must go home! I must go
home! I’m going home, please God ! ” She does not know who the
people are who talk to her, and then adds : “ Oh, I must go home ! I
don’t like this place at all. I’m going home as soon as my husband
comes.” The voices accuse her of “all kinds of things,” and she here
laughs in an erotic manner. She rapidly, however, relapses into a
tearful state and repeats her cry, “ Oh, I must go home.”

As a rule she is restless and often wanders about. She is very
excitable, and often very noisy, and has been violent. She often
refuses to undress at bed-time and has to be undressed, and in the
morning she at times refuses, till pressed, to get up and dress herself.
She is fairly clean in her habits, but has been dirty after medicine.
She often gets up suddenly and says that people are annoying her.
Sometimes she works, and she can sew very nicely. She may also
dust and make both her own and other beds. She, however, tends to
give up working and to wander about, and is of no use as a worker.
She reads and at times writes. She is at times noisy at nights.

Sub-class (3). Presenilc Insanity With Dementia .

This sub-class includes twelve cases, of which one is a male
and eleven are females.

The grade of dementia is mild in nine cases and moderate in
three. The general symptomatology is variable, and abnor¬
mality of the emotional tone is not a prominent feature.

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102 AMENTIA AND DEMENTIA, [Jan.,

Certain of the cases, which possess a greater degree of
degeneracy than the remainder, present a symptomatology
similar to that of the class of “ cranks and asylum curiosities ”
which has been described under High-grade Amentia; and
in nearly all the cases of the sub-class there is at least some
dissolution of the centres of lower association.

The average age of onset of the attack, 47 years, is that of
the presenile class as a whole.

The average duration of residence is longer than that of the
whole class, namely nine years, and it varies from one to
twenty-three years.

Only two of the cases suffered from previous attacks. In
one of these this occurred one year and in the other twelve
years before the present and final attack.

As regards social state, this sub-class differs markedly from
both the last, and from the presenile class as a whole, in
containing no less than 63*6 per cent, of unmarried persons.
The majority of the cases, in fact, are spinsters of eccentric
habits.

Of the twelve cases, eight were workers (three good, four
ordinary, and one poor), one refused to work, and three were
incapable of work.

The following three cases are inserted for purposes of illustra¬
tion :

Presenile Insanity with Mild Dementia; Garrulity , Inconsequence ,
Eccentricity , Delusions; certified seven years .

Case 454.—O. N—, female, single, dressmaker, set. 52. Certified
since the age of 45, and previously very peculiar in her behaviour.

A garrulous woman, with much loss of facial expression and a very
assertive manner. She at once tells me that she is “ Miss O. N—
and that she got this name “right from the Queen of England and
Empress at B—.” When I call her by her Christian name she objects,
as she could not be spoken so to when going out to her work at B—.
She asks me if I am copying down what she is telling me, and on my
replying in the affirmative she states that she was mistaken at B— (her
previous asylum) for pApie called by names similar to her own, but
different in the spelling. She gives me no less than six methods of
spelling similar names, sees that I write them down, and solemnly
warns me against anyone and everyone possessing such names. She
tells me that many people have taken the name of N—, as she spells it
herself, because they knew that she had “got into no scrapes,” and
they therefore thought that they would thereby become possessed of
her spotless character. She talks rapidly and almost inconsequently.

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BY JOSEPH SHAW BOLTON, M.D.

103

but in a very grandiose manner, and seems to have numerous ill-defined
ideas of persecution. When asked the name of the asylum in which
she now is, she reads it on the sheet and asks me where it is. On
my replying that it is near E—, this remark at once brings up a host of
reminiscences, and it is difficult to get her to allow me to ask her
further questions. She knows when she came and where she has come
from. She knows the date within a couple of days, and when asked
the day says yesterday was Tuesday and to-day is Wednesday; and
then remembers that yesterday was Wednesday and says that to-day is
Thursday (correct). She inform? me that “people at times get out ot
their prison-specks and fly about like birds, but if you discover who
they are and say, ‘ Is that you, Mrs. So-and-so ? ' you break the spell
and they have to go back again.” She also tells me that people outside
are able to see what is in one's pockets, etc., and she most strongly
and indignantly complains about this.

Whilst under observation she was usually quiet and well behaved,
but was most peculiar and old-maidish in her habits. She refused to
work, and was often aggressive and dictatorial. She used to persist
when going out-of-doors in wearing something white, e.g. y a sunshade
or a white veil, etc., and if prevented would get violently excited and
insist on staying in.

Prtsenile Insanity , with Mild Dementia; Eccentricity ; Delusions and
Hallucinations; certified eight years.

Case 456.—L. T—, female, single, domestic servant, aet. 62 ; certi¬
fied since the age of 54.

A curious looking woman, with a Mongolian-shaped head and a
somewhat “ death's-head ” appearance. Hair short, chronic seborrhoea
capitis. She gives her name, and states that her age is nearly 60. She
knows where she has come from, was there about seven years, and
was previously in a situation. She knows when she came here, and the
day and date. She informs me that poison was put in her food by her
mistress, “ who was told by someone, under pretence of religion, to do
it” It was a woman, not a man, who did this. Her mistress used
“ West Indian poison pencils,” and several modes of persecution were
also adopted towards her before she went to the asylum. Occasionally,
whilst there, poison was put in her food, and she thinks that “ someone
came into the house to perjure Miss D—, the matron.” A little
jackdaw talks to her, and says he was a Scotch priest when he was on
earth. If there is anything wrong with her at night “ he will tell me
pretty quick, if not at other times. He speaks very well. He was
burnt at C—, and was told to stay about a certain number of years.
He came down with the other tame birds when they came to dinner.
He said there were some birds, and about thirty were little ‘ Gurds'
which have a different nail. These are little God-birds.” She thinks
she has seen him once here. “ He said just now 1 1 can see you, but
you can't see me.’ They are very smart in looking after poisoners and
robbers’ gangs.” He tells her that he christened her, and so has a right
to look after her. The eczema on her scalp was put into her stomach,
and was discharged on to her head. She passes by the name of T—,

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104 AMENTIA AND DEMENTIA, [Jan.,

and has been brought up under this name, but he tells her that he
christened her “ Panelia.”

Whilst under observation this patient continued mentally unchanged.
She was a quaint and interesting old woman, and a great favourite.
She was a very willing and useful worker, but a great chatterbox and
very childish in some of her ways.

Pre senile Insanity , with Modtratt Dementia ; Delusions and Hallucina¬
tions ; certified eleven years .

Case 459.—F. H—, female, married, housewife, aet. 55; certified
since the age of 44.

A healthy-looking woman, who at once begins in a querulous voice
to inform me of her troubles. “ It is not right, as I am so stretched.
Tea and coffee pass, but not other things. My speech is very bad
under my tongue. 1 ’ She knows where she has come from, and when
asked how long she was there, she replies, “ I didn’t notice the time.
We might be standing in error.” When asked how long it is since she
came here, she says, “ As I counted day and night home, this makes
the eighth day ” (three days). When asked the day, she says, “ I think
it was Tuesday ” (Thursday). Her age is “ 62 in January,” and she
volunteers that she has three children, “for what I should believe.
Take the case of them When asked about hallucinations, she replies,
“I am too dead for voices now, but hear noises underneath.” She
thinks that she died “four years last July. I smelt death when I was
there. They pulled my shoulders back, and so oppressed me. My
husband was buried five years ago.” She says that she is still dead,
and that her hands are “ not a colour open to ruts in different kinds of
ways. I’m not alive to my nature. We expect to rise as Christ rose.”
She is very anxious to be buried.

Some months later patient was mentally unchanged. She is “very
poorly, and badly done by.” A Dr. W— can act on her and draw her
wind or take her speech when he likes, and other people in different
parts of the world can do the same. She lies very quiet at night as she
hears “ bangings. I have not any voices now. I’m too far gone for
voices.” She knows the day and the month, but neither the date nor
the year, and she has been here eleven weeks next Friday. She came
here from “ the house where they deceived me to, there at first.”

She is clean, and fairly tidy. She works fairly usefully, and can be
depended on. She rubs the floors, sews at times, cleans brasses, etc.,
and at times makes beds. She usually makes her own bed in the
morning. She is very excited and noisy at times about “ chains,” and
often wants “ to be undone ” from these. She is often noisy at night
owing to electricity, and to people under the floor. She is sometimes
quarrelsome, and she often laughs and talks to herself.

Sub-class (4). Simple Presenile Dementia .

This sub-class contains eight cases, four of which are males
and four females.

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105

1907.] BY JOSEPH SHAW BOLTON, M.D.

The grade of dementia is mild in two cases and moderate in
six. In this sub-class, therefore, the dementia is well marked
in three quarters of the cases, whereas in all the other sub¬
classes it is mild in no less than three quarters.

As has already been stated, it is likely that alcoholic excess
has at any rate contributed to this difference, as the percentage
of ascertained intemperance in the four sub-classes is respec¬
tively 10*5, 7*7, 16*6 and 37 * 5 .

It is hardly necessary to remark that in this sub-class the
process of neuronic dissolution is both more advanced and more
generally diffused than is the case in the other sub-classes.

No less than four of the eight cases have a history of previous
attacks, which occurred at the respective intervals of one, two,
seven, and twenty years prior to the present and final one.

Three of the eight cases were workers (one good, one ordinary,
and one poor), two refused to work, and three were unable to
work. The proportion of workers is therefore lower than in
any of the other sub-classes, as might be expected in view of
the greater amount of dementia which is present.

The following four cases are inserted as illustrative examples
of the contents of the sub-class :

Simple Presenile Dementia of Moderate Grade ; Syphilis ; Intemperance ;
certified five years.

Case 465—J. N—, male, single, bricklayer, aet. 56. Certified since
the age of 51. History of syphilis and intemperance. Nephew in
this asylum.

Pupils equal and react to light and accommodation. Tongue
tremulous. Palate high, of average breadth, and deep in front. Knee-
jerks dull. Superficial reflexes brisk. Scar to the right of and below
the meatus. Chronic syphilide on body, limbs, and forehead.

A pleasant-looking but rather dull man. He gives his name and says
his age is 44 32 or 3 ” He thinks this place is B— parish as it is not
N— Union. He says he cannot read, and supposes that he has come
from N—. When the name of his previous asylum is mentioned he
says “Yes, sir, I have heeard of it before.” Ever there? “No, sir.”
He knows neither the day, the month, nor the year. He owns to
44 drinking a drop ” and supposes that I have too ! He does not know
any one here. Asked what he has been doing lately, he replies 44 Lying
down.” When asked what work he has done, he replies 44 1 know what
work I have done, not what I can do now.”

Whilst under observation he remained dull and apathetic and
refused to work.

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[Jan.,

Simple Presenile Dementia of Moderate Grade ; Intemperance ; symptoms

for one year.

Case 467.—T. K—, male, widower, general labourer, set. 48.
Certified some months and has shown symptoms for one year.

Face blank, eyes restless, nose greasy, marked flush on face and
forehead. Pupils 4 mm. and react rapidly to light and accommodation.
Tongue is protruded by instalments. Palate high average; much
pigmented scarring of legs, especially the right. Frenum has been
badly torn. Knee-jerks -h-f* Plantars normal. Patient is at present
wet although he was only examined a few minutes ago.

Patient pves his name and says that his age is 26 and that he has not
been married. He came “ the other day.” He neither knows what
day nor the day to-day. He thinks it is “somewhere about winter”
(September). He does not know where he is. He came from “ B—
way somewhere” (approximately correct). He does not know the time
of day and has not had his dinner (3.45 p.m). When asked about his
previous asylum by name he says he “ has done in my time ” (i.e., has
heard of it) but has never been there. When again asked his age he
repeats “ 26 ” and also repeats that he has not had his dinner when the
question is again asked him. He does not deny intemperance. He is
dull and unemotional and appears to suffer neither from illusions nor
hallucinations.

Whilst under observation patient was dull, apathetic, uninterested in
his surroundings, and unemployed.

Simple Presenile Dementia of Moderate Grade; Intemperance ; certified

one year .

Case 470.—E. B—, female, married, housewife, set. 53; certified
one year. Cause stated to be intemperance. Father committed
suicide.

A dull-looking woman, with a very congested face and nose and a
greasy skin. Pupils dilated and act sluggishly. Tongue and lips very
tremulous. Palate narrow, high behind, and shelves very markedly
forwards. Knee-jerks absent. Both plantars brisk and right > left.
Radial arteries thickened and tortuous.

Patient is feeble and dull, and is hardly able to give any account of
herself. She gives her name, but in a shaky voice, and when asked
her age says, “I couldn’t tell you exactly my age.” She does not
know where she is or where she has come from. She owns that she
has heard the name of the asylum from which she has come, and also
that she has been there. She knows neither the day, date, month, nor
year, and as far as can be made out has no illusions of identity and no
hallucinations. Pain ? “ Not particular.” Married ? “ Yes.” How

long? “Don’t know.” Any children? “No.” The only voluntary
remark she makes is to the effect that she could sleep well if she could
be quiet.

Patient while under observation improved somewhat in general
health, but continued dull, listless, apathetic, uninterested in her
surroundings, unemployed, and practically lost to time and place.

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1907.]

107

Simple Presenile Dementia of Moderate Grade; certified two years ;
previously insane.

Case 471.—H. C —, female, married, housewife, aet. 50; certified
two years. Previously certified at the age of 41 years,

A rather dignified-looking woman. Forehead narrows upwards.
Palate high. Pupils and knee-jerks normal. Plantars very dull. She
is very deaf.

She gives her name and her age as “ about 48.” She knows where
she came from, and when, and where she is. She also gives the
month, but does not know the year. She states that she was at her
previous asylum two years and three months, and that she “ used to
work in the kitchen, but was called back,” and polished tables, made
beds, etc. When asked why she was taken to the asylum, she says
that her “head came bad, and I was obliged to be taken there.” She
remembers nothing about the cause of her detention or of the events
preceding it. She has heard people walking about the room and
talking at her previous asylum, and is sure that they were women and
also real women. She is very dull, childish, and apathetic, and it is
with difficulty that she can be got to smile.

Whilst under observation she continued dull, apathetic, uninterested
in her surroundings, and unemployed, but she was quiet and well-
behaved, and caused little or no trouble.

Group I.— Primarily Neuronic Dementia.

Class (c).

Mature or “ Adult ” Dementia.

(Dementia of Maturity.)

In this class are included sixty cases which exhibit various
types of symptomatology. These cases agree, however, in
possessing the two necessary characteristics of the class under
consideration, namely, (1) an attack of insanity during the
period of maturity, and (2) a greater or lesser degree of
dementia as its sequela.

From what has already been stated with reference to the
classes of “ senile ” and “ presenile ” dementia, which contain
cases in which involution of the cortical neurones has occurred
at a period of life later than that at which they were subjected
to the greatest degree of “ stress,” namely, that associated with
“ mature ” activity, it is to be expected that the present class
should present important differences from these both as regards
immediate etiology and general symptomatology.

In the senile and presenile classes an actual “ wearing out ”

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AMENTIA AND DEMENTIA,

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of the cortical neurones is the primary cause of their involution
—which term is perhaps more suitable to these cases than
“ dissolution ”—and the “ stress ” required to precipitate this
retrograde process is therefore in many cases much less than
that through which for many years they have passed unharmed.
The ensuing dementia is thus on the whole, as has been shown,
relatively slow in development and relatively mild in degree,
with the single exception of the last class of presenile dementia,
in which the additional influence of alcoholic excess has
apparently precipitated a more severe grade.

In the cases of the present class, however, the cortical
neurones, at the time of breakdown, are being subjected to the
“ stress ” of mature activity. In those examples in which
involution occurs under the influence of a degree of “ stress ”
which is equivalent to that constituting the normal environment
of the sane adult cerebrum, it is obvious that the durability of
the cortical neurones is lower than that present in cases which
have survived to the presenile or the senile periods of life.
Such cases exhibit relatively little dementia, as will shortly be
pointed out, and may be considered to be the analogues of
senile and pre-senile cases. In the majority of the cases of
the present class, however, involution—which here may,
perhaps, be more properly termed “dissolution does not
occur at maturity under the mere “ stress ” of normal activity,
but requires in addition for its precipitation the presence of
extraneous (toxic) factors. Of these the most potent, in the
male sex, are intemperance, and, in the female, intemperance
and the toxic and metabolic disturbances associated with
child-bearing.

In other words, direct toxaemia of the cortical neurones is,
during their period of mature or adult activity, an important,
and, indeed, almost a necessary, factor in the determination of
at any rate the severer grades of dissolution which occur at
this period of life.

It is evident from these considerations that a proportionately
greater amount of dementia is to be expected in the cases of
“ mature ” than in those of “ presenile ” and “ senile ”
dementia.

The evidence which has been derived from a study of the cases
included in the present class, and which will now be presented
in summary, amply supports the above introductory remarks.

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1907.] BY JOSEPH SHAW BOLTON, M.D. IO9

Of the sixty cases, twenty-six are males and thirty-four are
females. Even a cursory comparison of the clinical notes with
those of the cases in the preceding classes shows that the
amount of dementia present is greater than in these. Further,
the cases can only with difficulty be subdivided into types,
and these are of such an entirely artificial nature that any
hard and fast line of demarcation is obviously undesirable.
Dementia, in fact, in the present class is as prominent a
feature as is psychic aberration.

Of the twenty-six male cases, a moderately severe grade of
dementia exists in ten, and of the thirty-four female cases, in
eighteen; a total of twenty-eight, or nearly one half, of the
sixty cases thus exhibit dementia of a moderately severe type.

On the other hand, in the class of “ presenile ” cases, twenty-
one out of sixty-five, or barely one third, suffered from this grade
of dementia. As, however, the fourth sub-class of presenile
dementia, which includes eight cases of simple dementia with
a high percentage of ascertained intemperance, contains no
less than six cases of moderately severe dementia, it may,
therefore, without impropriety be considered that in fifty-seven
examples of the purer types of presenile dementia the grade of
dementia was moderately severe in 15 only, or just over one
fourth.

There is, therefore, considerably more dementia in the present
class than in the presenile.

Though the writer does not propose to divide the present cases
into sub-classes which would, owing to the degree of dementia
and the consequent obscuration of the symptoms of alienation, be
largely artificial, it seems worth while from the aspect of
dominant symptomatology (not of special type of case) to intro¬
duce the following table:

Excitement

• • 7

Total.

Depression

Unsystematised delusions

Simple dementia

Total

. . 26

Nearly one half of the male cases thus possess unsystema¬
tised delusions alone, and more than two thirds of the female
cases exhibit excitement. These proportions are naturally

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IIO AMENTIA AND DEMENTIA, [Jan.,

without intrinsic value, but they approximately accord with the
general experience of alienists and are, therefore inserted.

The average age on certification of the sixty cases is thirty-seven
years, being a few months higher in the case of the males and
a few months lower in that of the females.

The average duration of residence is nine years in the case of
the males and ten years in that of the females, and varies in
both sexes from one to twenty-eight years.

Previous attacks .—No less than eleven of the twenty-six males
(42 per cent.) had been previously certified, but in five of these
there is a history of intemperance and two of the five had been
previously certified on three occasions each.

Of the females, only four of the thirty-four cases (12 per cent.)
had suffered from previous attacks, and in none of these
particular cases is there a history of intemperance.

Social state. —Of the males 56 per cent, and of the females
35 per cent, are unmarried.

Etiological data. —Certain details bearing on the etiology of
the present class of cases will now be summarised. The per¬
centages are, as previously, prepared on the total number of
cases, and thus represent ascertained proportions only, as in
many of the cases no facts whatever which bear on personal
or family history are available. Though these data thus
possess merely a relative value, they are useful for comparative
purposes, as the relatively gross method by which they were
obtained was at any rate a constant one throughout the whole
series of cases included in the present paper.

Ascertained intemperance. —The percentage of cases with a
history of intemperance is thirty-two, and is thus more than
double that in the class of presenile cases, which is fourteen.

This exciting cause existed in the case of the males to the
extent of 42 per cent., and in the case of the females to that of
24 per cent. On classification of the cases from the aspect of
dominant symptomatology, the following interesting result is
obtained:

Percentage of intemperance.

Excitement

. 27*6

Depression ....

. . 22*2

Unsystematised delusions .

. 25*0

Simple dementia

• 83-3

Total

. 31*6

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1907.] BY JOSEPH SHAW BOLTON, M.D. I I I

These percentages may be usefully compared with the lower
percentages in the sub-classes of presenile dementia, which
are as follows:

Percentage of intemperance.

Mania with dementia .... 10*5

Melancholia with dementia . . 77

Chronic insanity with dementia . . 16*6

Simple dementia .... 37*5

Total .... 13*8

It will be seen that, whilst a similar relationship exists, the
percentage in the fourth line being much the highest, the
actual amount of intemperance in the “ mature ” class is more
than double that in the “ presenile.”

In view of the introductory remarks to this section, this
larger proportion of intemperance in the “ mature ” class, as
compared with the “ presenile,” is at least highly suggestive
that alcoholic excess is an important exciting cause of the
breakdown of cases of “mature” dementia. It is not
suggested that intemperance is the cause of the higher per¬
centage of cases of moderate dementia in the “ mature ” class,
though cases with a history of intemperance, and in which the
dementia is simple , certainly do more often develop the pro-
founder grades.

The “ stress ” required for the determination of the onset of
dissolution of the cortical neurones is necessarily greater in
cases of the present class than in the presenile cases, in many
of which natural involution is imminent, and therefore a greater
degree of dementia, in the “ mature ” class generally, is a priori
to be expected.

This observation falls under the general law that the greater
the “ stress ” required to produce dissolution of the cortical
neurones, the greater is the amount of this when it occurs.
Conversely, in cases which readily break down under “ stress,”
eg., high-grade amentia, the injury which results is negligible;
and in patients whose cerebra possess such a low functional
capability (low-grade amentia) that “stress” cannot intervene
to any material extent, dementia, except in consequence of
senile or “ presenile ” wearing out of the cortical neurones (or
of gross destructive lesions) does not occur.

Child-bearing .—In six of the thirty-four females (18 per

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AMENTIA AND DEMENTIA,

[Jan.,

cent.) the onset of the attack was precipitated by child-bear¬
ing, this term being here employed to include all the usual
types.

Syphilis. —A history or physical evidence of a former attack
of syphilis was present in four of the twenty-six male cases
(15 per cent.), and in all these cases the degree of dementia
was mild. This is to be expected, in view of the remarks to
be made later in the section on Progressive Dementia, for,
in the experience of the writer, a higher grade of dementia is
incompatible with a history of syphilitic infection unless the
patient suffers either from one of the forms of dementia
paralytica (i.e., general paralysis of the insane) or of cerebral
syphilis.

Ascertained heredity of insanity. —After the remarks inserted
under this heading in the section on presenile dementia, it is
merely necessary here to state that the percentage of cases
with a family history of insanity is twenty-five, being nineteen
in the males (c/. the greater percentage of ascertained intem¬
perance in this sex) and twenty-nine in the females. It may
be added that, as in the case of the previous etiological data,
the percentages are made out from the total number of cases,
in many of which no facts whatever which deal with personal
or family history are available.

The present description will now be completed by a brief
reference to the capacity for work exhibited by the individuals
who compose the class of “ mature ” dementia.

Of the sixty cases in the class, forty-two were workers, 9
eleven refused to work, and seven were incapable of work.
The high proportion of workers is worthy of attention. It is
probably due partly to the age of the patients, which is not
beyond that of useful activity, and partly to the amount of
dementia, which is large enough to curtail the exhibition of
the more marked phenomena of mental alienation, and at the
same time is not of so severe a grade as to prohibit the per¬
formance of useful work.

The proportion of workers is similar in the two sexes. Of
the twenty-six males, seventeen were workers (sixteen good
and one ordinary), seven refused to work, and two were
incapable of work. Of the thirty-four females, twenty-five
were workers (eleven good, seven ordinary, and seven poor),
four refused to work, and five were incapable of work.

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I907-] BY JOSEPH SHAW BOLTON, M.D.

The following fourteen cases have been selected as illustra¬
tive examples of the contents of the class under consideration.
In the absence of specific sub-classes, the cases are inserted,
for convenience of reference, according to their predominant
symptomatology, in the order of excitement, depression, un¬
systematised delusions, and simple dementia.

Mama; Mild Dementia ; certified eight years .

Case 475.— J. B —, male, married, farm labourer, set. 47; cause,
intemperance. Certified eight years, and has shown symptoms
since the age of 36.

A dull-looking man, with deep horizontal wrinkles on his forehead
and bright eyes. He says “ Good-day,” and at first refuses to sit down
“as I like standing.” He gives his name and age, but does not know
where he is, although he knows whence he has come. He can state
the present day and knows that he came here six days ago. He
objects to my “ foolish questions,” and especially so “ on a Sunday ”
(correct day). He was at his previous asylum about seven years, and
at times got tobacco, which was “ given to prevent him from cutting up
rough, as he was a very refractory patient ” (private information). He
tells me that he never worked at his last asylum, and “I won’t here.”
He is an “ outside man, and would be a lunatic if I worked in lunatic
clothes.” He complains about the doors being always kept locked.
“I don’t understand indoors work, and was not brought up to it.” . . .
“The gentry are keeping me away from work and from earning my
living, and want me to work in other people’s clothes.” . . . “ If I
stood up and worked in other people’s clothes I should lose my life
and my wife, and you know it! ”

Patient settled down comfortably, and though he was at times
troublesome, he was on the whole readily managed and became a good
and useful worker.

Mania ; Moderate Dementia ; certifiedfifteen years.

Case 484.—E. F—, female, married, housewife, set. 49. Cause,
puerperium; certified fifteen years. Two brothers insane.

A dull-looking woman, with a fatuous smile. Several coarse, hori¬
zontal wrinkles on forehead. A small moustache and imperial.

She does not know where she is, or when she came, although she has
only been here two days. She knows neither the day nor the month,
but remarks that it is summer (correct). She volunteers that her age is
53. She states what asylum she has come from, and says that she was
there three years, has been from home ten years, and was 51 years of
age when she left home. When I point out that these statements do
not agree, she remarks that she thought she was ten years away from
home, as it is ten years since she left her husband. She then informs
me that she has been married twenty-two years, and that she has had

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I 14 AMENTIA AND DEMENTIA, [Jan.,

ten children; also that her youngest child is ten years old this year,
and that it was two months old when she was taken to the asylum.

Whilst under observation she was as a rule dull and quiet, and at
times she did a little work, but she was often bad-tempered, excitable,
quarrelsome, and even impulsive. If not watched she would, apparently
without suicidal intent, swallow different articles. On one occasion, for
example, she swallowed a bottle of ink, and on another a quantity of
washing soda, and she stated, as her reason for doing this, that she was
suffering from wind in the stomach. She was a more difficult case to
treat than an actively suicidal patient would have been, as her degree
of dementia was such as to make it easy, though inexcusable, for her
attendants to neglect their instructions.

Mania; Mild Dementia; certified twenty years.

Case 486.—E. H—, female, married, set. 55 ; occupation “said to
be literary ”; certified twenty years.

A duli-looking woman, with a narrow forehead. She gives her name
as “ Mrs. Alice, Blenheim House, Havelock Road, Hastings, Sussex,
in Surrey’s sight.” Age ? “I was very little in ’44.” Children ?
“They haven’t put it in my bill anything of that, sir.” Married?
“ Not in our way of speaking, sir.” Married ? “ Not in these directions

quite sure, sir; it’s not been entered in any writing” . . . “If

they wouldn’t allow the Elizabeth books, the Elizabeth couldn’t settle
the Elizabeth’s accounts.” When now asked her name she repeats
exactly what she said at first. She then remarks, “If there were four
by of Battle, four times two and four of them again, it a very good piece
for forty-eight ebonets, fifty dreads the minute nearly, every minute that
is run.” Hear people talking? “ Yes, sir, very often indeed.” What ?
“ According to the themes.” . . . “ Seventy-eight to-day, sir, and

ninety of them, twelve by seven apiece and twelve by fifty and twenty-
live of them an hour for forty years more,” etc. She speaks rapidly
and indistinctly, and almost as if she had pronounced her numerous
remarks so repeatedly that she had quite forgotten their proper sound.
She, however, speaks as if she were talking sense.

Whilst under observation patient was often noisy and quarrelsome,
and she talked a good deal to herself. She showed considerable
intelligence, and was a useful worker. Her behaviour and remarks often
suggested that she had originally been of considerable intelligence and
education, and had developed more dementia than a comparison with
the ordinary patients would at first suggest.

Mania y Moderate Dementia ; certified seven and a half years.

Case 493.—L. C. H—, female, married, housewife, aet. 48; cause,
pregnancy ; certified seven and a half years, and symptoms for two years
previously.

An excited woman, with a narrow, peaked forehead. She gives her
name as “ Mrs. T. F. H—,” and her age as 40, and adds, “ I have six
little boys and three little girls.” The youngest of these is just over

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1907.] by JOSEPH SHAW BOLTON, M.D. 115

6 years old, and the oldest 21. When married? “12th September.”
She cannot give the year, but says, “ We were married by licence at a
registry office. We didn’t sleep together till next day. That is twenty
years ago.” She then says that her oldest boy would be 22 years old if
alive, and that she was married twelve months before he was bom.
She cannot appreciate the discrepancies in the above data, and persists
that they are true. She knows when, or approximately when, she went
to her previous asylum, and adds, “ On my oath to prove my true life,
and I was bearing my youngest child four months as incense.” She
gives the exact date of its birth in the asylum.

She tells me correctly how long she has been here, and then rapidly
runs on to her personal matters, complaining bitterly that “all the
women in the ward here are the cause of me and my husband being
apart for seven years.” No evidence of hallucinations is obtainable.
She remarks, “The man in the surplice, who reads the prayers at H—”
(her previous asylum), “kept haunting to my commandments, as if
wearing my cloak. I have kept my own commandments. They
mocked me, and made my eyes their eyes, and my commandments
their commandments, and there was no connection between them,”
and wanders on rapidly and excitedly in a similar vein.

Whilst under observation patient continued unchanged. She was
restless and excitable, and at times quarrelsome, and, though not un¬
willing, was of very little use as a worker.

Mania ; Moderate Dementia ; certified fifteen years .

Case 495.— M. U—, female, married, housewife, set. 60. Cause,
parturition. Symptoms since the age of 42, and certified fifteen years.

A determined-looking woman with a beard and moustache, and a
right haematoma auris. She chatters away to herself in a low tone, but
at the same time obviously notices what I am doing. She gives her
name and states that her age is 50. (Where are you ?) “ I’m staying
here; they call it all sorts of places.” It is “ Sebastopol,” “ Constanti¬
nople,” also “Zoological,” “Mayfield,” “the Indies,” “Mount Ephraim,”
and “The Lord’s Station Houses.” When asked for further names she
says “ I don’t know what else it is at present” She has been here since
she “came by the trains.” (How long?) “We tabled so many tables
since I’ve been here.” She has heard the name of her previous asylum
when it is stated to her and has “ been there lots of times. I’ve stayed
there also a long time.” When again asked her age she gives it as 58.
She does not appear to suffer from hallucinations and states that “ we
all talk of a night”

Four months later she was unchanged on the whole, her mental
condition being as follows : She knows neither the day nor the month.
She states that she goes to church, but the name of the minister she
gives is that of the official at her previous asylum. She does not know
the names of the different nurses she sees daily. She hears voices
saying “ lots of things.” She saw something done last night, but she
does not know “ whether it was a murder or not.” Her age is now given
as 58. She is nervous and apprehensive, but is neither noisy nor
quarrelsome. At times she mutters to herself and makes signs with

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Il6 AMENTIA AND DEMENTIA, [Jan.,

her hands. She never writes, but at times she reads odd bits of paper.
She is very willing and is a worker of ordinary type. She is fond of
sitting over the kitchen fire, but is willing to work and remembers
what she has to do day by day and also when she has been told over¬
night to do anything. She is clean and tidy.

She showed no mental change whilst under observation.

Melancholia; Moderate Dementia; certified four years .

Case 505.—G. K—, male, single, labourer, aet. 41, certified four
years. Mother insane.

A vacant-looking man, whose eyes are very close together. He
takes no notice of me, and slowly picks his teeth with his nails. When
asked, he gives his name, but he says he does not know his age. He
knows that he is in an asylum and whence he has come, also the day
he came and the present day. He cannot give either the present date,
the month, or the year. When asked how long he was in his previous
asylum, he replies, “ God knows, I don’t.” He worked on the farm
there and received tobacco for doing so. He hears “ all sorts of things
at nights, the devil sometimes. Worst thing I’ve done, to come in
one of these places. I don’t know what he do say.” When asked why
he was taken to his last asylum, he says it was owing to “ the harm I
have done. I have taken all the goodness in my body away.” He
then sighs deeply and says, “ Dear me, I was a silly fool. I see my
folly now it’s too late.” He here becomes extremely depressed. He
adds that he has starved many men and women to death. “Silly
fool! I didn’t know when I was well off. I see it now it’s too late.”

Whilst under observation patient was unstable and often depressed.
He was a willing worker of ordinary capacity.

Melancholia ; Mild Dementia; certified one year .

Case 508.— S. T—, female, single, dressmaker, aet. 32. Cause
stated to be intemperance; certified one year. Two aunts and a sister
insane.

A dull and vacant but somewhat depressed woman. Tongue
tremulous. Palate very high and very narrow in front. Knee-jerks
absent. Superficial reflexes dull. She gives her name, and states that
she was at her previous asylum “ about a year, but I do not exactly
remember.” She came yesterday (correct), and thinks that to-day is
Wednesday (Tuesday). She knows neither date, month, nor year, but
thinks that it is summer (correct). She states that her age is 32.
She was sent to the asylum as she was ill and gave up work.
Whilst there she “ helped a bit to wash up and wipe.” She spent most
of her time there “ sitting and looking like the rest of ’em.” She says
that she was depressed when she first went there. She is dull and
uninterested in her surroundings, and speaks in a peevish and dissatisfied
way. She tends, where possible, to reply in a contrary or contra¬
dictory manner. She does not suffer from hallucinations.

Whilst under observation patient showed no sign of mental improve-

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1907 -]

BY JOSEPH SHAW BOLTON, M.D.

II7

ment. She continued dull, listless, peevish, and generally dissatisfied.
She did a moderate amount of work, and performed it in a slow,
mechanical, and perfunctory manner.

Unsystematised Delusions; Mild Dementia ; certified six years .

Case 510.—N. A—, male, married, gardener, aet.48 ; cause, syphilis;
certified six years, and showed symptoms for no less than ten years
previously. Father intemperate.

An excitable and wide-awake man of considerable intelligence. He
knows where he is, where he came from and when he came here, and
also knew beforehand where he was coming. He knows the day and
the approximate date, and, after thinking a time, tells me the year.
He knows how long he was in his previous asylum. He gives his
age as 45. He has been married twice. By his first wife he
had two children, a boy now eighteen years of age, and one who died.
He had had no children by his second wife.

His pupils are equal and do not react to light. Tongue tremulous.
Palate very high. Knee-jerks brisk. Superficial reflexes normal. Left
inguinal hernia. Testicles large. No visible scar on penis. Arteries
tortuous and very rigid. Patient states that he had a “ chancre a lot
of years ago and about four runnings during eight years in the
merchant service.”

He worked in the garden during his last four years at his previous
asylum, and was only in three wards during his residence there. He
hears voices from the 11 orb ” in the air. They are “ chiefly sounds,
and what they say depends on what they want to say.” When asked if
they tell him to do things, he becomes excitable and speaks so rapidly
as almost to be unintelligible. “ We don’t take their orders from the
orb. We don’t belong to B— but to the town of H—,” etc. When
asked why he says “ we,” he replies that there were several men in his
previous asylum waiting for their discharge, “who used to hear the
orb,” and that “ it seems more natural-like to say * we ’ than ‘ I.’ ”
They are in this asylum to “ take up our discharge as well as signed
for discharge,” and at the previous asylum they were “ there as
discharged patients, but couldn’t get out. We knew we were
discharged from the doctors, and the attendants were much chastised
and prosecuted for keeping us in,” etc.

Whilst under observation patient was excitable, and quarrelsome if
provoked, and was very garrulous on the subject of the “ orb.” He
was a good and useful worker, but was distinctly feeble-minded and
childish, in spite of his generally excellent memory.

Note .—As will be pointed out later under Progressive and Secon¬
dary Dementia, this case, in the opinion of the writer, has avoided the
onset of dementia paralytica owing to the possession of neurones of
average durability. Such cases as the present, who have previously
suffered from syphilis, either develop little or no dementia, or become
examples of dementia paralytica. In the experience of the writer,
therefore, previous syphilis in either a sane or an insane individual
whose neurones are of normal durability does not cause either
stationary or progressive dementia. In all cases, however, in which

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I 18 AMENTIA AND DEMENTIA, [Jan.,

the durability of the cortical neurones is deficient, previous syphilis
results in one or other of the numerous types of dementia paralytica, a
progressive dementia.

Unsysiemaiised Delusions ; Moderate Dementia; certified eleven years .

Case 514.— R. W. A—, male, set. (?) 45. Cause, intemperance.
Certified eleven years, and also a year earlier at the age of (?) 33.

A man of hypochondriacal appearance, who knows where he is, where
he has come from, and the day he came. He also knows the month
and the year, but he does not know the present day although he has
only been here five days. “ I was reading a paper yesterday, but forgot
to look at the date.” He states that he is single and that he is 46 years
of age on October 29th next. He exhibits much mental apathy,
but when he has got worked up to it he talks rapidly and minutely, and
also as far as is known fairly accurately, regarding his history and
previous whereabouts. He states approximately the number of years
he lived in the different asylums to and from which he was transferred,
and remarks that the cause of his original incarceration was “ a mere
nothing, a bit of drink and no serious offence.” When his present
troubles are discussed he informs me that “the cushion I lie on at
night plunges and makes my head sore.” He cannot recollect any words,
but he says that he certainly hears people talking to him. The
“ cushion comes on and off. It can leave off and go on at times as if
it were alive itself.” It is “only the cushion ” at night and not his bed¬
clothes, and it has appeared in any bed in which he has slept. It
never troubles him during the day, nor does any similar thing. He
remembers that when asked the other day by the Superintendent about
voices he denied them, and remarks “ I did not think of the cushion
from that point of view.” In different asylums he has slept both in
side rooms and dormitories, and in each bed he was troubled by the
“ cushion.”

Whilst under observation patient continued mentally unchanged. He
was often noisy at night, but was, as a rule, quiet during the day. He
was able but unwilling to work.

Unsystematised Delusions ; Mild Dementia ; certified eleven years .

Case 521.—J. S—, male, married, carpenter, aet. 52 ; certified eleven
years, and has shown symptoms since the age of 38.

A dull man, of phlegmatic appearance. He gives his name, and
states his age to be 50 or 51. He knows when he came, whence he has
come, and where he is. To-day is “ Monday or Tuesday—I forget.
Which is it?” (Tuesday). He was at his previous asylum “nine, ten,
or eleven years.” He did not do much work, but “ I was busy with the
Supreme, that was like God, Him being with us.” When he got to his
previous asylum, “ I found I was with the Supreme, and then found I
had worked up to this before when I married,”etc. . . . “I wasn’t

sure if the wife married me for it, or if I married her for it.” Have you
been “ with the Supreme ” all these years ? “ Must have been, for I

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BY JOSEPH SHAW BOLTON, M.D.

1907.]

I 19

haven’t joined or met any of my parts for understanding.” Have you heard
“the Supreme ” ? “ Yes, He’s been busy with the understanding all the

time. That was in my happiest time with the Supreme when I used to
get a few understandings and feelings that with me, or me with that, or
through me, or in me. I knew I was with it if I went out for a walk,
but not so much as if I was in the asylum.”

Whilst under observation patient remained mentally unchanged. He
was always ready to talk about “ the Supreme,” and used this idea as his
excuse for refusing to do any work at all. He was quiet and well-
behaved if left alone.

Unsystematised Delusions (?) ; Mild Dementia ; certified nine years.

Case 524.—M. T—, female, married, housewife, set. 48. Her present
illness commenced as melancholia during pregnancy, and she has been
certified nine years.

A healthy-looking woman, with a low forehead and a wide-awake
appearance as regards the eyes. Palate high, and narrow in front.
Marked corns on both knees. She gives her name, and her age as 49.
When, from her watchful appearance, she is asked about hallucinations,
she says that she has “ not heard voices for months.” She then remarks
that she used to think that she heard people swearing at her, but “ it
was only fancies, and was people in the ward.” She is obviously here
trying to hide something from me, as she remarks, “ I used to try not to
hear them, and not to tell the doctor, and I used to try hard to get home,
but I am not at home yet. I worked very hard in that asylum.” She
did ward-work there and also some needlework. She used to help
another patient, for whom she appears to have great respect, if not awe,
to do the latter. She can give the day, and the date within a day, and
she knows how long she was incarcerated in her previous asylum* “ My
husband put me in the asylum, as I tried to drown myself—I don’t
know what for. I had a baby three months after going there, and it
died.”

Whilst under observation she was simple-minded, childish, facile, and
easily led, and was an excellent worker. She was, however, easily upset
by injudicious treatment or environment, and at times, owing to her
hallucinations being particularly obtrusive, was suspicious and secretive.

Mild Dementia ; certified seven years.

Case 526.—W. H—, male, married, miller, set. 47 ; cause, intem¬
perance ; certified seven years.

A quiet and well-behaved man, of rather dull appearance. Pupils
normal. Plantars dull. Knee-jerks practically absent. A marked
band of dilated venules round the chest at the diaphragm-line. Arteries
tortuous and somewhat thickened.

Patient has a fairly good memory, and gives all the usual details
readily and accurately. He worked in the scullery for several years in
his previous asylum. Till two years ago he received beer and tobacco
for his work. After that date the beer was stopped, and then he got

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120

AMENTIA AND DEMENTIA.

[Jan.,

more tobacco instead. He shows much mental apathy, but talks
sensibly and intelligently. His recent memory is better than his
remote, but both are fairly good. Before admission he admits having
drank a good deal of both beer and spirits. His wife has not seen
him for years, and he does not know where she or the ten-year-old
child is. He never bothers himself about them, as “I was kept
pretty well busy from morning to night.” He is quite comfortable, and
doesn't seem to have either thought or “ bothered ” about getting his
discharge.

Whilst under observation he was feeble-minded, and showed great
mental apathy and lack of initiative, but he was a willing and useful
mechanical worker. He was sent out to the workhouse at the request
of the guardians.

Moderate Dementia ; certified eleven years; three previous attacks .

Case 527.— W. R. B—, male, married, grocer and gardener’s
labourer, set. 47; cause, intemperance; certified eleven years and
previously, with very short intervals, at the ages of 32, 33-34, and 35-36.
Mother insane.

A stout man, with an expressionless face. Ears without lobules.
Right knee-jerk just present, left absent. Pupils react normally.

Patient comes up to me with a fatuous smile and shakes hands. He
informs me that he came here a “ little more than a month ago ” (two
days). The day is Wednesday (Saturday). He then remarks, “ I’ve
been bucking up with another brother.” . . . “The last rice we
packed up wasn’t so good.” Work? “I can drive, good drive,
steady reins.” Anything else ? “ Sleep. I can sleep.” . . . “ I’ve

come all the way. A good many in the Albert Edward, they say. I
was off my beer and lots of things.” What is this place? “ Thornton
Heath.” . . . “ I’ve always heard it highly spoken of—madhouse.”
Why were you brought here ? “ Fast wife.” He says he has been

married nine years, and has “ just about ” two children. He hears
people talking to him “all day, Sunday, Monday, and Tuesday when I
came out on the round. They said * coffee ’ . . . Bar going out of
business on my round.” He does not hear them “quite so bad” at
night. He has not drank so much, but he has “ looked after a drink
place.” He can tell the time of day to within an hour. When again
asked the day he now says “Thursday.” He has been in this asylum
“ five years with the major. Hack mare won several plates on this
county.” When asked who sent him to the asylum he replies that
“ Mamma put me here. She thinks a good deal of making a slight
change in the family.”

Whilst under observation patient continued mentally unchanged,
and was a good and useful worker and quiet and well-behaved.

Confusion; Moderate Dementia; certified one year.

Case 531.—J. A. N—, female, single, dressmaker, set. 38. Cause
stated to be intemperance ; certified one year. Mother died in a fit.

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I907.] ON THE FORMATION OF CHARACTER.

A dull-looking woman, who tells me that she is called by several
names, “but my right name is J. A. N—.” People call her “Jeru¬
salem,” “old lady,” “or just what they think” . . . “ I suppose

they call it for fun.” Who do ? “ Anyone.” When ? “ Always during
the day, but not so much since I’ve been in this house.” She then asks
if this house is M—r Buildings. Are you married? “I think I’m
meant to be married, as they sent several rings to the last house for me.”
The name of that place was H—, but “ I don’t remember going into
that one.” She does not know how long she was there, but “ it seemed
summer all the time, so it couldn’t have been so wonderfully long.”
She knows neither the day nor the month, but can state the year. She
gives her age correctly, and says that she had a child when between 20
and 21 years of age. When asked who the nurse is, she says, “ I seem
to know her face,” and asks, “ Is it Mrs. Wilson ? ”

Whilst under observation she showed no sign of mental improvement,
but became less actively confused and more dull. She persistently
refused to work.

On the Formation of Character: an Address to the
Nursing Staff at the Retreat , York, delivered
November 1st , 1906. By William Bevan-Lewis, M.Sc.,
(University of Leeds), L.R.C.P.(Lond.), M.R.C.S.(Eng.),
Medical Superintendent and Director of the West Riding
Asylum, Wakefield, and Lecturer and Examiner in Mental
Diseases to the University of Leeds.

When a few months since I was asked by Dr. Bedford
Pierce to address the nursing staff of this time-honoured insti¬
tution it was a moot point in my mind whether I should take
as my thesis some general subject connected with the history
and profession of nursing or direct my remarks to you in a
more personal appeal than so general a theme would permit.
I might have taken as my text:

(<?) The present position of the nursing profession in the
hospitals and asylums of Great Britain.

(b) The history of the several organisations of nursing, and
the work accomplished by them.

( c ) The aims and special features of mental nursing in
particular.

(d) Or, lastly, the proposed legislation which has been set on
foot for securing for this profession certain desirable ends.

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122 ON THE FORMATION OF CHARACTER, [Jan.,

I decided to ignore all these subjects and endeavour to get
nearer to each and all of you by a very personal consideration ;
and if at times I appear too personal I at least have the plea to
present that I have for this profession so profound a respect, I
may say affection, that after thirty years* work amongst some
two hundred nurses and attendants at Wakefield Asylum I am
convinced that no question can appeal more to you all than
the one I have chosen for this occasion.

The formation of the nurse's character is my theme, her
moral as distinguished from her intellectual development.
Character above all things is essential to her success in life,
to her real and lasting happiness, and is the one thing
needful upon which she may rejoice in the absence of wealth,
fame, talent, and social position in the usual acceptation of
those terms.

The word “ character ” comes from a Greek root signifying
to cut down into, to engrave deeply, and denotes, therefore, the
permanent elements which have been engraven into a man’s
soul by the stress of circumstances and experiences.

“ Character,” says one, “ is nature in the highest form. It is
of no use to ape it or to contend with it. Somewhat is
possible of resistance, and of persistence, and of creation, to
this power, which will foil all emulation. Men of character
are the conscience of the society to which they belong.” Now,
these are strong terms to use, and the attainment of character
is a very lofty ambition ; but for all that, remember it is open
to all alike, whether gifted or not from an intellectual point of
view, to aspire to and acquire this richest of all prizes that life
can bestow—the sanctity of character.

I must, however, first congratulate you on the good taste
exhibited by all in the choice you have made of a professional
career. There is, indeed, no profession so noble in its aspira¬
tions, so unselfish in its aims, so truly social in its pursuits, and
so replete with opportunities for making life beautiful as that
of nursing. Each sphere of life, of course, has its heroes—men
and women large of soul. Sailors, soldiers, legislators, historians,
poets, philosophers, scientific worthies, and divines afford us
examples of illustrious lives and noble thought; but I doubt
much if any profession can present us with so many genuine
heroes whose lives, although not emblazoned upon the world’s
records, are more deeply engraven upon the hearts and memories

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1907.] by william bevan-lewis, m.sc. 123

of humanity, more silently yet more sacredly cherished, than
the heroes of the nursing profession. Nor is the reason for
this far to seek, for of all occupations it pre-eminently is dis¬
tinguished by the most human of all traits, self-sacrifice. The
nurse of all others can enter the holy of holies of the human
soul, and in the most sacred of moments communicate that
comfort which poor humanity then so truly depends upon.

Often when I see before me a body of men and women de¬
voted to this great vocation of nursing, as I do on the present
occasion, I ask myself the questions : u Do they in any way
adequately realise the lofty nature of their vocation ? Do their
hearts thrill at times at the conception of the mission to which
they have been called ? Do they recall the wondrous examples
which have preceded them in this career and the mighty
power which can be wielded by them for the good of their
fellow-creatures? And if they do, do they regard it as a sacred
trust confided to them, to be treasured with due humility, and
not to arouse in their breasts over-weening self-confidence ? ”

Specially applicable are these remarks to you nurses of the
York Retreat, trained as you are at an institution which was
the first in Great Britain to grapple with the inhuman methods
of treating the insane once so prevalent, trained at an institu¬
tion the fame of which has been rendered immortal by the
illustrious work of William Tuke and his noble band of coad¬
jutors and successors, and who have now to sustain by your
energy, devotion, and loyalty the reputation of an institution
which dates back to 1796.

You are all aware that of late years the education of the
nurse has undergone a wondrous transformation, and that a far
greater intellectual element has entered into her training and
pursuits. Formerly there were few demands made upon the
nurse's intellectual efforts ; gentleness, patience, forbearance, a
ready eye for observation, a ready hand and will to help and
relieve, were the chief requirements of our nurse. Her know¬
ledge of the human frame and its economy, her acquaintance
with diseased processes, and the rationale of our methods of
controlling these, were of an infinitely crude description. Now
she is trained in elementary anatomy and physiology, is sup¬
posed to have a fairly clear notion of healthy organic processes,
and to recognise the early signs of departure from the normal
state ; she is required to gauge the temperature by the ther-

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124 ON THE FORMATION OF CHARACTER, [Jan.,

mometer, to record pulse and respiration, to attend to all that
concerns the hygiene of the patient and his surroundings, the
care and distribution of dietary and medicines, to aid the
physician or surgeon in multiform ways, and to be ready and
expert on occasions of sudden emergency which are sure to
arise.

Now, with the advent of a more intellectual element into her
life by this scholastic training, the nurse is exposed to a new
danger which may seriously interfere with her usefulness. The
old adage “ A little learning is a dangerous thing ” is as true
now as it ever was, and is most appropriate to the nurse at
this period of her career. She is apt to attach too much
importance to acquirements which must be of a very ele¬
mentary nature, and she therefore tends to appraise her
attainments at too high a value. Thus it is that you meet
with examples in hospital and asylum life where the nurse,
instead of being the modest handmaid of science, becomes
obtrusive in her desire to exhibit her knowledge, worries and
distracts the physician by her constant attempt to note facts
which, although quite relevant to the case, will probably be
taken in at a glance of the eye of an experienced prac¬
titioner. This tendency to fussy prattling at once stamps its
possessor and places her at a great disadvantage when con¬
trasted with the calm, self-controlled, silent behaviour of the
accomplished nurse, who is ever ready to afford information
when questioned by the doctor. The great William Penn
used to say “ Have a care, therefore, where there is more sail
than ballast.” The typical nurse knows full well that know¬
ledge of this kind is not to be valued for its own sake , or for
the glorification of its possessor, but rather for its application
to the wants of suffering humanity, and thus without a word
amiss she goes silently about her work, ever watchful, ever
observant, ever ready when asked why this or the other thing
is done to give a rational explanation, and winning thus the
confidence of both patient and physician.

Modesty, therefore, you will agree with me, in respect to her
intellectual attainments, is always to be aimed at by one who
would take a high position in the nursing profession. Obtrude
not these prized gifts for idle show, to satisfy the pride of the
moment, but be ever ready to apply these powers at the
appropriate moment to the great advantage of those under

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BY WILLIAM BEVAN-LEWIS, M.SC.

125

your care. Above all things, cultivate a quiet demeanour and
treasure in your hearts the dictum of the truly wise: “Speech
is silvern, silence is golden/*

The class of nurse required for our large hospitals and
asylums should, above all things, embrace the characteristic of
a high standard of moral excellency . Now, the types of moral
excellency, as you are all aware, vary with the age, the country,
the occupation, and the sex. The stern stoic virtues of the
old Roman, with his disdain for suffering, indifference to death,
small value attached to the life of others as well as his own,
was a type essential to a great military power destined for the
conquest of the world ; whereas the humanising effects of art,
literature, poesy, are revealed in the amiable virtues of the
Greek, whilst the self-sacrificing virtues of Christianity spread
further over the pagan nations of Europe as a happy union of
the heroic and tender virtues, the highest type of manhood.

There is one picture in these olden times which always
seems to remind me of the birth of the true nursing instinct of
the present times ; it is a charming picture to dwell upon. At
a time when Athens was a centre from which art, science, and
literature shone with a steady lustre over the whole civilised
world, and gave encouragement to the teaching of all religions
in her midst, there was to be found one altar in particular, not
inscribed to any god, not distinguished by any ceremonial
rites, yet thronged by worshippers and reverenced before all
other shrines, an altar to Pity, “ the first great assertion/* as
Lecky informs us, “ to mankind of the supreme authority of
mercy.” With this worship there was naturally spread a
deepening sense of the sanctity of human life, the pathos of
human suffering, the yearning for its relief, which form, I con¬
ceive, the very foundation of the nursing instinct. I have
always been fascinated by this great feature of pagan times.
Classic lore presents us with no more pathetic feature to dwell
upon than this human instinct striving to assert itself against
the cruelty, rapacity, and indifference to life of the age. We
expect from the nurse in particular the highest development
of this sense, a keen sense of the sanctity of human life and a
capacity for pity and sympathy with human suffering.

The word “ pity ** comes from the root pietas —pious, i.e.,
reverence and love for the Deity, indicating how lofty is the
sentiment. But sympathy is still more than pity, and indicates

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126 ON THE FORMATION OF CHARACTER, [Jan.,

a feeling in common, a co-operation, so that whilst pity may
be a passive emotion sympathy is by its very nature active for
the good of the sufferer. For both of these the faculty of
imagination must be keen ; the nurse who is devoid of sympathy
must learn the unpleasant truth that she is devoid of imagina¬
tion, that her mental faculties are to this extent blunted and
dwarfed.

Young children, as most of you know, show early defect
of imaginative vigour by their senseless, purposeless, cruelty
towards small animals, or even towards their own kind ; they
fail, in fact, to place themselves in the position of the sufferer
so as to realise what is endured. When, however, we arrive at
man’s estate a defect of imagination leading to acts of cruelty,
or to defective pity, should warn us that our mental organisa¬
tion is at fault, and this should be regarded with shamefacedness
and sorrow as a defect in one of the loftiest attributes of
humanity.

Yet remember, pity is not sufficient. If you properly fill
your sphere it must be translated into action. As that great
German philosopher Johann Gottlieb Fichte said in 1799,
“ Not for idle contemplation of thyself, not for brooding over
devout sensations ; no, for action art thou here ; thine action,
and thine action alone, determines thy worth.” And again,
he reiterates, “ Not merely to know , but, according to thy
knowledge, to do is thy vocation.” A nurse devoid of such
sympathy should strive to rouse her imagination by placing
herself in the position of the sufferer or by mentally placing
her mother, father, sister, or anyone most dear to her in similar
trouble.

We should all strive to maintain this noblest of our faculties
the gentleness begot of pity, and emulate that noble nature
which Shakespeare makes Mark Antony attribute to the fallen
Brutus:

“ His life was gentle; and the elements
So mixed in him, that Nature might stand up,

And say to all the world, * This was a man.’ ”

Such gentleness, such pity, is indeed akin to love—I mean
to that Divine love for our fellow-men of which an eloquent
writer says:

“ Not to love is not to live, or it is to live a living death.

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1907.] by william bevan-lewis, m.sc. 127

The life that goes out in love to all is the life that is full and
rich and continually expanding in beauty and in power/*

Discipline or Subordination .

All of you know what military discipline means at a time
of war, how absolute must be the control, the decision, of the
leader; how implicitly his orders must be carried out by his
officers; how united and harmonious must be the co-operation
of the several units or bodies of men who constitute the army.
You well know that if any one unit or regiment acts upon its
own initiative in defiance of orders because it did not understand
such orders or their import, infinite confusion would result, and,
similarly, what chaos would ensue if his men refused to obey a
certain manoeuvre because they questioned the motive or the
discretion of the officer.

Now, in a well-organised nursing staff the same unquestioning
obedience must be demanded, an obedience which pertains just
as much to the several subordinate officers acting under their
chief as to the several individual units of a ward, the nurses
and attendants. Your regulations are framed as much for your
own development as for the welfare of the institution and its
inmates, and, therefore, their dictation must be regarded as final
and absolute.

It is not, however, the printed regulations which are so
much the subject of question amongst the junior nurses as
that unwritten law involving minor matters connected with
the individual moral conduct, the manner and spirit in which
such regulations are carried out, the general tone of discourse,
the esprit de corps , and the prompt attention to what may seem,
perhaps, the trivial dutes of the day.

Now, discipline or subordination begins at home, is carried
further at school, and prepares us for the real work of life,
and those who have been blessed with a good home and wise
parents enter the field of nursing far better equipped for sub¬
ordinating themselves to their superiors and for understanding
what discipline means.

If, however, undisciplined minds enter upon this course of
training the usual result is that the orders of the superior are
subjected to criticism because the motive dictating the order
is not understood; the sister or charge-nurse is regarded as

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128 ON THE FORMATION OF CHARACTER, [Jan.,

overbearing when she insists on the letter of the law being
carried out; the matter is referred to the chief officer or matron,
from whom, of course, no redress can be expected, and the
junior, in a discontented spirit, probably throws up her post.

Now let us see wherein the error consists. In the first
place, it is not the function of a junior ever to criticise orders
given by a superior. In the next place, her position and
experience would render her judgment quite inadequate to
express an opinion upon such matters in general. It is pre¬
sumed that all grades of officers in a well-organised institution
hold their posts by virtue of merit; in other words, the superior
officer is usually of higher intellectual and moral development
than her subordinate, and although there may be exceptions to
this rule, the subordinate is bound to assume that the judgment
of the superior is dictated by a fuller acquaintance with her
profession and a keener insight than is the case with the junior;
in fact, the higher plane of office to which she has attained is
presumptive of a more highly developed mind in that particular
sphere, and that she has passed through the developmental
stages of her subordinate staff.

Let me ask you, therefore, to remember, when any point
of discipline arises which mystifies or worries you, that the
old teaching, old as the hills, is, “ the higher mind looks
down into and understands the lower , but the lower cannot
comprehend the higher .” It has ever been so. The lower
intelligence fails to grasp the meaning and motives of the
higher, begins to carp and cavil, to question authority, to nurse
bitterness, or resentfully ends in direct insubordination ; whilst
the higher intelligence looks down with concern and pity on
the lower with a perfect comprehension of its difficulties, of the
questionings to which it was also itself a subject, and puts down
its arms to aid the lower to rise to a higher plane of being.

If you but conceive the constitution of a nursing staff from
this point of view, it would end in your respect and devotion
to your superiors, in a consciousness of progressive development,
and in a refreshing sense of the dignity and charm of a well-
disciplined mind, and surely this is worth the getting. Burke,
speaking of such disciplined minds, says, “ Full of dignity them¬
selves, they respect dignity in all, but they feel it sacred to the
unhappy.”

Now do not for a moment suppose this to be an easy task;

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BY WILLIAM BEVAN-LEWIS, M.SC.

129

nothing worth the getting is easy of attainment. Chalmers
tells us that “ the acts of virtue ripen into habits, and the
goodly and permanent result is the formation or establishment
of a virtuous character.” We know full well that this is a
psychological fact. “ Every new achievement of principle
smooths the way to future achievements of the same kind,”
renders the struggle less difficult, and virtuous acts become the
very habit of our life.

What is it that I have asked you to do ?

(a) First, to look into yourself, recognise your own in¬
efficiency, admit your own restricted stage of development—
in other words, acquire self-knowledge.

(b) To subordinate your natural inclinations and will to a
higher law which you may not understand at the time, but to
which you submit because it is higher —in other words, self-
abnegation, self-sacrifice, a sinking of your own personality in
what you feel to be higher than self.

Self-knowledge .—A few words upon the virtue of self-know¬
ledge. The Grecian philosophy held as sacred above all truths
that dictum which they would have had inscribed upon every
temple and deeply engraved upon each heart: “ Know thyself.”
If we all bore this ancient maxim in mind, it would have a
most refining influence upon both our natures and actions. To
know yourself is to probe deeply into the origin of your motives
to action, which is a very difficult task to undertake, yet the
truly wise will strive to do so. Now, although you may not
be able to pry into and to understand the motives of a higher
mind than your own, yet your own motives will, when honestly
inquired into, in most cases be revealed.

But there is a very ready way to knowing oneself, and this
also philosophy has dictated for us. It has been the treasured
guide of some of the greatest intellects who have given their
thought seriously to their own moral development, and I,
therefore, warmly commend it to your notice.

It is this: Carefully note the judgments you pass upon
your fellow-man. Ask yourself what the voice of scandal
or slander sometimes prompts you to repeat and even be¬
lieve ; then say bravely to yourself, “ These are my own
shortcomings, either actually or potentially.” Rest assured

LIII. 9

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130 ON THE FORMATION OF CHARACTER, [Jan.,

that the teachings of philosophy have fully vindicated the
truth that what one is ready to suspect his fellow of is
just the very fault he himself is likely to be guilty of; his
suspicion is but a reflection of his own mind . Do remember
this, that the world is what we make it for ourselves ; and just
as the artist sees the landscape or other form of beauty with a
very different eye from the uncultured eye of the peasant, so
the world and your fellow-creatures are coloured by the
reflection of the several minds which conceive them.

I am not afraid of wearying you with the enunciation of
this great truth ; perhaps I may hope that as students of
mental operations this truth will have already been fixed in
your minds ; but if not, tell me why yon melancholiac is assured
that life is a horror, that all is hopeless and sad, that the
former days of happiness have passed for ever away for all.

“ Disease,” you reply. Yes,but in like manner all healthy states
vary in the tone and colouring that they give to the environ¬
ment, and vastly different are the views of life we severally
enjoy. You think, may be, that your companion beside you
sees the landscape with the same eye as yourself, that it
creates the same feelings and sentiments. You were never
more mistaken in your life; no two of us ever see things or
judge people exactly alike.

Therefore, remember the world is what you make it, or, in
other words, is a reflection of your own minds. Self-know¬
ledge is acquired by noting your judgments on your fellow-
men, your views of life, your motives and principles of action.
If your judgments are harsh, if you see chiefly the unlovely in
your fellow-man, be assured the unloveliness is in yourself also.
Seek to eradicate the evil lurking there, examine the known
weaknesses to which you are yourself subject, and ten to one
but it is the very lapse you are fond of attributing to those
you come in contact with.

Follow this principle out bravely, and honestly attempt to
suppress your faults as thus revealed, and reward will certainly
come by a view of life and your fellow-creatures greatly to be
desired. Suspicion will fade away, better motives will be
credited to those around you, and your purer mind will reflect
its own nature on all things and make life really beautiful.
The acceptance of this principle of self-reflection, by which we
acquire that most desirable of all acquisitions, self-knowledge, is

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the secret of those eminent lives which have shed such lustre
upon the history of ancient and modern times. Above all
things will self-knowledge aid you in eradicating from your
nature those cancerous pests of institution life, gossip, scandal,
suspicion, ill-will, wrong-doing, and envy. Surely this is also
worthy of attainment!

The second effort I asked you to make was to subordinate
yourself to the higher law because you know it to be higher.
And here we come to the virtue of self-knowledge. There are
proud natures which cannot readily become subservient to
other minds, too proud to submit to rules and regulations
which they regard as irksome and the import of which they
fail to grasp. Now, self-knowledge leads to true humility,
and soon begets that reverence for the higher law, that respect
for authority as well as that striving after higher things, which
renders them above all things dutiful and loyal. Sinking
oneself in the higher law, placing oneself loyally at its dis¬
posal, is the surest road to advancement and moral excellence.

Self-constraint, the acquiescence in what you know to be
right, however unpleasant to you, is demanded of the asylum
nurse to a very notable degree. It is here, I think, that the
nursing of our asylums shows a lustre which no hospital, so-
called, can ever hope to attain to ; no comparison, I think, can
possibly be drawn between the tests to patience, endurance,
and loyalty to which our mental nurses are subjected and those
imposed upon her hospital sister. As Emerson truly says,
14 to measure character we use the resistance of circumstance,”
and surely no one who has watched for a day the life of a
good nurse in our refractory wards would otherwise than main¬
tain that the worries, anxieties, and at times the real tragedies
of her life are resistances which tend to bring out the noblest
characters in their true light.

This is why I think that a long training is desirable for the
formation of a really good nurse, and why I believe that
your Superintendent has acted so wisely in requiring of you
a four years* course of training—none too long a period for the
serious work before you. Such a system can only issue in the
weeding out of those undesirable ones who are not prepared
to make nursing the one serious business of their life, and upon
whom, therefore, nursing lectures, ambulance work, and clinical
teaching is so much wasted energy ; and in the next place, it

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132 ON THE FORMATION OF CHARACTER, [Jan.,

must result in a sound and systematic training which should
find you at its termination accomplished nurses, gifted with
powers which make you the most valued assets of an institu¬
tion and of a community. Let me ask you to recall the words
of Dr. Bedford Pierce in his last Annual Report of this institu¬
tion, and which I most cordially endorse: “ It is also important
to remember that the training of a mental nurse is very
different from that in a general hospital, and no nurse can
be considered qualified for the difficult duty of nursing the
insane without special training ; nor, on the other hand, should
a nurse with only asylum training be considered a trained
hospital nurse” I would only add to this statement my
opinion, that the mental nurse requires a far longer period for
her course than a hospital nurse, and this because of the large
demands made upon her moral culture.

But it is not alone as regards the serious trials I have
alluded to that you will require to exercise self-constraint, but
in your relationships to your nursing colleagues, your superior
officers, and the interests of the institution which, above all
others, demands your loyalty.

The patience begot of self-constraint is evidenced by the
invariable gentleness you have to observe towards your patients,
however wearisome they may be, and also by the spirit of
cheerfulness which you must strive to cultivate amongst all
circumstances whilst going about your work. Such cheerful¬
ness is highly infectious, and reflects its influence far and wide
upon patient and staff alike. Little do you know, perhaps,
you who pursue your work with quiet watchfulness, gentleness,
and a constant cheerfulness, how many silent and unsuspected
blessings you gain from those around you. There are times,
of course, when from fatigue or from physical causes cheerful¬
ness may be hard to assume. On such occasions, if still you
succeed in bringing a ray of light into your midst, you may
feel assured your growth in self-constraint is progressing.

Were you to ask me what class of nurse shows the most
vicious lack of self-constraint I should not reply, as some of
you might expect, the hasty or passionate ; for the sudden
outburst, over, is followed often by a degree of real shame and
grief; but I would name above all others the nurse fond of
gossip and scandal.

Be assured if you fail in this respect, if you lightly handle

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BY WILLIAM BEVAN-LEWIS, M.SC.

*33

the characters of those around you, if you pass harsh judg¬
ments unnecessarily, or take pleasure in dwelling upon or
exposing the frailties of others, you are sadly wanting in this
great virtue of a true nurse—self-control. Such a nurse is
always open to suspicion, for if she be a gossip about her
colleagues and their doings, how can she be entrusted with the
numerous private matters which a large institution brings
before her notice ? To prattle to the outside world about her
patients and their private histories and doings is as culpable as
for a physician to talk too freely about the patients entrusted
to his care. Let your self-control, therefore, exclude the possi¬
bility of gossip. Learn to respect the necessity for privacy,
and gain thereby that self-respect which issues from a
consciousness of loyalty.

Vigilance .—Just as much as there is a temptation to gossip
amongst yourselves, to your own injury and that of others, so
there is ever a temptation to a lack of vigilance, evidenced by
a dreaming, brooding tendency. This is often seen in un¬
disciplined minds, and the peril of this tendency rests on the
fact that few regard it as a fault at all. It has always been
their nature to indulge in reverie, to allow the mind to wander
aimlessly. Now, this tendency is obviously opposed to the one
great merit of a good nurse, the quality of vigilance. Watch¬
fulness is eminently demanded of the asylum nurse, and if she
permits her dreamy tendency, her castle-building, or her reveries
to obtrude themselves when upon duty she will utterly lose this
most desirable quality of vigilance, anddisasters are sure to ensue.

There is a secret power in genuine love for suffering
humanity which necessarily excludes the faults I have de¬
lineated ; such love should, of course, be quite natural—how
rarely this is the case I fear we all see too often. Still, those
who try to acquire it in spite of natural tendencies are striving
after a higher ideal; nor should they cease their efforts until
life and love are one, or, as is so beautifully rendered by
England’s greatest poet:

“ Tis even thus :

In that I live I love; because I love
I live: whate’er is fountain to the one
Is fountain to the other; and whene’er
Our God unknits the riddle of the one,

There is no shade or fold of mystery
Swathing the other.”

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134 on the formation of character, [Jan.,

In fact, it is on this Divine love for her kind that the secret
influence of a good nurse depends. With tenderest insight she
sees in the demented and suffering who throng our wards—

“ A body joumey’ng onward, sick with toil,

The weight as if of age upon the limbs,

The grasp of hopeless grief about the heart,

And all the senses weakened, save in that
Which long ago they glean’d and garner’d up
Into the granaries of memory.”

And her heart goes forth with strong love to the afflicted one,
whilst her tender watchfulness and care strive—

“To stay his feet from falling, and his spirit
From bitterness of death.”

Let me now digress for a moment to invite your attention
to three ideals of life realising this high type of being, yet
separated the one from the other by the bridge of centuries :

During mediaeval times, when the thousand years of the
so-called Dark Ages brooded as a cloud over continental
Europe, two great lights cast their beams athwart the gloom,
bringing out the shadows into still darker relief, as though to
solace Europe for the decay of learning, which was then at its
lowest ebb. The first great luminary appeared just prior to
the plunge into mediaeval darkness, as though to support with
hope those who otherwise would have been given over to abso¬
lute despair ; the second near the termination of the Dark
Ages, as if to augur the return of the sun of learning in its full
lustre.

The first I allude to was that of a noble Roman lady, her
work and its momentous results. The woman’s name was
Fabiola, who as an act of penance founded at Rome the first
public hospital that history records ; her example, copied by
noble emulation throughout Christian Europe, spread like a
flood throughout civilised nations, with the wondrous results
you perceive at the present time.

The second great luminary was the Spanish monk Juan
Gilberto Joffre, who, tortured by the horror to which wan¬
dering outcast lunatics were subjected, built the first asylum
for the insane at Valencia in 1409 ; the cities of Saragossa,
Seville, Toledo, and Valladolid followed with their respective
asylums, and a new era began to dawn, the doctrine of witch¬
craft and demoniacal possession was doomed, and we stand

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1907-] BY WILLIAM BEVAN-LEWIS, M.SC. I 35

here to-day a witness to that sterling human instinct which
was aroused by these two wondrous characters.

Coming to our own times, we have a signal instance of
noble initiative, with self-sacrificing devotion, displayed by a
nurse whose name is a household word in every British home,
to remind us what one woman by sheer force of character, and
by strength of an exalted love, can accomplish. In October,
1854, Florence Nightingale sailed for Scutari with a staff of
seven and thirty devoted nurses to organise nursing of the sick
and wounded and to relieve the distress existing amongst the
Anglo-French troops during the terrible Crimean campaign.
So great was the influence of her self-devotion upon the nation
at large, that huge sums of money poured in to establish
institutes for nursing and further her great exertions at Scutari ;
and thence sprung those noble national brotherhoods termed
the Red Cross Service, the St. John Ambulance Association
with the numerous affiliated Corps, the medico-psychological
nursing classes, and the innumerable nursing guilds throughout
the kingdom.

Now, you who have taken your stand amongst others in
this great nursing reform, remember that although you cannot
all be Florence Nightingales you can all play a noble part in
this profession. Brilliant as such achievements are, remember
that the noble trend of Christian charity has been in the direction
of quiet, unostentatious work, and that the hundreds of thousands
who have sacrificed their lives for the relief of suffering
humanity have left a record of undying nobility. Do not, I
repeat, ignore the day of little things ; the most trifling details
as they may appear to you are absolutely essential in a nurse's
daily work. She must keep her attention continuously upon
such little details which insure her patient’s happiness and
comfort Securing your patients from unnecessary noise, from
surprise, from anxiety, from hurry ; gentleness of handling,
quietness of tone, absence of officious interference, the power
which foresees the patients’ wants, thinking for them ; in fact, the
little details connected with their clothing, bedding, bathing, the
ventilation and warmth of their rooms, the cheerful encourage¬
ment to occupation where allowable, or to amusements when
the mind should be diverted from morbid brooding—all these
indicate the tact which is of inestimable value in the asylum
nurse.

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136

ON THE FORMATION OF CHARACTER,

[Jan.,

To you charge nurses I would repeat the admirable advice
given by Miss Florence Nightingale: “To be ‘in charge* is
certainly not only to carry out the proper measures yourself
but to see that everyone else does so too, to see that no one
either wilfully or ignorantly thwarts or prevents such measures.
It is neither to do everything yourself nor to appoint a number
of people to each duty, but to insure that each does that duty
to which he is appointed. This is the meaning which must be
attached to the words by (above all) those ‘ in charge * of sick,
whether of numbers or of individuals (and I think it is with
individual sick that it is least understood). It is often said
that there are few good servants now ; I say there are few good
mistresses now. They neither know how to give orders nor
how to teach their servants to obey orders—*>., to obey intelli¬
gently, which is the real meaning of all discipline.” Miss
Nightingale wrote these words in the days of crinolines, and I
will save you her remarks upon that terrible development in
dress ; you may imagine how she inveighed against the fashion
of those days. However, we must warmly agree with her in
her horror of rustling clothing, rattling keys, and creaking
boards and furniture in the sick-room. Another remark of this
great teacher of the nursing art I cannot refrain from repeating :

“ Walking on tiptoe, doing anything in the room very slowly,
are injurious (*>., in the sick room). A firm, light, quick
step, a steady, quick hand are the desiderata, not the slow,
lingering, shuffling foot, the timid, uncertain touch. Slowness
is not gentleness, though it is often mistaken for such ; quick¬
ness, lightness, and gentleness are quite compatible.”

A few words on companionships and I have done.

Companionships.

The young nurse joining a large institution for the first time
is usually much impressed by the esprit de corps —the spirit of
apparent unity obvious amongst the numerous members of the
staff; the spirit of comradeship is to her not only very refresh¬
ing and novel, but develops within her a healthy enthusiasm.

It is only later that she discovers that this apparent harmony
is to a certain extent broken up by a distinct line betwixt those
who aim at the prizes of their profession, and who are deter¬
mined to work out their moral advancement, and the opposing

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I907-] BY WILLIAM BEVAN-LEWIS, M.SC. 137

class, who are devoid of any such instincts or ambitions, or at
least careless and indifferent or it may be actively vicious.
She will soon learn to discriminate between the two classes and
will be drawn to the one or the other by the natural attraction
subsisting between similar minds.

Emerson says very truly: “ A secret freemasonry runs
through all persons of virtuous character; they cannot be
hidden from each other—they mutually attract” We may
also add that a similar freemasonry runs through those who are
by nature vicious ; and do what she will, the young nurse will
find herself constantly tending towards one or the other camp.
You are, therefore, called upon very early to make your choice
of friends, and I cannot here insist too strongly on the caution
you should exercise. Here it is that a wise officer will often
turn the tide in a young girl's destiny by advice and timely
suggestion on the desirable associates for her subordinates. By
a friend I do not mean mere acquaintances whom you neces¬
sarily meet with in constant association with the staff, but those
one or two with whom you can exchange the most solemn con¬
fidences, to whom you can with confidence entrust your every
trouble with a certainty of sympathy in return. The
distinguished W. Penn says in his quaint style: “ Friends are
Twins in Soul, they sympathize in everything, and have the Love
and Aversion.” And again, if you ask me how such a true friend
is to be known, the same writer adds : w A true friend unbosoms
freely , advises justly , assists readily , adventures boldly , takes all
patiently , defends courageously , and continues a friend unchange¬
ably? Remember, friends will not hesitate to tell you your
faults, will encourage your lapses neither by levity nor leniency,
and will equally expect the same openness upon your own part
to themselves.

Whichever of you has the stronger mind will influence the
weaker. If you are the weaker, you will be under the sway of
the stronger, whether she be virtuous or vicious ; if you are the
stronger nature, remember the serious character of the responsi¬
bility thus cast upon you. Be, therefore, most guarded
in the choice of your intimate friends ; and w hen you have
secured such a prize be true as steel to her best interests and—

“ This above all,—to thine own self be true ;

And it must follow as the night the day

Thou canst not then be false to any man/’

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I3»

LOCALISATION OF CEREBRAL FUNCTION, [Jan.,

On the Localisation of Cerebral Function: a Reply to
Dr. Joseph Shaw Bolton. By Alfred W. Campbell,
M.D.

In his paper on “ Amentia and Dementia ” Dr. Bolton has
intercalated such a vigorous dissent from some of my specula¬
tions on the localisation of cerebral function, and a complaint
so bitter of my criticism of some of his earlier researches, that
I am forced to offer a defensive response.

The reference to my chapter on the visual areas may be
briefly dismissed, because I feel that unprejudiced readers will
recognise that to underrate Dr. Bolton’s well-known work in
this direction was the reverse of my intention, not to mention
that it would have been folly on my part to attempt to take
unto myself credit to which obviously I had no claim.

Our chief difference concerns the prefrontal cortex. Dr.
Bolton gives a direct denial to my statement that this cortex
presents a degree of cell- and fibre-poverty greater than that in
any other region, and points his denial by casting distrust on
my technique.

To open my defence of this statement let me point out that
Dr. Bolton has wofully misunderstood and misrepresented my
definition of the pre-frontal area. The field to which he alludes,
and which corresponds with the loosely-defined prefrontal
region, lobe, or area of other authors, differs greatly from the
area prefrontalis, mihi; thus, touching its extent on the
antero-lateral surface of the hemisphere, that surface in which
we are interested, in Dr. Bolton’s words the region includes
“ the anterior two thirds or so of the first and second frontal
convolutions . . . and the anterior third or so of the third

frontal convolution ” ; whereas, according to my description,
“ on the lateral or frontal surface, the field is small, and only
takes in the most anterior portion of the middle (second) frontal
gyrus.”

Considering the sharpness of Dr. Bolton’s attack, it is sur¬
prising that he has overlooked a territorial discrepancy so great
as to confound his two most important surmises.

First, he infers that the area prefrontalis, mihi, embraces
Professor Flechsig’s nodal point, a hypothetical point whereon
the long systems of fibres linking the “anterior association

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1907]

BY ALFRED W. CAMPBELL, M.D.

area ” with numerous sensorial zones are thought to impinge.
This is incorrect. Unfortunately, I am unable to quote the
Leipzig professor verbatim, but I think I am right in stating
that he locates this nodal point on the anterior half of the
middle frontal convolution; therefore more of it lies without
than within the prefrontal area as defined by me.

Secondly, to illustrate the structure of prefrontal cortex,
Dr. Bolton has employed sections from the middle of the sulcus
fronto-marginalis of Wernicke (inadvertently he calls this the
transverse fissure of Wernicke), but this sulcus also lies partly
without and partly within the area prefrontalis, mihi, and at
its middle I have often found, and would expect again to find,
cortex having what I regard as a combination of “ frontal ” and
“ prefrontal ” characters, not true and typical prefrontal cortex.

The way leads now to a reply to Dr. Bolton’s condemnation
of the method for displaying nerve-fibres, that elaborated by
Walters and Kulschitzky, which I have employed. It is urged
that in using this method I have relied on an untrustworthy
support. But I would inform Dr. Bolton and my readers that
in the excellent microphotographs reproduced to illustrate his
condemnation I recognise appearances with which I am per¬
fectly familiar from an inspection of my own sections; indeed,
these reproductions, instead of shaking, actually strengthen my
faith in the utility and reliability of the method he despises.
My sole regret is that Dr. Bolton has not aided my contention,
and confirmed, not only my observations but those of one more
learned in the fibre framework of the cortex than myself, Kaes,^)
of Hamburg, by offering for comparison reproductions of views
of cortex from other parts.

Here I must note that in the addendum to a recent and
important paper on the structure of the olfactory lobe and
cornu ammonis ( Brain, No. 113, 1906) Dr. Turner states that
the minute intercellular fibrils which he has succeeded in
displaying by a specific method elaborated by himself are
probably more numerous in the prefrontal cortex than in any
other. The statement appears to support Dr. Bolton’s point.
I understand, however, that these fibrils are different from the
finest fibres which any modification of the Weigert-Pal method
will demonstrate. And much as I welcome Dr. Turner’s
discovery and the objection founded thereon to my specula¬
tion regarding the function of the prefrontal area, I think he

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140

LOCALISATION OF CEREBRAL FUNCTION. [Jan.,

will concede that more investigation will be needed before it is
decided what part these fibrils play in cerebral function.
Moreover, considering the wealth of the fibrillar plexus,
revealed by other specific methods in other regions, we may be
pardoned /or requesting more proof that these fibrils occur in
greater abundance in the prefrontal cortex than elsewhere;
besides, there is no exact statement as to what prefrontal part
the observation refers.

In regard to nerve-cells, also, Dr. Bolton’s description and
representation of the lamination fail to alter my original
impression.

Therefore, I adhere to the conviction that the appearance
presented by sections of cortex stained by the Weigert-Pal
method, or any modification thereof, and by the method of
Nissl, suggest that the area prefrontalis, mihi, is in comparison
with the cortex of other areas poorly supplied with nerve-fibres
and nerve-cells. Also, I will continue to maintain that, in the
process of cerebral wasting, on account of architectural frailty,
this part and others similarly constructed will show gross
changes earlier than others more substantially built. This was
the crucial point in my criticism of Dr. Bolton’s assumptions,
and, in my opinion, it still carries weight.

Finally, referring to function, I repeat that in forming a low
estimate of the value of this particular field I have been
influenced, not so much by histological findings, as by the
observations of workers in other departments. Specially
I have felt the difficulty of reconciling high function with the
following data : In several well-authenticated cases of isolated
prefrontal lesion in the human brain no intellectual change has
been apparent; in the case of animals lower than man some
competent observers have failed to observe any effect as a
result of experimental ablation of the homologous part; and,
lastly, in the anthropoid ape the anterior end of the frontal
lobe is the only part of the brain which yields no reaction to
electrical stimulation, a point which, in these animals at any
rate, suggests imperfect anatomical associations.

( l ) Discussing the degrees of fibre endowment of different cortical regions, Kaes
writes: “ Als faserfirmster Bezirk muss die ganze vorderste Stirne auf der

Convexitiit bezeichnet werden” (Archiv fur Psychiatre, Band xxv, Heft 3, p. 757).

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RECENT MEDICO-LEGAL CASES.

141

Recent Medico-Legal Cases.

Reported by Dr. Mercier.

[The Editors request that members will oblige by sending full newspaper
reports of all cases of interest as published by the local press at the time of the
assizes.]

For this very interesting account I am indebted to Dr. Sheldon.

Rex v. Tunnicliffe.

Tried at the Chester Assizes on Wednesday, July 18th, 1906,
before Mr. Justice Sutton.

The prisoner was employed as a journeyman painter by
Mr. S. Whittaker, who had entered into a contract with the
Committee of Visitors of the Cheshire County Lunatic Asylum
at Parkside, Macclesfield, for the painting of the interior of a
new infirmary annexe to the asylum. The prisoner was
charged under the Criminal Law Amendment Act, 1885, s. 5 (2)
.for carnally knowing or attempting to have carnal knowledge,
on March 23rd and 26th, 1906, of Mary Ann Allcock, a female
patient in the said Asylum. He was also charged with the
same offence under the Lunacy Act, 1890, ss. 324 and 325.

Mr. Justice Sutton expressed his opinion that Section 324 of
the Lunacy Act, 1890, did not apply to this case, and Counsel
for the prosecution did not argue the point. Under the
Criminal Law Amendment Act, s. 5, the Judge put two
questions to the jury : First, “ Did the prisoner carnally know
or attempt to have carnal knowledge of the patient ?” and the
jury found that he had attempted to have carnal knowledge of
her. The second question was, “ Did he, when he did this,
know that she was an imbecile ? ” and the jury found that he
did not know this. The verdict of the jury was, therefore, that
the prisoner had committed the offence (that is, the attempt),
not knowing at the time that the patient was an “ imbecile,”
and the Judge said that was a verdict of " Not guilty,” and
directed prisoner to be acquitted. The prisoner gave evidence on
his own behalf, and admitted that he knew the woman Allcock
was an inmate of the asylum, and that she was at the time of
the offence wearing the usual asylum dress; also that he knew
“ she was a bit wrong.”

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RECENT MEDICO-LEGAL CASES.

[Jan.,

The case turned to some extent upon the technical point,

“ What was an imbecile ? ” Dr. McConaghey, the Senior
Assistant Medical Officer of the Parkside Asylum, stated in his
evidence that the difference between an imbecile and a lunatic
was that an imbecile was a person born with a congenital
mental defect, whereas a lunatic was a person with ordinary
mental capacity which deteriorated. It is understood that the
above is the view generally taken by the medical profession of
the difference between an imbecile and a lunatic. It would,
however, appear from the case of Reg. v. Shaw (L.R. i, C.C.
145) that the Court of Criminal Appeal in that case held that
imbecility might arise from “ decay of the faculties through old
age or intemperance,’ 1 and that such imbecility would constitute
the patient a person of unsound mind, and consequently a
lunatic within the meaning of Section 90, which deals with
orders for inquisitions in lunacy.

The effect of this remarkable decision appears to be that
under the Criminal Law Amendment Act 1885, s. 5, in order to
secure a conviction it has to be proved that the "prisoner has
knowledge which he could not have unless he is able to dis-.
criminate between different sorts of insanity in a patient con¬
fined in an asylum. If this is so, then Section 5 is no protection
whatever either to inmates of an asylum or to idiots or imbe¬
ciles outside. The difficulty, no doubt, arises through the
Lunacy Act using the word “ lunatic,” and the Criminal Law
Amendment Act using the words “idiot or imbecile.”

Under Section 324 of the Lunacy Act, 1890, the words are
“ or other person employed in any institution for lunatics.” It
does not say “ employed by the committee ” and the only argu¬
ment, it seems, in favour of the Judge’s decision is the doctrine
that, where there is a previous description of any particular
person or persons, then the general words following are limited
to persons ejusdem generis . The special persons mentioned in
Section 324 are “ manager, officer, nurse, or attendant.” On
the other hand, however, there was no doubt that the prisoner
was “ a person employed in the Parkside Asylum.” The above
special words do not include “ servants” as Section 323 does, or
artisans, both of whom must occasionally be employed in the
female wards.

It was suggested to Mr. Justice Sutton by the counsel for the
prosecution that the case should go to the jury, and that his

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1907-] RECENT MEDICOLEGAL CASES. 143

lordship should state a case for argument before the Court of
Criminal Appeal, where the legal points in question could have
been fully discussed, but this suggestion was not adopted by
Mr. Justice Sutton.

A great miscarriage of justice appears to have occurred in the
above case, and if this is to be prevented in the future and due
protection given to lunatics, idiots, and imbeciles, whether inside
or outside an asylum, it appears necessary that the law should
be made more explicit. With regard to lunatics, idiots, or imbe¬
ciles confined in asylums, if Section 324 of the Lunacy Act,
1890, does not cover a casual workman in an asylum not
directly employed by the Committee, the section should be so
amended as to cover this without having recourse to the
Criminal Law Amendment Act, 1885. The words in Section
324 are “ manager, officer, nurse, attendant, or other person,”
etc., and it should be made clear by the insertion of other
words that this section applies to artisans, servants, and also to
persons employed in or about the asylum by firms or individuals
who have undertaken work for the Committee by contract or
otherwise. The amendment might be brought about by a
section defining iwhat class of persons the words " or other
person ” in Section 324 include.

It is found necessary at times to get work such as painting,
installation of electric light apparatus, etc., done by outside
contractors rather than by the regular artisans at an asylum,
and on these occasions it is impossible to prevent the workmen
employed by such contractors from entering from time to time
the asylum female wards.

Criminal Law Amendment Act, 1885, s. 5 (2); Offence
against Imbecile Woman; Definition of “Imbecility.”

At Bodmin Assizes, before Mr. Justice Kennedy, a man was
indicted for an offence under Section 5 (2) of the Criminal Law
Amendment Act in respect of an imbecile woman. It appeared
that the imbecile when she was fourteen years of age was in
the second standard at school, where the average age of the
children was only eight years. At the present time she was
not fit to be trusted alone, and was not considered capable of
going out to service.

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OCCASIONAL NOTES.

[Jan.,

On behalf of the prosecution it was pointed out that there
was no definition of the word “ imbecile” contained in the
Act, and it was submitted that an “ imbecile ” was a person of
defective mental power of less degree than idiocy, and not
congenital.

For the defence R. v. Barratt, L.R. 2 C.C.R. 81, and R. v .
Fletcher, L.R. 1 C.C.R 39 were cited.

His lordship, in the course of his summing up to the jury,
said that there had not been many cases under that section of
the Act, which had been passed to prevent men, either by a
trick or superior will power, from taking advantage of women
who, from physical or mental disabilities, had special claims
on the law’s protection. There were cases where, although a
woman had will and understanding, it might be so weak that
a man who by persuasion overcame her scruples ought to be
held to have broken the law. He cited Taylor’s Medical
Jurisprudence (twelfth edition), pp. 1045 and 1046, and R. r.
Turner, Sessions Papers of the Central Criminal Court (1886), and
proceeded to direct them that there must be such weakness
that under the will of the man there was no fair chance for the
woman. The woman must be incapable of resisting persuasion,
of exercising an act of her own will, or of giving or withholding
her consent.

He left the following questions to the jury: (1) Was the
woman an imbecile ? (2) Did the prisoner know it ?

The jury answered both the questions in the affirmative, but
strongly recommended the prisoner to mercy on account of
his age.

Occasional Notes.

The Lunacy Commission .

The extension of the scope of the Royal Commission on the
Feeble-minded has unexpectedly brought the desirability of an
increase in the strength of the Lunacy Commission under
consideration. The Report of a Royal Commission is not
soon issued, and its recommendations are not usually acted on
with precipitation, so that the hoped-for change may still be
far distant.

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OCCASIONAL NOTES.

145

The necessity for an increase in the Lunacy Commission
has been dwelt on in this Journal so frequently that nothing
more need be said on this head at the present time—the
manner of increase is now the vital point. The union of the
two offices that now supervise the insane independently would
seem to be the readiest means of effecting this in part. The
Medical Visitors of the Lord Chancellor if combined with the
Lunacy Commission would strengthen the latter both in
numbers and influence. The Lunacy Act of 1892 gave the
Lord Chancellor power to effect this fusion, and as this pro¬
vision was passed with the sanction of the then Lord
Chancellor, after due consideration, it may be concluded that
there is no possible objection on the side of the Chancellery.
The advantage is obvious. Much of the visiting of the two
bodies is a re-duplication of effort. The Visitors and the
Commissioners visit the same localities, and often the same
patients. The fusion would result in considerable economy in
travelling expenses, and would be equal in the saving of time
and effort to the work of at least one commissioner.

An increase of pay of the Medical Commissioners is a question
which should now receive consideration. Since the salaries of
these officials were fixed the pay and emoluments of the Asylum
superintendents, from whom the commissioners are usually
selected, have greatly increased. Many medical superintendents
of a length of service qualifying them to hold such a post would
be giving up considerable advantages in pay and prospects of
pension in joining the Lunacy Commission. Hence the Com¬
mission is deprived of the candidature of many very eligible
men, and the knowledge of this does not tend to increase its
influence.

The increase of the Commission by the fusion of the two
offices would, however, reach but a little way in enabling it to
cope with the many duties that it ought to undertake or that
ought to be transferred to it.

Deputy commissioners, as in Scotland, would appear to be
the simplest and most economical means of increasing the
working power of the Commission. There is considerable
difference of view in regard to the share of the work that
should be taken by the deputies. In Scotland they are largely
engaged in the work of supervising the boarding-out system,
which, unfortunately, at present is almost non-existent in

LIII. 10

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146

OCCASIONAL NOTES.

[Jan.,

England. Their work should probably consist in the super¬
vision of such boarded-out cases as at present exist, and, in
fact, relieve the senior commissioners as much as possible of
the attention to individual patients, under ordinary conditions
leaving them free, at their visits to asylums, to deal with the
broad, general means of care and treatment.

The majority of the members of the Medico-Psychological
Association probably favour the view that the deputies should
be general, but there is much to be advanced in favour of a
territorial division of work, so that each deputy should have
a special knowledge of the patients in a given area. There are,
however, disadvantages in this plan, and the non-territorial
system is probably the more desirable.

The deputy commissioners would, no doubt, furnish a large
proportion of the senior commissioners in course of time, but
this should by no means be the sole avenue to the senior
posts.

The Commission thus strengthened would be in a position to
deal with many things that it is now too ov^er-burthened to
attempt—the boarding-out question, the defect of the present
law, the treatment of the incipient insane, and many other
important matters which have been too long neglected and
which would absorb all the powers of the enlarged Commission.

The Increase of Temperance .

The Inland Revenue returns show a steadily progressive
decrease in the consumption of beer and spirits in the United
Kingdom since 1899; that is in encouraging contrast with the
equally steady but more rapid increase up to that date.

The beer consumption in 1899—1900 was 32*2 gallons
per head of the population, making a total of 36*5 million
barrels, but in 1905—1906 this had fallen to 27*9 gallons per
head and to 33*5 million barrels.

The spirit consumption has also fallen each year from 1*17
gallons per head and a total of 48 million gallons for 1889—1900
to *90 gallons per head and 39*1 million gallons in 1905—1906.

The reduction in the consumption of spirits is very striking,
and in addition to the reduction in the total quantity of beer
consumed there is to be added the large increase in the pro¬
portion of the lighter beers of home and foreign manufacture.

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OCCASIONAL NOTES.

147

Pauperism, crime, and insanity are so largely attributable to
the abuse of alcoholic drinks that the statistics of each should
be carefully watched during the next few years for any indica¬
tion of an improvement. It is, of course, possible that this
reduction may be due only to the greater moderation from
necessity or improved habits of the middle and upper classes
only, although it would appear to be too large to be thus
explained.

Abuse of alcohol, in the statistics of the causes of insanity,
has fluctuated very little for many years past, so that any dis¬
tinct diminution would be very significant, and should encourage
a still more vigorous crusade in favour of true temperance—the
use without abuse of the cup that cheers and may inebriate.

The Grantham Railway Disaster.

It is agreed that all statistics require careful reading, but
those relating to insanity are more exposed to misreading than
are most others. The following abuse of statistics is so grotesque
that it would not be worth criticism had it not tended to cause
unnecessary alarm and mischief.

At the time of the Grantham railway disaster, the cause of
which still remains a mystery, the sudden onset of insanity in
one of the two engine-men was put forward as a possible solu¬
tion. On this question the Standard newspaper in its issue of
September 13th founded a principal-page disquisition, not
without help from the outside. It was stated therein that, as
i2 - 7 in every 10,000 engine-men became insane every year, this
calling stood very high (seventh) in liability to mental disease;
that, as 40 per cent . of all admissions were cases of acute mania,
so 40 per cent, of the engine-men becoming insane might be
taken to suffer from acute mania; that every case of acute
mania might become insane without any warning whatever.
The conclusion drawn from the foregoing statements as applied
to an erroneous estimation of the number of engine-men at
40,000 is that 20 engine-men are liable in each year to become
insane suddenly and unexpectedly.

As to the relative liability of engine-men to insanity, no
doubt the ratio, correctly taken from the Commissioners’ last
occupation-liability tables, appears to be high in comparison

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148

OCCASIONAL NOTES.

[Jan.,

with the ratios of some other callings. But it must never be
taken as an absolute proportion. It was arrived at by com¬
paring the mean of five years’ admissions of engine-men into
asylums (1896-1900) with the absolute enumeration of the class
in the census of 1891, which latter had perforce to do duty as
the standard of comparison till a new census was taken. If
the actual number of engine-men in 1898 (the centre year of
the five) could have been known and applied to the average
admission rate of engine-men for these years, then a reasonably
accurate proportion could have been struck. It undoubtedly
would have been smaller. The same argument of course could
be applied to other callings, but the case of the engine-men
stands by itself. They numbered 13,000 in 1871, 40,000 in
1891, and 66,000 in 1901. Few, if any, other callings could
have shown an increase of 66 per cent, in ten years. Assuming
the increase to have occurred regularly through the ten years,
the engine-men numbered about 58,200 in 1898, and this com¬
pared with the average admission rate centring on that year
would show a ratio of 87 only.

It is surely ingenious to suggest that the general proportion
of acute mania cases in all admissions should apply to engine-
men, but it is very awkward, for it would entail a certain
proportion of the latter at the time of their falling ill being
congenitals, with or without epilepsy, epileptics, senile
dements, etc.

Further, the quotation of acute mania as forming 40 per cent .
of all admissions is ridiculously erroneous. This ratio stands
for all sorts of mania, acute, chronic, recurrent, etc.

We think that most who have experience will deny anything
like a general liability to an attack of insanity coming on with¬
out any prodromata recognisable by wife, friends, officials or
doctors. It may occur, of course, but so rarely as to be in¬
capable of statistical consideration. In the case of engine-men
the infinitesimal risk is probably more than obviated by the
close inspection that each man receives when he goes on duty,
and also by the constant observation of his mates and superiors,
who must always be thinking how their lives and interests are
in the hands of the folk on the footplate.

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1907]

REVIEWS.

149

Part II.—Reviews.

The Sixtieth Report of the English Commissioners in Lunacy. June,

1906.

The Report of the Lunacy Commissioners still grows in bulk and in
evidence of the vast amount of work that is done.

The number of persons certified as insane in England and Wales on
January 1st, 1906, was 121,979, being 2150 in excess of the previous
year, this being 404 less than the average excess of the last ten years.

The distribution of these patients varied little in the year. The
county and borough asylums increased their numbers by 2251 to a
total of 89,342, while the licensed houses decreased by 199.

The private patients have increased by 162 during the year, 137
being added to the number of this class in borough and county
asylums. The Commissioners mention the fact that in London an
asylum patient is classed as private when a part of the cost of main¬
tenance is refunded by the friends. It would be of interest to know
whether this arrangement, together with the increased facilities for
private treatment in the county and borough asylum annexes, accounted
for the rise in the proportion of the private insane since 1899. Prior to
that date the private class had shown a gradual diminution.

Attention is drawn to the fact that since 1859 the number of pauper
insane in asylums has increased by 441 per cent., whilst the out-door
pauper insane have decreased from 18*5 to 5 per cent, only of the total
insane pauper population. That boarding-out is possible in England
and Wales to a very much larger extent than generally exists is shown
by the fact that the patients residing with relatives and others number
25 per cent, in the Plymouth and over 20 per cent, in Norwich boroughs.
If boarding-out can be carried to this extent in two boroughs, why can
it not be done in the others, especially if a better-arranged system could
be brought into action ? With a strengthened Commission great pro¬
gress should be made in this direction.

The statistics of the accumulation of the insane are illustrated by
charts based on the tables giving the numbers of the insane known
to the Commission since 1859. The table (Appendix F, No. Ill)
shows that the ratio of all admissions per 10,000 of the population had
steadily risen to 6*93 in 1902, since when it has fallen each year to 6*33
in 1905. The ratio of first admissions recorded since 1898, when it
was 4‘92, rose to 576 in 1902, and has fallen in each of the succeeding
years to 5*21 in 1905. This may only represent a temporary fluctuation,
but it is from these statistics of primary admissions alone that any con¬
clusion can be drawn of the actual increase or decrease in the greater
or less frequency of the occurrence of insanity. These first ad¬
missions still certainly include cases that have been insane for many
years prior to admission, and hence do not represent actually, but only
approximately, the occurring insanity of a given year. Even with this
uncertain element the first admissions will in time give some guidance

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REVIEWS.

[Jan.,

150

in the much debated question of the increase in the occurrence of in¬
sanity, but much more statistical analysis should be given to these first
admissions than they now receive. It is desirable, for example, that
their ages should be given apart from the ages of all admissions, also
the forms of mental disorder and the duration of disorder prior to ad¬
mission. Such information would permit a much more reliable com¬
parison of the admissions in different years than is now possible.

The recovery-rate (Table VIII) given in quinquennial periods since
1873 h as fallen, being lower in the period 1898—1902 than in any
previous period, viz., 37*58 per cent, of recoveries to admissions.

The death-rate has also declined from 10*26 in the first to 8*87 f>er
cent, of deaths to daily average number resident in the sixth quin¬
quennium.

A chart showing the relative mortality of the insane to the general
population in age-periods is also given, and a map indicating the fre¬
quency of heredity in the insanity of various counties. In fact, the
Report shows a distinct advance in various ways in the endeavour to
make use of the statistics furnished to the Commission.

The average weekly cost of patients in asylums has fallen by \d.
below that of the previous year, due apparently to provisions and cloth¬
ing being cheaper, while the farms and gardens have been more pro¬
ductive, these overbalancing the rise in wages.

Numerous alterations and additions to asylums are recorded, and
mention is made of the new asylums in course of construction— viz.,
Essex (second), Colchester, London (tenth), Long Grove, Manchester
(second), Barnsley Hall, West Riding Asylum, Starthes Hall, and the
Cardiff Borough.

An important return is given of the cost of asylums per head in the
various counties and boroughs up to January 1st, 1904, together with
the cost of maintenance and other matters of considerable interest for
reference.

The casualties recorded during the year include an extraordinary case
in which a husband was convicted of murdering his wife at the Horton
Asylum, when visiting her.

An outbreak of typhoid fever at the Cambridge Asylum caused six¬
teen deaths out of a total of sixty-eight cases.

The recurrence of dysentery and the mortality from it receives very
careful consideration, with analysis of the statistics given in a separate
table (No. XIV, Appendix B), and a diagram which credits the smaller
asylums with a larger proportion of dysenteric deaths. As yet little way
appears 10 have been made in the reduction of the disease. Deaths from
tuberculosis are dealt with in a similar statistical method.

The rates of payment (including all “extras”) for private patients in
registered hospitals (excluding Bethlem Hospital and idiot establish¬
ments) during the year 1904 are given in a table, which is one of great
interest and demands very careful consideration.

St. Luke’s Hospital sets a good example to these institutions in
maintaining no less than 20*1 per cent, of its patients gratuitously, Bethel
(Norwich) following with 6*7 per cent., followed by Wonford House
with 3*3 per cent. The large number of educated persons who need the
help of such hospitals, and, being unable to obtain it, have to become

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REVIEWS.

I SI

pauper patients, makes it a matter for serious consideration whether
much more help for this class cannot be obtained. In all the registered
hospitals, excluding St. Luke’s, only forty-five patients are maintained
gratuitously, although these institutions receive no less that 329 patients
paying from three to four guineas per week and 317 paying four guineas
per week and upwards. The amount of charity conferred is remi¬
niscent of FalstafPs pennyworth of bread.

This table will enable a careful comparison to be made from year
to year of the actual amount of charity conferred, and possibly a more
powerful Lunacy Commission may exert some influence on these in¬
stitutions, to extend their activities to the object of saving a much
larger number of persons of the educated classes from becoming paupers.
A return of the total number of persons of this kind now in pauper
asylums would be most valuable in inciting public effort for the relief
of these unfortunates.

The Report on the whole compares favourably with those of pre¬
ceding years, is of greatly increased value in its statistical aspect, and
bears throughout ample evidence that the Commission struggles man¬
fully to discharge its overwhelming duties and responsibilities.

The Forty-Eighth Annual Report of the General Board of Commissioners
in Lunacy for Scotland,\ 1906.

This last Report of the Scottish Commissioners contains many
features of interest, particularly the statistics of, and the remarks upon,
the increased death-rate from general paralysis of the insane and the
prevalence of tuberculosis, in the Scottish asylums.

On January 1st, 1906, there were in Scotland 16,946 registered
insane and 504 non-registered insane persons (in criminal department
of Perth Prison and in training schools for imbecile children), giving a
total of 17,450. Of the registered insane, 2366 were maintained from
private sources and 14,580 by parochial rates. These figures show a
decrease of private patients by 13 and increase of pauper patients by
176, and hence a total increase of 163 as compared with the previous
year.

Of the 504 non-registered insane persons, 51 were maintained at the
expense of the State in the department of Perth Prison for the Criminal
Insane—an increase by 1 as compared with the previous year—while
453 were in training schools for imbecile children—an increase of 45
as compared with the previous year. Of these 453 imbecile children,
183 were maintained from private sources.

Increase of insanity in proportion to population .—For the first time
since 1858, the Commissioners are able to state that no increase of the
insane has occurred in proportion to the population. While this is a
matter for congratulation, we are reminded that, as proved by the
last census returns, there is still a large number of persons of unsound
mind who do not come under the official cognisance of the General
Board, and, further, that there are doubtless many individuals of unsound
mind who are not recorded as such in the census returns. The Com-

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152

REVIEWS.

[Jan.,

missioners give an interesting statistical table, commencing with the
year 1858, when they had official cognisance of 5769 insane, and
ending with the year under review, when there were on the register
16,946—an increase of about 200 per cent. During the same period
the increase of population was 56 per cent. Quinquennial averages
show that there has been a steady increase in the number of registered
insane in proportion to population in the case of both private and
pauper patients, but the increase is much more marked in the pauper
class. Further, the increase in the number of pauper insane is par¬
ticularly striking when viewed in relation to the pauper population. In
1858 the number of pauper insane in every 100,000 of registered
paupers was 5980, and the quinquennial averages show a constant
increase up till the beginning of 1905, when it was 21,561. On the
other hand, there were 2630 registered paupers in every 100,000 of
population in the year 1858, while the quinquennial averages exhibit a
marked decrease down to 1900, when there was a rise as compared with
the previous quinquennial figure, followed again by a fall in the
succeeding quinquennial period ending 1905, when the average was
1464 per 100,000. That is to say that during the last half-century there
has been an almost constant decrease in the number of registered
paupers in proportion to the entire population, while there has been a
steady increase in the number of pauper insane in proportion to the
pauper population.

Number of first admissions registered. —A table is given showing the
number of private and pauper patients registered for the first time in each
year from 1874 and their ratio to the population. The ratio in the
case of private patients has fluctuated within narrow limits, and is the
same for 1905 as for 1874. In the case of pauper patients the table
shows a fairly constant increase in the ratio to population up to 1902,
when it reached its maximum of 52*6 to 100,000. Since then it has
diminished slightly and for the year 1905 it was 47‘9.

Admissions to establishments during 1905.—The number of private
patients admitted to asylums during 1905 was 545, or 18 less than in
the preceding year and 24 less than the average for the quinquennium
1900-1904. The number of pauper patients admitted was 2920, or
171 le?s than in the preceding year and 88 less than the average for
the preceding quinquennium. Transfers are excluded from this calcu¬
lation.

Voluntary patients admitted into asylums during 1905 numbered
96, which is 12 more than the average number for the preceding
decennial period. The Commissioners adhere to their opinion that
no objection can be raised to the admission of such patients into
asylums.

Discharges of the recovered. —The details given in this section of the
Report are of a very disappointing nature; for in the face of increased
knowledge, advanced therapeutic methods, architectural, sanitary, and
generally speaking, environmental improvements, there has been a con¬
tinuous diminution in the number of recoveries during the past twenty-
five years, at least amongst the pauper patients, who form the great bulk
of the insane population.

The following statement shows the recovery-rate from all establish-

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REVIEWS.

1907 .]

*53

ments during the past twenty-five years among private and pauper
patients respectively.

Recoveries per cent, of
admissions, excluding transfers.

Average of five years.

Private.

Pauper.

1880—1884

41*0

47*6

1885—1889

39*0

45 ’ 1

1890—1894

39*3

44*1

r895—1899

43 °

44*1

1900—1904

44*3

42*9

1905

448

. 41*6

It is to be noted that there has been a fairly continuous increase in
the percentage of recoveries among the private patients, while the per¬
centage among the pauper patients has steadily diminished from 47*6 to
41*6 in the same period. After due consideration of all the facts of the
case, there can be no doubt, however, that the diminution in the
recovery-rate is due, not to diminished efficiency in treatment of the
patients, but to the larger number of patients of all ages admitted
suffering from incurable physical diseases complicated by mental aber¬
ration, many of them patients who, in former times, would have been
sent to general hospitals or allowed to die at home.

Discharges of the unrecovered. —During the year 1905 there were dis¬
charged unrecovered 134 private patients, and 438 pauper patients. Of
the latter, 358 were discharged by minute of parish council and 25 on
expiry of a period of probation. The remarks of the Commissioners
seem to urge an extension of the method of liberation on probation for
periods not exceeding one year. There can be no doubt that this pro¬
vision is a very wise one, and it certainly ought to be taken advantage
of more frequently. In many cases the fitness of a patient to take care
of himself in the outer world is a very doubtful matter, and can only be
decided by experiment. Considerations of possible failure ought not to
deter the superintendent from giving the patient the benefit of the
doubt and making the necessary experiment. One thing is certain—
viz that the wider employment of the probationary system would lead
to a larger number of permanent discharges.

Insane persons in private dwellings .—On January 1st, 1906, there
were 2752 pauper patients living in private dwellings, with the sanction
of the Board of Commissioners. This is the largest number of patients
living under family care yet recorded, being 48 more than in the pre¬
ceding year. Of these 976 were boarded with guardians who were rela¬
tives, and 1776 with unrelated guardians. Altogether, 325 patients were
admitted to the roll of the pauper insane in private dwellings during the
year 1905—that is to say, 3 more than the preceding year. Of these,
108 were resident in private dwellings when first reported to the Board,
and remained under private care with the sanction of the Commis¬
sioners, while 217, or 14 more than the preceding year, were removed
from asylums.

In the course of the year 26 were certified sane, 25 were removed
from the poor roll by their friends, 24 were removed to asylums, and
102 died, the death rate being 37 per cent.

One pregnancy was reported during the year, in the case of a con-

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REVIEWS.

[Jan.,

154

genital imbecile, at. 29, living under the care of a married sister. It is
pointed out that of the ten cases that have occurred during the past
ten years, seven were under the care of their nearest relatives, while one
was under the care of a woman who had brought her up from childhood,
and only two cases occurred among the many young females boarded
with strangers.

The Reports of the Deputy Commissioners on the system of family
care of the insane, as carried out in Scotland, are interesting, and tend
to the conviction that the system is at once beneficial to the patients
and economical to the ratepayers.

Death-rate in establishments. —The deaths in establishments during
1905 numbered 183 private patients, or 8*2 per cent, of total numbers
resident (which is 19 more than in 1904, and 15 more than the average
for the quinquennium 1900—1904), and 1137 pauper patients or
9*6 per cent. (90 more than in 1904, and 123 above the average for the
five years 1900—1904). The statistical tables show a tendency to an
increased percentage of deaths calculated on the total numbers resident
and an increased proportion of deaths taking place within the first year
after admission. This is regarded as confirming the view expressed as
to the lowered recovery-rate, that physical wrecks are being admitted to
the asylum in increasing numbers.

Deaths from general paralysis of the insane. —Very particular remarks
are made with regard to this matter, which the Commissioners have
made a subject of special inquiry. It is clearly shown that the number
of deaths from general paralysis in proportion to the admissions has
increased continuously during the past twenty-five years. This increase
has been more rapid in recent years, and remarkably so in the case of
female patients. It is difficult to decide to what extent the increase
shown in the tables represents a true increase in the prevalence of the
disease. The reviewer is convinced that a few years ago many of the
cases now returned as having died from general paralysis would have
been described as cases of cerebral softening, disseminated sclerosis,
and cerebral paralysis, and the cause of death certified accordingly.
This is especially true with regard to general paralysis in female patients,
in whom the disease is now diagnosed with greater accuracy and fre¬
quency.

Deaths of patients in whom consumption or other tubercular disease
was present either as a principal or a contributing cause. —This matter
also forms the subject of a special Report by the Commissioners. Figures
are given showing an average annual number of deaths in which tuber¬
culosis was present per 1000 patients resident, ranging from 35 in the
Edinburgh Royal Asylum to 8*7 in the Aberdeen Royal Asylum, 4*1 in
the wards for the insane of Old Monkland Poorhouse, and nil in the
wards for the insane of six other poorhouses. Not only are remarkable
differences shown to exist between different asylums as regards the pre¬
valence of tuberculosis, but in individual asylums there is frequently a
considerable difference between the male and the female sections in
this regard. Again, when the annual average percentage of deaths in
which tubercular disease is present in any particular institution is com¬
pared with the average percentage of deaths from tuberculosis in the
general population of the district served by that institution the result is

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always a striking excess on the side of the institution. The Com¬
missioners conclude that the enormously greater prevalence of tuber¬
culosis in certain institutions as contrasted with others is due in great
measure to causes which are avoidable, such as overcrowding. The
accuracy and the legitimacy of the Commissioners’ conclusions are far
from being incontrovertible. There are many points on which further
information may reasonably be demanded. One hesitates to believe
that the patients in the Scottish institutions live under less hygienic
circumstances than in their own houses—at least in the vast majority of
cases; yet it would appear from the statistics that the number of patients
who acquire tuberculosis whilst resident in asylums is about twice as
great as the number affected prior to admission.

Expenditure for maintenance of pauper patients .—The salient feature
of the financial statement contained in the Report is the fact that for
the last dozen of years the gross annual expenditure per patient in
district asylums has been steadily increasing. The main rise has
occurred under the head 44 Salaries and Wages,” while a decrease has
taken place under 44 Food.”

The expenditure in different asylums under the same heads varies
considerably, and one is inclined to attribute extravagance to some
asylums in certain directions.

The Commissioners’ Report for the past year deserves the atten¬
tion of asylum administrators, who will be amply repaid by a careful
study of it.

Supplement to the Fifty fourth Report of the Inspectors of Lunatics
on the District , Criminal , and Private Asylums in Ireland; being
a Special Report on the alleged Increase of Insanity.

This 44 Supplement ” is a document which has been waited for with
patience—perhaps, more correctly speaking, with impatience, as more
than two years have elapsed since the returns asked for from the various
district asylums (in February, 1904) upon which this 44 Supplement ” is
based were available, and we are already half-way through another
census decade before we have been put in a position to form any esti¬
mate of the general increase in insanity during the previous one; so
that up till the issue of this booklet we have only been conscious of the
fact that 44 we don’t know where we are.”

At the opening of their Report the inspectors refer to a similar
special Report furnished by them in the year 1894 on the alleged in¬
creasing prevalence of insanity in Ireland, and recapitulating the con¬
clusions arrived at on that occasion. These are summarised as
follows:

(1) That the great increase of insane under care was mainly due to
accumulation, and was, so far, an apparent and not a real increase.

(2) That the yearly increase of admissions was drawn, in a consider¬
able proportion of the cases, from the reserve of the unregistered insane
existing throughout the country, as shown by the reduction in the
number of lunatics and idiots at large, as given in the census returns.

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(3) That the annual increase, in face of a shrinking population, of
the number of first admissions, including such a large proportion of first
attacks of insanity, almost irresistibly pointed to some increase of
occurring insanity in particular districts.

These conclusions seem to have been fair deductions from the
statistical returns at their disposal, and from the opinions of the super¬
intendents of the various district asylums, although on some points these
latter cannot be said to have been quite unanimous. But there is room
for difference of opinion on such questions of causation as consanguineous
marriages, the abuse of nerve-stimulants, such as alcohol, tea, and
tobacco, and the effects of acute agricultural depression.

In the present Report the figures are brought pretty well up to date,
the decade 1894-1903 being the period selected for review.

To deal with the census returns first, in the fifty years 1851-1901 the
population of Ireland fell from 6,552,385 to 4,458,775, or, in round
numbers, 32 per cent '., while the number of insane rose from 9,980 to
2 5>°5°> or 151 per cent., and the ratio of insane to population from
15*2 to 56*2 per 10,000, a rise of 267 per cent.

These figures, alarming as they may well be regarded, must, however,
be taken cum grano salts . For if the number of insane in the year 1851
had been computed on the same lines as were followed in 1901 it is
more than probable that a very much higher figure would have been
returned as representing the total number of insane than was actually
done. For, fifty years ago comparatively few cases of mental enfeeble-
ment from old age were returned as insane, whereas nowadays these
cases form a not inconsiderable proportion of the admissions into
asylums. As the inspectors remark later on :

“ As an additional factor in swelling the numbers of the insane, it is
important to note that the medical recognition of what is considered
certifiable insanity has nowadays widely extended. For instance,
symptoms which are deemed sufficient evidence of mental disease to
warrant a certificate of insanity and a transfer to an asylum are now
accepted in cases which in days gone by would not have been regarded
as more than evidences of dotage in old people who were cared for at
home by relatives as best they could. The mental breakdown of old
age is now looked upon as requiring, with other nervous diseases, greater
care and supervision, and the admissions of the aged to lunatic asylums
have, therefore, in recent times greatly increased.”

And in the section dealing with the age classification of the insane it
is shown that during the thirty years 1871-1901, while the proportion of
insane per 100,000 of population between the ages of twenty and fifty-five
increased by 64 per cent., the ratio of those over fifty-five increased by
185 per cent., these figures clearly demonstrating, as urged by the
inspectors, that by far the greatest increase in the ratio of the insane to
population occurred in the old age period. This element of causation
of the “ increase of insanity ” is one which is not likely to lessen as years
roll on —au contraire.

If the sister countries are compared with Ireland as regards their
insane population, she is found in this respect to maintain an unenviable
pre-eminence; for during the same thirty-year period the proportion of
insane per 10,000 advanced in England from 30*4 to 40*8, a rise of 34

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1907 .]

1 S7

percents in Scotland from 34*0 to 45*4, arise of 30 percent,^ but in
Ireland it increased from 30*5 to 562, ora rise of over 85 per cent
This startling difference, however, if taken as indicating a much
greater prevalence of insanity in Ireland, must be largely discounted, as
the difference in death-rate in the respective countries alone will
account to a great extent for the higher proportion in Ireland. The
death-rate in county and borough asylums in England and Wales
averages 10 per cent, on the daily average, that in Irish district asylums
only 7*5. Low death-rate means a high rate of accumulation, and
if the English death-rate were the same as the Irish, the proportion of
insane to population in the former country would approximate much
more nearly than it does to the Irish ratio. We need not, therefore,
conclude from merely statistical evidence that the Irish are a much
more insane people than the English, but rather that they keep their
insane patients longer with them. The mortality from general paralysis
of the insane is four times greater in England than in Ireland, and
this disease alone is accountable for the greater part of the higher
mortality in England. In the year 1903, but 37 per cent, of the total
number of deaths in Irish asylums was due to this disease, whereas
the proportion in English asylums was 157. The ratio of deaths
from this disease, however, to the general mortality in asylums does
not appear to be on the increase, as from a table on page 16 of the
Report we learn that in 1899 the proportional mortality in Irish
asylums was 4*4, and in England and Wales 177 per cent.

The number of freshly occurring cases of insanity is the only reliable
index of its rate of increase. But even here statistics are more or less
elusive, as many cases included among the “ first admissions ” to asylums
are not of fresh occurrence at all, some of them being congenital or chronic
cases— viz. y persons who in previous years had already been enumerated
as insane in workhouses or at large, and are therefore to be looked on as
merely transfers from one category, or locale , to another. However,
with this reservation, the number of first admissions, or more, accurately,
the ratio of these to the general population, enables us to form the
closest approximate estimate of any methods employed for computing
the increase or otherwise of insanity.

Ten years do not count for much in the statistics of insanity; even
twenty are too few to give any solid ground for forming a forecast of the
future. Still, more legitimate deductions can be derived from the longer
than from the shorter period. And if we analyse the figures for the
twenty years 1884—1903 inclusive, instead of the ten dealt with by the
inspectors, we shall obtain a wider survey of the whole problem. The
statistics of district asylums, as the inspectors very properly advise us,
deal only with a portion of the insane—“approximately 67 percent, of
the total”—but if we compute the increase in insanity on the ratios per
10,000 of population of the first admissions into district and private
asylums during the four quinquennia of the period referred to, this will
probably bring us as near accuracy as we can hope to reach. Calculat¬
ing on these lines, it will be found that the average ratios of first admis¬
sions per 10,000 of population for the four five-year periods were 47, 5*3,
5 8, and 7*0 respectively, which denote a percentage increase in the
second quinquennium over that of the first of 127, in the third of 9*4,

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REVIEWS.

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and in the last of 2o’o, from which we are driven to the conclusion that not
only has there been a steady increase of freshly occurring insanity during
this twenty-year period, but that the rate of increase has been accelerat¬
ing in latter years, notably during the last five years ; but in accepting
this estimate the qualifying consideration already adverted to must not
be lost sight of—namely, that not all cases noted as first admissions are,
properly speaking, cases of freshly occurring insanity; so that things
may not be quite as bad as they seem.

A significant fact alluded to by the inspectors when dealing with the
ages of the insane in asylums is that the proportion of patients from
twenty to fifty years of age fell from 68 per cent, of the total in 1890 to
63 per cent. in 1903, while the proportion over fifty years of age rose
from 26 per cent, in 1890 to 33 per cent, in 1903. A warrantable in¬
ference from this is that as the average age of patients in asylums is
likely to show a progressive increase, sooner or later the death-rate will
probably increase from mere senility, and so provide one check to
accumulation.

We have often urged in these columns the uselessness of the returns
regularly made every year as regards the causation of insanity. The
mere fact that only one cause has been allowed to be given, whereas in
almost every case which undergoes adequate scrutiny there is found to
be a plurality of causes, is sufficient to render quite valueless any de¬
ductions from these figures. The inspectors have shown that they were
aliye to this fact in that they requested medical superintendents when
furnishing their returns under this heading to enter ail the contributory
causes in each case. Of course, the value of such returns altogether
depends on the conscientiousness with which each case was investigated,
and full allowance must be made for any failure in this respect, but in
any case the method adopted on this occasion is correct in principle,
however short it may fall of being thoroughly carried out in practice.
The inspectors summarise the facts as to causation as follows:

“Taking the causes for the entire decade in their relation to the
total, it will be seen that heredity heads the list, being about 36 per
cent,.of the total. Alcohol comes next, with an average of 15 per cent,
of the total. Then anxiety, worry, and shock, and other physical diseases
and ailments, each averaging about 14 per cent, of the total.” Other
less important causes need not here be specified.

Of these causes some appear to be increasing in potency, others
decreasing. To compare merely the first and the last years of the
decade, as is done in the Supplement, is not the best way of arriving
at reliable conclusions, and is sometimes misleading. For instance, the
climacteric is stated to have an upward tendency because the percentage
of cases in which this was a factor was 1*5 in 1894 and 2*1 in 1903 ; but
if the first and second halves of the period are compared, this cause will
be found to have decreased by 9'4per cent, in the last quinquennium.
Again, alcohol, which only shows o*8 per cent, of an increase if the first
and last years alone are taken into account, shows an increase of 10 per
cent, in the last half of the decade over the first. The question of the
amount of increase or decrease as regards the several causes will be
made more clear by simply tabulating them as follows:

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1907 ] REVIEWS. 159

Other physical

Cause

Syphilis.

Senility. Alcohol. diseases.

Heredity.

Increase.

33*3 •

33 *o . 10*1 . 3*7 •

3*2

Anxiety,

Adoles¬

Cause

Tuberculosis.

worry, etc. Other toxins. Climacteric.

cence.

Decrease

20*4

197 . 15*4 . 9*4 .

3*5

There is probably hardly any subject so hedged round with difficulties
as that of the causation of insanity, there being frequently a very great
uncertainty as to whether an alleged factor is really a cause or an effect.
Notably is this the case as regards alcohol. On this point the inspectors
very properly lay stress in their observations under this heading.

In the sixth paragraph of the summary at the close of the Report the
inspectors state their conclusions generally on the subject of causation:

“ While the statistics dealing with the exciting causes of insanity do
not exhibit any marked variation from those shown in former reports,
it cannot be too prominently pointed out that—next to heredity, which
is itself in some cases the direct result of alcoholic excess in the pro¬
genitor—intemperance in the use of alcohol continues to head the list;
and therefore every effort should be made to promote the cause of
temperance throughout the country. The statistics also show that
general paralysis of the insane—a disease at one time almost unknown
in Ireland—is now increasing in the more populous urban districts. At
the same time this disease is still much less prevalent than in other
countries and in the rural districts is practically non existent. This
is, perhaps, to a large extent due to the high standard of sexual morality
which obtains all over Ireland.”

It is to be noted here that while, as stated by the inspectors, general
paralysis is on the increase, if the absolute number of cases is alone
considered, it is a fact that the relative mortality from this disease has
not increased during the ten years under review, the proportion of
deaths from this cause to those from all causes having been precisely
the same in the first and last half of the decade, viz., 37, the cor¬
responding ratio for England and Wales for the last quinquennium
being 16*8 per cent.

A good deal of space is given in the Report to the subject of emigra¬
tion. It has long been the fashion to attribute to emigration the great
mass of the ills and disabilities from which Ireland suffers, and amongst
these the high proportion of insanity which exists there has been given
a conspicuous place. The old stock argument is to the effect that by
emigration large numbers of its younger and more robust members are
removed from the population, thus leaving behind a higher proportion
than normal of the more aged and less vigorous class. This, no doubt,
is a fact But how much higher is the proportion ? If we take the
census year 1901, for which we may count on greater accuracy of figures,
the population of Ireland in that year was 4,458,775, and the total
number of insane 25,050, which gives a ratio of insane of 56*18 per
10,000 of population. During the same year 39,613 emigrated, and if
this number be added to the population we get a total of 4,498,388,
which represents the population of Ireland supposing there to have been

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160 reviews. [Jan.,

no loss from emigration. This new total gives a ratio of insane of
55*68 per 10,000, a difference of 0*5 per 10,000, or, in other words,
had there been no emigration the ratio of insane to population would
have been reduced by 1 for every 20,000 persons—this, too, on the
assumption that none of those who emigrated would have died or
become insane during the year. But as regards the latter contingency
the inspectors have something to say. From a special return (Appendix
I, Table VII) we learn that on December 31st, 1903, there were a total
of 1450 “ returned emigrants ” of Irish birth in Irish asylums and work-
houses, of whom 1277 were in the district asylums, being over 7 percent
of the aggregate number resident, of whom 867 had been admitted
within five years of their return. This establishes one fact, that it is
highly probable that many of the Irish who emigrated would have
become insane had they remained at home; for although the sudden
and complete change of environment, no doubt, may have acted un¬
favourably in a certain number of cases, playing the part of “ stress ”
or exciting cause, from what we now know of insanity it is more than
probable that in the majority, if not all, of these cases there was an
inherent tendency to mental breakdown which, sooner or later, and
under any form of stress, would have operated to bring about an attack
of insanity.

But here there crops up another sinister fact, a fact which; in the
words of the Report, is “of grave portent to the welfare of our race ”—
viz., that “the ratio of insanity amongst the Irish-born in America
throughout the different States is far higher than amongst any of the
other foreign-born peoples.” This statement is based on the figures in
the volume of the twelfth American Census dealing with insanity,
and on articles from the American Journal of Insanity , from which the
Inspectors extract some striking quotations. From these sources of
information it appears that in 1900 only 15*6 per cent . of all foreign-
born whites in the United States were of Irish birth; but of foreign-
born white insane 29*6 were Irish; and this holds good in individual
States no less than in the country at large. In a group of nine
States which contain the largest number of Irish-born persons,
the average percentage of Irish being 187, the average percentage
of Irish in asylums (1903) was 34*3, or nearly double what it
ought to be. In the American Journal of Insanity for October,
1903, Dr. Rollin H. Burr writes that as regards Connecticut “the
proportion of insane among the Irish is more than double that of any
other nationality. ... In proportion to population the Irish lead
all other nationalities in the production of insanity.”

On the authority of the Annual Report of the New York State Com¬
mission in Lunacy it is mentioned that almost 3*4 per cent, of the Irish-
born population became inmates of the State asylums during the sixteen
years 1888-1904—that is to say, a proportion of 340 as compared with
56 per 10,000 in the mother country. If this be correct—and there is
no reason to doubt the statement—the incidence of insanity in the case
of the Irish emigrant must be truly appalling. The vast disproportion
between the ratios of sane to insane Irishmen at home and abroad seems
to indicate that emigration itself constitutes a powerful form of “stress,”
the new environment and conditions of life too often working havoc in

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161

the rather unstable mental economy of the Irish peasantry. The fact is
deplorable—an added sorrow for our island of tears.

In this Journal for January, 1904, Dr. Bannister, in reference to
Dr. Burr's article, writes: “ It is a little curious that the Irish immi¬
grants to this country should show so large a percentage, being, as
they must be, the more active and healthy of the race. We should
look for more insanity to be left behind in the old country, where
intermarriage and the culling out of the more vigorous would have its
effect; but it is a fact that in this country the Irish are notably
numerous amongst the asylum population.”

The old stock argument previously alluded to as regards the effects
of emigration surely here receives its quietus.

With these facts in front of them it is not surprising that the
Inspectors find themselves driven to the conclusion that “the Irish
branch of the Celtic race is specially predisposed to mental breakdown,”
of which they refrain from offering any explanation, except that not
improbably “ the innutritious dietary and other privations of the
majority of the population of Ireland must, when acting over many
generations, have led to impaired nutrition of the nervous system, and
in this way have developed in the race those neuropathic and psycho¬
pathic tendencies, which are the precursors of insanity.” This view,
though speculative at best, may possibly be correct, but something must
be set down to the natural temperament of the people, which is decidedly
of an impulsive and excitable cast, and often associated with unstable
or ill-adjusted mental arrangements, and therefore more likely to break
down, and on slighter provocation than is the case with the more cool-
blooded and phlegmatic nationalities. In too many instances this
natural excitability is aggravated by habits of intemperance, which
prevail all too widely amongst the population at large.

In the summation of their opinions as to the causes of the increase of
the insane in asylums the views of the inspectors do not differ from
those generally accepted by all authorities on the subject. These, briefly
stated, are as follows :

(а) Accumulation.

(б) The gradual absorption into asylums and workhouses of the un¬
registered insane.

(d) The greater confidence in the treatment of the insane in asylums.

(e) Increase in number and accessibility of asylums.

(/) Greater longevity of the population generally, owing to the pro¬
gress of sanitation.

(^) Influx of returned emigrants the subjects of mental breakdown.

Arid to these may be added, in the case of Irish asylums, a peculiar
proneness of the Irish branch of the Celtic race to mental disease.

The most cheering piece of intelligence in the Report is contained
in the concluding paragraph, immediately before the “ Summary,” in
which the writer says :

“The first admissions into our Irish asylums during the most recent
years show, as will be seen in our annual Reports, a progressive and
substantial falling off. Whether or not this diminution will continue in
LIII. 11

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REVIEWS.

[Jan.,

any marked degree we are not in a position to state at all positively;
but it seems to us that—while there will remain in the asylums for
some years an accumulating number of patients, due to increased
longevity—we are reaching, if we have not already reached, the highest
curve of the line indicating the annual rate of insanity in this country,
apart from any artificial swelling of the numbers by repatriation of
persons who have become insane abroad.”

With the hopefulness which inspires this utterance we are, it is
needless to say, in heartfelt sympathy. Whether the expectation is of
too sanguine a character or not time alone will show.

Fifty-fifth Report of the Inspectors of Lunatics on the District , Criminal\
and Private Asy turns in Ireland for the year ending December 31 st,
1905.

As the progress of lunacy in Ireland for the more important period
of ten years has just been the subject of review here, it will not be
necessary to make any lengthened commentary on the last annual Blue
Book.

There was a total increase of 369 in the number of insane in institu¬
tions during the year 1905, which was a good deal higher than that of
the previous year (202), but 131 less than the average increase for the
past ten years, which was 500.

The numbers in district asylums increased by 442, while those in
workhouses decreased by 105, the total of insane inmates of which has
now reached the lowest figure since the year 1880. The highest
number occurred in the year 1894, viz., 4076 ; and since then, with one
or two fluctuations, there has been a steady decrease in workhouse
patients up to last year, when they numbered 3215, being a reduction
of 861 in the eleven years. In 1880 of the total number of insane
under care 67 per cent, were in district asylums and 27 per cent. in
workhouses. In 1905 81 per cent, were in asylums and 14 per cent, in
workhouses.

The total admissions for 1905 showed a decrease of 115, those to
district asylums having decreased by 138, while the admissions to
private asylums increased by 23. The number of admissions into dis¬
trict asylums was lower than for any of the three previous years, but in
the case of private asylums it was the highest on record. While the
readmissions to district asylums decreased by only 1, the first admis¬
sions were 137 less than in 1904.

During the past twenty-five years the proportion of insane under care
to the general population has more than doubled, having risen from
250 to 532 per 100,000. If those at large be included, the ratio
reaches the high figure of 620 per 100,000.

The recovery rate was 36*8 per cent, on the admissions, and the
average death rate 7*7 per cent, on the daily average, both about the
same as the average for many years past. Consumption accounts for
28 per cent . of the total mortality. If the last two quinquennia be com¬
pared, although the absolute number of deaths from consumption has—
like the general mortality from all causes—increased, the relative mor-

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163

tality from this disease has fallen from 29 in the first to 27 per cent, in
the later period.

The inspectors comment unfavourably on the neglect of pathological
studies in Irish asylums, which, they say, show little signs of progress.
This is, unfortunately, a fact. But in singling out the medical officers
as those upon whom the responsibility for this mainly rests, and to
whom, inferentially, blame is to be attached for remissness in this
respect, they put the saddle on the wrong horse. They say, “An
obligation would seem to be cast on the medical officers of asylums to
utilise those materials for the study of the morbid histology of the
nervous system which are available in their institutions.” No doubt;
and in this probably most of the medical officers would agree with

them. But they say not a word about the difficulties which attend any
efforts of the medical staff in Irish asylums. Only in the case of
unclaimed bodies, and very rarely with the consent of relatives in other
cases, can post morterns be held. So long as the reprehensible custom
of “ waking ” the dead is adhered to the same difficulty will continue.
And to urge a duty on men who are, in the large majority of instances,
prohibited from fulfilling it, while holding up as an example the excel¬
lent work that has been, and is being, done in other countries, where
“the investigation of the pathological changes induced by mental
disease is being pursued with praiseworthy energy,” is merely a counsel
of perfection. No doubt some asylum doctors may by superior tact
and power of moral suasion succeed better than others in overcoming
popular prejudice, but there is no denying the fact that this forms, over
the greater part of Ireland, an almost insurmountable barrier to pro¬
gress in pathological study, just as it did for many centuries in the very
countries alluded to by the inspectors, which have, however, reached a
more enlightened stage in their appreciation of the value of scientific
work.

We are heartily in accord with the inspectors in their regret that
“some arrangement is not come to by which a number of asylums
might combine in providing a common laboratory, and in appointing
a pathologist who would give instruction to the junior members of the
staff and carry out the most important investigations.” That this has
not been done is not due to any apathy on the part of the medical
officers, but altogether, or almost altogether, to the indifference of the
committees of management. Some four years ago this Association took
the initiative in an endeavour to bring about the founding of a central
pathological laboratory such as the inspectors desiderate, but the pro¬
posal met with only a chilling reception from the asylum committees;
and at the conference of these committees, which met in Dublin in
1903, the subject was again brought prominently forward, and a resolu¬
tion approved of in favour of such an institution, but, as is not unusual
in Ireland, calling on the Government to provide funds for its establish¬
ment Needless to say, the project has not advanced one step since

then, nor is it likely to until the committees themselves show a livelier
interest in achieving it by sanctioning the very moderate annual contri¬
bution required for the purpose, which, if distributed over all the asylum
districts except, perhaps, the large urban ones which are in a position to
do their own pathological work, would involve a very inconsiderable

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[Jan.,

addition to the ordinary expense of maintenance. Or, if laboratories in
the Dublin and Belfast asylums were made centres for pathological
work for the north and south of Ireland respectively, towards the main¬
tenance of which the various district asylums would contribute in pro¬
portion to their size, a good deal of preliminary expense would be saved.
Unfortunately, the average county councillor is not, as a rule, imbued
with even the feeblest enthusiasm for scientific progress, and if he does
not see the prospect of some immediate and palpable advantages from
any proposal, the purse-strings which are entrusted to his control auto¬
matically contract, and there’s an end of it

An important legal decision from a financial point of view was
obtained, mainly by the energetic action of the governing body of the
Richmond Asylum, in 1905, who brought a Petition of Right, and
obtained a judgment in their favour, subsequently affirmed on appeal,
to the effect that all cases committed under the Army Act, 1881, s. 91, and
the Naval Enlistment Act, 1884, s. 3, are “criminal ” lunatics within the
meaning of the sixth section of the Act 1, Edward VII, cap. 17. The
entire cost of the maintenance of such cases now devolves on the State,
and must be paid out of monies voted by Parliament, thus relieving the
local rates to that extent

Another legal decision of some importance was given by the Law
Officers of the Crown, that so long as a patient remains insane he cannot
be discharged from a district asylum to a workhouse. Formerly, it was a
common practice to discharge unrecovered but harmless patients to
workhouses, thereby relieving overcrowding in asylums. This pro¬
cedure is no longer permissible, and, provided that there is sufficient
accommodation available in asylums, the award is unquestionably
wholly in the interests of such patients.

The inspectors record with regret the deaths during the present year
(1906) of Dr. L. T. Griffin, of the Killarney Asylum, and of Dr.
Oscar T. Woods, of Cork Asylum. They dwell in sympathetic terms
on the lovable character of Dr. Griffin, which endeared him to patients
and staff alike. He has been succeeded by Dr. E. W. Griffin, A.M.O.
of the asylum. Dr. Woods’ personality was better known to the
members of this Association of the Irish division, of which he was at
one time Secretary and subsequently President. His all too early
demise was a matter of the sincerest regret to all his former colleagues
in the work of the Association, most of all to those who knew him best.
One of his assistants has been appointed as his successor, but owing
to some alleged legal informalities in the election, the appointment has
not, as yet, received official sanction.

The retirement of Dr. J. H. Hatched, R.M.S., of Maryborough
Asylum, in 1905, is also noted, who was superannuated “after thirty-
seven years’ faithful service.” He has been succeeded by Dr. Coffee,
formerly A.M.O. in Limerick Asylum.

In their Report of the Youghal Auxiliary Asylum the Inspectors
write on the whole favourably as to its internal management Un¬
doubtedly the condition of insane patients who were transferred there
from workhouses has been materially improved—there would not be
any great difficulty in that—and the kitchen, laundry, heating, lighting,
and sanitary appointments appear to be excellent and up to date. There

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are, however, some grave defects connected with this novum (and yet
alium) experimentum. The staff is far from being numerically adequate
to the just treatment of the patients, as a result of which the number of
casualties is unusually heavy; and the patients are frequently kept
indoors all day, and when they do get out, exercise appears to be
allowed only within the confines of airing-courts, a system long since
abandoned and obsolete in most well-managed asylums.

But what they regard as “the great defect” is the insufficient medical
supervision, which consists merely of a short daily visit from an outside
medical man who has had no special training in the treatment of the
insane, and whose main interests lie altogether outside those of the
institution, which are, in fact, a mere subordinate incident in his pro¬
fessional life. It is here that the retrogade character of the principles
upon which this institution is sought to be conducted on supposed
economical grounds are seen in their most unfavourable light. An
asylum for the insane, of no matter what class, is essentially an hospital,
and the principal officer, administrative no less than professional, should
be, as in all properly constituted asylums, a medical man, who should
be in direct, immediate, and continuous charge of the patients—not a
mere casual and, not improbably, uncritical visitor. The scheme is
still in a more or less experimental stage, and it remains to be seen
whether it will eventually justify the sanguine anticipations of its
promoters.

Psychiatry. By Stewart Paton, M.D., Director of the Laboratory
of the Sheppard and Enoch Pratt Hospital, Maryland. J. B.
Lippincott Company, 1905. Price 18 s. net.

This text-book for students and physicians is an interesting and
compendious volume of over 600 pages. It opens with a chapter
describing the scope and methods of modern psychiatry, claiming that
the latter is a branch of general medicine, and that the progress made
by the addition to our knowledge in regard to those morbid conditions
of the body essentially connected with the “ sources of rational thought
and action ” is the justification for this book.

Dr. Paton urges the necessity in America for a fully equipped and
well-organised psychiatrical clinic, under the control of a university, a
proposal also much favoured in our own country. The author advo¬
cates the necessity for biological study before the meaning of disordered
function is understood in regard to the central nervous system. Dr.
Paton attaches little importance to the theoretical or speculative study of
the nature of mind. The metaphysical relationship of mind and body is,
in his opinion, of little interest to the clinician or the alienist, who, he
states, is concerned only with the physico-chemical changes of cerebral
processes, and he very rightly states that the increased study of psycho¬
pathology has given a new interest to psychiatry.

As a test of insanity he agrees with writers in this country that
conduct gives the truest measure of the functional defects of the nervous
system, and he rejoices that functional psychology has taken the place

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of speculative or pure psychology. In the earlier part of the work he
advocates the study of sociology, economics, and ethics. He recognises
the importance of an exact and even scrupulous attention to symptoms,
with a view to their proper differentiation and full appreciation. In
the second chapter the nature of alienative disorders of function is
considered, and it is pointed out that mental disorders are essentially
disorders of the whole brain, not localised but general. He points out
how much remains to be done by the pathologist who works in “ serene
peace ” in his laboratory, and especially does he call for some standard
in regard to nerve-cells for different tracts in the brain, whereby certain
deviations might assist a positive diagnosis in regard to pathological find¬
ings, as, for instance, where Tuczek describes the disappearance of the
tangential fibres in general paralysis and Alzheimer has differentiated
between certain arterio-sclerotic lesions and those found in general
paresis. Again, Nissl has stated the possibility of differentiating be¬
tween paretic lesions and others due to syphilis, all founded upon some
assumed normal state. In this chapter it is suggested that material
changes in any organ will give rise to disorders of function, and when
disturbance of mental functions does occur these may, so to speak,
become “self-accumulative.” There is support for this view, and we
ourselves believe that long-continued functional disorder may in the
end become structural. As an earnest student of Kraepelin, Dr. Paton
strongly urges the necessity for a general survey of the whole course of
the disease whereby clinical pictures rather than analysis of individual
symptoms are obtained, and he cites dementia praecox and manic-
depressive insanity as examples. In his strong advocacy of a bedside
study of insanity we heartily concur.

Chapter III, which extends over ioo pages, is devoted to the sympto¬
matology of alienation, the whole chapter referring to the various mental
symptoms met with in cases of insanity. After emphasising the state¬
ment that all insanity is the result of bodily disease, and that the cortex
is the especial substratum for the reception, retention, and elaboration
of sensory stimuli, Dr. Paton details the highest cortical functions as
those of attention, judgment, and volition. He rightly regards the
activity and integrity of the associative memory as closely affecting con¬
sciousness. Inferences are formed by the elaboration of sensory images
received in youth, and they depend upon recollection or memory. It is
by a comparison of these inferences that judgments are formed, which
are intellectual processes of slow growth ; hence the variety of insanity
known as paranoia, a reasoning insanity, is rare in children, who are domi¬
nated by sensory abnormalities, affective states, or memory pictures.

It is pointed out that much of the complex personality is dependent
upon organic sensations, and the muscular sense is an essentially impor¬
tant factor ; a disturbance of the organic sensations causes apprehensive¬
ness and a feeling of distrust; a condition of bodily unrest thus occurs
which tends to fix the attention, as is inevitably the case with the person
of one idea, whose attention is riveted upon the emotional tone associ¬
ated with the idea. The genesis of insane ideas and the growth of
hallucinations, anomalies of memory, emotions, and conduct are dealt
with at length. Although a useful chapter, this is by no means an
interesting one, and we find that characteristically American tendency

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in it, viz. the introduction of new words, and the appearance in a text¬
book for students of such terrifying polysyllabic neologisms as nodpsyche,
thymopsyche, allospsychic, akoasmata, accustomata, parageusias, pseudo¬
reminiscences and many others which may even somewhat tax and per¬
plex those “ physicians ” to whom the work is dedicated.

Chapter IV should not be missed by any student of psychiatry. It
deals with the examination of mental cases, and here the author most
wisely deprecates the taking of records on specially constructed charts
on which a list of symptoms is printed, the observer being expected
to state categorically whether such a given symptom is or is not present,
a most pernicious practice, as he states, in which all who teach students
or who appreciate the value of a description of the salient features in
a case will readily concur. The whole personality is missed in notes
of this kind, for no clinical picture will fit into an arbitrarily con¬
structed frame which is meant only for untrained observers and time¬
servers. Such case-sheets do well as impositions for indolent school¬
boys, but they miss the point for those who desire a complete know¬
ledge of clinical methods and who appreciate research. Importance
is placed upon the family history, especially in regard to evidence of
deterioration, degeneracy (suicide, alcohol, eccentricity, etc.), and of
causes of death. Stress is also laid upon the ante-natal personal
history, «k, as to mental shock, trauma, nephritis, etc., in the parents
— important particulars often overlooked. The personal history
through infancy (convulsions, teething, walking), childhood, and
puberty up to the full attainment of vigour is also emphasised.

The history of the present illness is sketched, and valuable hints
afforded as to stigmata of degeneration revealed by the state of the
ears, eyes, teeth, mouth, skeleton, hair, senses, the motor and trophic
systems. In this chapter also the manner of response and its content, the
foots , attention, distraction, dress, pose, impulse, or negativism, are all
fully discussed, and it concludes with a diagnostic feature of much
value and greatly resorted to of late, viz ., the examination of the cerebro¬
spinal fluid. The method of ascertaining definitely whether a case is or
is not one of general paralysis in its early stages can easily be effected
by lumbar puncture, centrifugalising the fluid in a uniform manner,
and then preparing slides after staining. Given due care, there is now no
danger in carrying out this method of diagnosis, the significance and
the details of which are fully explained in this chapter.

Chapters V and VI deal with general treatment and special hospitals
for the insane, and Chapter VII deals lucidly with causation. Then
follow chapters upon clinical pictures or “ classification,” and upon the
so-called dementia praecox—a division which has not hitherto found
favour in this country. It would take too long to deal with the
classification and terminology of insanity, which have so recently found
adequate space in the Journal\ and we pass to Chapter XV, in which
the Dementia Paralytica group is described, commencing with a short
but interesting historical sketch.

Dr. Paton draws attention to the importance of a careful study of
disturbances referable to disorders in the internal viscera, even in the
earliest stage of the disease, and it is certain that clinicians are more
and more recognising the importance and significance of pathological

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[Jan.,

states of the internal organs in mental disease, as the recent work of
Drs. Lewis C. Bruce and Ford Robertson has thrown much light in
this direction. The auto-intoxication theory of these observers is noted,
but no mention is made of Ford Robertson’s diphtheroid bacillus as an
etiological factor in general paralysis. As regards syphilis, he says, “ It
is obvious that in the great majority of cases syphilis is an important
etiological factor, but it is impossible to substantiate the view that all
others are necessarily of secondary importance.”

The question of the etiology of general paralysis in this work is con¬
sidered as being sub judice , and the absence of dogmatism in this
connection is in keeping with the general open-minded handling of the
subject which is so comprehensive a feature of the work.

As foreshadowed in the earlier chapters, much stress is laid here, as
elsewhere in this book, on the important part played by the organic
sensations in the early development of morbid mental states.

An admirable description of the symptoms of this disease terminates
with a concise and well-illustrated account of its pathology.

The next chapter deals with the Epilepsy group. In discussing the
pathogenesis of epilepsy great stress is laid upon hereditary influence,
and especially upon a history of alcohol in the ancestry.

The author goes on to give timely warning by saying that “ while it
is only right to be exceedingly cautious in minimising the importance
of this drug as an etiological factor, yet the fact must be kept in mind
that existing evidence does not fully justify the statements so frequently
made to the effect that there is an immediate causal connection between
the occurrence of alcoholism in a remote ancestor and of epilepsy in
the individual of a later generation.”

In Chapters XVII and XVIII will be found a lucid and instructive
account of the hysteria group and of the neurasthenic and psychasthenic
states. For the sake of facility in description—which Dr. Paton regards
as a strictly provisional expedient—neurasthenic and psychasthenic
states are grouped together. Under the heading of the former are placed
the chronic nervous exhaustions and “constitutional depressions,”
under the latter those cases “ in which the symptoms have a tendency
to change and recur with ’some degree of periodicity.” He regards
psychasthenia as occupying a medium positon between epilepsy and
hysteria. In this group are described the various obsessions and im¬
perative processes.

Chapter XIX is devoted to those psychoses associated with organic
disease of the central nervous system. The mental symptoms associated
with arteriosclerosis are well and fully described. Much attention has
lately been given to the pathological conditions which occur in the
central nervous system as a result of vascular sclerosis, and the import¬
ance of these changes cannot be over-estimated. The author gives a
detailed description of the early mental symptoms, a thorough know¬
ledge of which should be of great interest and value to the general
practitioner. He describes a case occurring as early as twenty-two
years, in which the arteries were uniformly thickened and sclerosed.

The paragraph which deals with syphilis in this connection seems too
much compressed. It is suggested that “ the so-called juvenile paretics,
as far as the present evidence indicates, should be classified as heredi-

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tary syphilitics, as they usually present more of the symptoms of cerebral
syphilis than of general paresis.”

Chapter XX deals with the paranoia group. As in other forms of
insanity so in paranoia it has been a prevalent custom to include under
one heading a number of totally different mental states, a custom arising
from attempting too hastily to diagnose the condition based upon the
prevailing symptom—whether mania, melancholia, or the “ systematisa¬
tion ” and persistence of insane ideas. Such methods serve no imme¬
diately useful purpose, and only retard the scientific development of
mental disease. Improved clinical methods and the careful study of
the development, cause, and termination of the various symptoms-
complex can alone, in many instances, lead to a real advance in our
knowledge. The great importance of this point is never lost sight of in
this work, and in this chapter Dr. Paton carefully distinguishes the
various paranoid states (such as occur in certain alcoholic psychoses, in
acute confusional insanity, in the so-called dementia praecox group, and
in manic-depressive insanity) from the “small residual group of cases
which cannot as yet be definitely assigned to any of the psychoses
hitherto described, and which are conveniently described under this
heading.” This chapter closes with an interesting description of the
44 litigious insanity ” described by Hitzig.

An interesting analysis of senile involution and a description of the
senile psychoses terminate a work which is a very valuable text-book and
book of reference.

Studies in Clinical Psychiatry. By Lewis C. Bruce, M.D., F.R.C.P.E.

London : Macmillan & Co., Limited, 1906. 8vo. Price 10 s. 6d. net.

Dr. Bruce has produced a book which is a record of sustained and
careful observations continued over a considerable number of years.
He has broken new ground and harvested a wonderful crop, and we
congratulate him upon his methods and results. Dr. Bruce does not
present his conclusions as final and irrevocable, but rather admits that
his views and his evidence are still incomplete. Consequently, his
classification, broadly under the headings of “ non-toxic ” and “ toxic ”
insanity, may require revision and rearrangement. That is of secondary
importance, and need not detain us at present. The point of im¬
portance is that he has attacked the problems of psychiatry with the
aid of new forces untrammelled by ancient formulae. It is now long
since Skae directed special attention to the bodily conditions associated
with insanity, but it has only been within very recent years that the
logical development of his teaching could have been carried to these
decisive findings. Dr. Bruce reiterates what many have stated—that
the prominence and bizarre character of mental symptoms have confused
the issues and done much to prevent the advance of knowledge. His
methods of investigation have been adopted from recent clinical and
laboratory experience, and are designed to estimate the somatic con¬
ditions which result in mental disorder. Consequently, the book opens
with a consideration of the physical symptoms of mental diseases on
the ground that some diseases, such as smallpox, appear to confer

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immunity upon the person who has contracted them and recovered;
while others, such as rheumatism, appear to confer no immunity, but
render the person more liable to another attack.

In fact, the position is that the diseases issuing in insanity are gene¬
rally of a toxic character. This, of course, is evident in a case of
myxcedema, but it has been less evident in a case of ordinary mania.
Dr. Bruce has adopted the methods of Widal, and finds agglutinines
very generally in the blood of acute cases of mania. Further, in every
case of acute continuous mania which has been examined (not once, but
by repeated observations for weeks or months) leucocytosis was demon¬
strated. Early in the acute stage this reached from 18,000 to 20,000
per c.mm., and the percentage of polymorphonuclear cells never below
70 per cent. The leucocytosis varied with the exacerbations of the
disease, and as recovery became complete the percentage of polymor¬
phonuclear cells fell, while in many cases the leucocytosis persisted—
probably in a protective leucocytosis.

It is difficult to convey in a few words what requires many pages of
records and illustrative charts to make plain. The study of the blood,
and especially the behaviour of the leucocytes, may be regarded as the
last expression of medical science. The opsonic index will, no doubt,
carry Dr. Bruce’s observations still further; meanwhile, unless the
advanced workers are hopelessly wrong, he has established a new
foundation for psychiatry, which gives occasion for hope in treatment
It may be that some will vigorously oppose these conclusions, or give
a reluctant consent; but they can only be combated by a devotion
and experience commensurate with Dr. Bruce’s. Many of us have
insisted on the importance of prodromal somatic symptoms, many of
us have clearly recognised the toxic nature of various mental disorders,
but we have now a method of demonstrating the truth of these vaguer
guesses. A word of warning, however, for the demonstration is neither
easy nor rapid. Dr. Bruce has given a practical, unvarnished account
of his labours, but the technique is not to be acquired in a day, nor are
the facts to be recognised without guidance, experience, and hard
study. No doubt in time much of the new method will be simplified
and rendered available for the purposes of everyday practice, especially
in reference to questions of prognosis.

We need not, in this brief notice, enter on a full account of Dr. Bruce’s
researches on the blood-pressure in melancholia, and the pre-urea bodies
which he regards as possibly toxins effective in causing mental disorders,
for the book will be read by those who are concerned to understand
insanity and to promote effective treatment. It is not given to everyone
to devise new methods and experimental proofs, but it is easy to study
original and suggestive work, especially when it clears up obscurity in
the causation of disease and deals with a rational system of treatment.
The distinguished merit of Dr. Bruce’s work is his success in bringing
the physiological chemistry of the morbid processes of insanity into line
with other similar somatic conditions and in directing due attention to
these facts of disease.

Quite recently the Times gave space to an attack on the psychiatrists
of the country, freely condemning them for what they had done and for
what they had left undone. We are well accustomed to those captious

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critics who use the public press to abuse the public ear, and are not
ashamed to make manifest their ignorance in writing about “the
practical exclusion of insanity from the area of scientific investigation.”
If the distinguished writer had condescended to inform himself of the
work published by Dr. Bruce and others from time to time, he could
hardly have offended so unwarrantably. We trust that, in the course of
time, he will gain some slight inkling of what is being done and rely
less confidently on the sport of his inner consciousness. We have every
confidence that these clinical studies will not remain unheeded by the
general physicians and the neurologists of the country, but that they will
become familiar to all who have to deal with insanity, incipient or
declared.

Mysticisme et Folie. By Dr. A. Marie. Paris : Giard et Brifcre, 1907.

Pp. 342, 8vo. Price 6 frs.

Dr. A. Marie, who, in addition to his functions at Villejuif Asylum,
is also a Professor at the College Libre des Sciences Sociales, has in
this very thorough and comprehensive study of normal and pathological
psychology taken up and developed the question of the relations of
religious mysticism to insanity, which half a century ago was so admir¬
ably discussed by Calmeil.

The recent advances which have been made in the investigation of
the primitive ways of thinking of savages have, however, rendered pos¬
sible a broader and more thorough discussion of the question, and the
author has fully availed himself of the results reached by Tylor and
others. In order probably to emphasise his anthropological point of
view, he has obtained an Introduction to the volume from Dr. Thuli£,
the Director of the Paris Ecole d’Anthropologie. It can scarcely be
said, however, that this Introduction strikes quite the right note. Thulig
belongs to an aggressively free-thinking school of anthropologists which
flourished in France thirty years ago, but no longer corresponds to the
calmer and more judicial attitude of investigation to-day. The main
object of his Introduction seems to be to assert that “ religions are the
scourges of humanity.” Dr. Marie himself indulges in no anti-theo-
logical declamations, although he evidently regards theological ideas
as belonging to the past rather than to the future of humanity; he is
careful to point out that he makes no attempt to dismiss the great
mystics of history as merely pathological cases, and that he is far from
wishing to identify theology and insanity.

Dr. Marie’s fundamental point of view throughout is anthropological
and evolutionary. He believes that mankind will always require a
religious faith in ideas of some kind, but that there is a regular pro¬
gression in theological conceptions from primitive savagery onwards.
When a man, born in civilisation, returns by a kind of atavism to the
attitude of animism, fetichism, magic, or other religious conception
which prevailed among primitive men, it is then only that religion
becomes an insanity. The morbid deviations of to-day reproduce
various historic anomalies presented by psychic evolution. “Every

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cerebral malady causes a fall to subjacent mentalities which were in
their time the highest points attained by human intelligence. All the
mystical aberrations are thus a necessary fatality of the human mind.
They were the efforts and errors of tottering intelligence seeking points
of support beneath the recognised inanity of initial conceptions. The
brain of contemporary man, when mutilated, takes up again the moral
crutches used by the ancestral brain.”

The book is divided into two parts. In the first, which is mainly
anthropological, the author traces the results now reached concerning
the origins of religions and mystic conceptions, and their evolution from
naturism, animism, and magic to monotheism. In the second part,
which constitutes the more important portion of the work, the various
mystic and religious psychoses are discussed in order, with their relation
to degenerescence. Havelock Ellis.

Sammlung Kleiner Schriften zur Neurosenlehre (Collection of Short
Studies on the Neuroses). By Professor Freud. Leipzig and
Vienna: Deuticke, 1906. Pp. 234, 8vo.

Professor Freud’s elaborate and painstaking efforts to elucidate the
mechanism of hysteria and of various allied neurotic conditions, not¬
withstanding the opposition with which they have sometimes been met,
have aroused a growing interest, and he has been induced to bring
together the various studies (three of them in French) which he has
published on this subject during the past fourteen years. The volume
forms an admirable introduction to Freud’s work. We are enabled to
follow the course of his thought—which has constantly undergone fresh
modifications in various directions—from the period when, as a pupil of
Charcot’s, he struck out on a new road down to the present. The first
paper is a sympathetic obituary notice of Charcot, which at the same
time reveals his own point of departure from the master’s standpoint;
the last is a new statement of “My Views on the Part played by
Sexuality in the Etiology of the Neuroses.” Charcot would have said
it played no part, for he believed that the whole of the etiology was
covered by heredity; but Freud is more than ever convinced that this
is not the case, and he endeavours to set down as clearly as possible
where he considers that sexuality intervenes as a factor, and in what
direction his views have been modified by experience. Hysteria he
still regards as “ the expression of a special relationship of the indi¬
vidual’s sexual function,” and he still believes that childish experiences
have an influence over the later direction of the patient’s hysterical
state, but he no longer speaks of early sexual experiences as “trau¬
matic,” and he recognises the part herein played by hysterical imagina¬
tion ; “ infantile sexual trauma ” gives place to “ infantilism of sexuality.”
Along this line he has been brought somewhat nearer to Charcot’s posi¬
tion and attaches primary importance to heredity and constitution, adding,
however, that he thinks more of “sexual constitution” than of general
neuropathic disposition. Masturbation he regards as a main cause of
neurasthenia, and coitus interruptus as producing neurosis of anxiety.

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This view certainly requires for its justification the emphasis on heredity,
for minor sexual aberrations are far too common to be regarded as in¬
jurious to a constitution that is not aboriginally unsound.

While these studies are mainly concerned with neurasthenia and
allied states, in one interesting passage (pp. 124 et seq.) Freud suggests
that in some cases paranoia resembles hysteria and imperative ideas in
that its symptoms may be determined by the suppression of painful
memories of a sexual character dating from early life. A case is brought
forward in which this could be clearly shown. This idea is suggestive,
s and it is probable that many readers, recalling cases of systematised
delusion with which they were intimately acquainted, may bring to mind
instances in which an ancient episode of sexual nature which the patient
had, so far as possible, pushed out of consciousness, serves to form
part of the basis of the later auditory hallucinations.

In an essay on psychotherapy the author discusses the origin and
development of his method in its therapeutical aspects. The method
appears to have been originally due to Breuer, who called it the “ ca¬
thartic ” method; Freud prefers to call it the “ analytic ” method. It
is entirely distinct from hypnotism (which Freud has abandoned for
over eight years), being indeed the exact opposite of hypnotism. By
the hypnotic method it is sought to put something into the patient; by
the cathartic or analytic method it is sought to take something out of
him. Freud illustrates the difference by reference to Leonardo da
Vinci’s technical distinction between the different ways of art, the via
di porre , or the painter’s way, of putting in something that before was
not there, and the via di levare , or the sculptor’s way, of removing some¬
thing that is there.

Freud’s style is always clear, attractive, and sincere, and this book is
well worth the perusal of all who desire to become acquainted with the
work of one of the subtlest and most original investigators in a difficult
field. Havelock Ellis.

The Dissociation of a Personality . By Morton Prince, M.D., Pro¬
fessor of Diseases of the Nervous System, Tufts College Medical
School; Physician for Diseases of the Nervous System, Boston
City Hospital. New York : Longmans, Green & Co. 10s. 6d. net

This book, which is an amplification and continuation of a paper read
before the International Congress of Psychology, Paris, 1900, is a study
of perhaps the most remarkable case of multiple personality, or, to be
more accurate, of dissociated personality, that has been recorded. The
patient presented three distinct personalities, in addition to minor
hypnotic states, and it was not till she had been carefully watched for
almost four years that her real self was discovered—and found to be
none of the three. One of these individuals was very remarkable ; the
other two were alternating personalities of the more ordinary type, but
this was not only an alternating personality—in which form she displayed
robust health and a vigorous character—but also an extensively
developed subconsciousness. As such she appeared to have existed

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since childhood; she remained sane when the patient was delirious
during an attack of pneumonia, so that later, as an alternating
personality, she was able to give an account of the delirious thoughts
and explain the delirious acts; she could influence the other personalities,
and even hypnotise them. As an alternating personality she had full
knowledge of the other states, but they had none of her, nor had the
real self when finally reintegrated. The book before us is the first
volume of a larger work —Problems in Abnormal Psychology —and is to be
followed by another, in which the psychological questions involved will
be discussed. It will be better to defer a complete review of this first
volume till the work has been concluded. In the meantime, however,
attention may be drawn to a few points. First, we must congratulate
Dr. Prince on the insight he displayed, on the care and labour he
devoted to following up the case, and on the success he so deservedly
achieved. Secondly, his view of neurasthenia deserves careful attention;
he holds it to be a perverted reaction to environment, due to dissocia¬
tion of the consciousness. Another point is the very incomplete
success of hypnotism when it consisted merely of suggestions to a dis¬
integrated personality ; its true work seems to lie in the direction of
reintegrating the original self. Indeed, it is to be observed that whereas
the patient had exhibited only one abnormal personality for several
years before hypnotic treatment began, a second followed very rapidly
on the commencement of that treatment, and the third appeared little
over a year later. Though there is not sufficient proof, one cannot help
suspecting that this further dissociation was due to the hypnosis. If
this be so, it confirms the view that hypnotism is a dangerous weapon
to use, its direct effect being to increase the evil. On the other hand,
if the true original personality be carefully sought out and reintegrated
by skilful suggestions, the good thus done may far outweigh the
immediate ill-effects. Dr. Prince seems to have benefited his patient
greatly; had he been less clear-sighted and unwearying, he would
probably have done her harm.

The book is well written and extremely interesting. Indeed, the
only fear is that the story of the three personalities, with their different
characters, their trials and difficulties, the practical jokes played by one
upon the others, and the efforts of that one to outwit Dr. Prince, so
that the original personality might not be reintegrated and she herself
“ squeezed ” out of existence in the process, may obtain a vogue among
unscientific readers and fall into the hands of the patient's friends. It
should be read by all who are interested in normal psychology as well
as by those who devote themselves to pathological states of mind.

P. C. Smith.

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NEUROLOGY.

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Part III.—Epitome of Current Literature.

i« Neurology.

On the Functions of the Nucleus Caudatus (. Riv . di PatoL Nerv. e
Ment^July^ 1906). Pagano.

These researches form a study of the basal ganglia of the encephalon
which Dr. Pagano has been prosecuting for two years. With the help
of his method of injections of curare he has succeeded in discovering
in the cerebellum distinct motor centres, and a zone in which irritation
provokes evident emotional excitement. In a review of the contribu¬
tions of the physiologists who have treated of the functions of the
nucleus caudatus he shows how they differ from one another.

Dr. Pagano has made more than eighty experiments to ascertain the
functions of this organ. After a method which he describes, he claims
to have succeeded in passing injections of solutions of curare into dif¬
ferent parts of the nucleus caudatus. He used neither narcotics nor
anaesthesia, as he considered that these masked the symptoms which
he wished to observe. His experiments are given in detail in a paper
filling thirty pages.

Dr. Pagano presents the following conclusions :

(1) That the excitation of the anterior third and of the middle third
of the nucleus caudatus provokes in dogs something very like the
emotion of fear. This effect is best brought out when the injections
reach the internal half of the organ. All the characteristics of this
emotion are present: the gesticulations, the play of the physiognomy,
the cardiac and respiratory phenomena, the actions of the intestines and
the bladder, the state of the pupil, and the effects of threats and noises,
all go to form conclusive evidence of this emotion.

(2) The excitation of these points, but especially of the middle third,
provokes a strong erection of the penis, which appears immediately after
the injection, and persists until death.

(3) The excitation of the anterior extremity of the nucleus caudatus
produces an agitation which presents the appearance of fear modified
with anger.

(4) The excitation of the posterior third of the nucleus caudatus
provokes a series of manifestations of anger; the grinning and barking,
the readiness to attack and bite, and the whole attitude leave no doubt
as to the nature of the emotion.

(5) The excitation of the outer part of the anterior third of the
nucleus caudatus, besides some emotional disturbance, provokes in a
greater degree intestinal and vesical phenomena.

Dr. Pagano has, by varying the direction in which he introduces his
injecting needle, taken precaution to keep distinct the result of irritation
of neighbouring organs. With him the nucleus caudatus is a centre of
some of the emotions. He favours Bechterew’s views that in the thalamus
opticus we have a centre of reflex innervation of the groups of muscles

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EPITOME.

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which afford expression to the different affectional and emotional states.
Pagano adds that many clinical observations have confirmed this view.
Bechterew’s researches have also shown that the posterior corpora quadri-
gemina have to do with the expression of emotional states. Their destruc¬
tion is followed by deafness, aphonia, and paralysis of muscular exertion
in standing and walking, while their excitation provokes the emission of
vocal sounds, movements of the eyes and of the limbs of the opposite
and then of the same side with elevation and pushing forward of the
ear of the opposite side. William W. Ireland.

On the Left Hemisphere and Motor Actions \Die Linke-Hemisphare und
das Handeln J [original articles in the Munch med. Wochenschrift ,
Nos. 48 and 49J. {Cbl. fur Nervenheilkunde u. Psychiat., July 15 thy
1906.) Liepmann .

Dr. Liepmann, in a series of observations on ninety paralytics in the
Infirmary of Berlin, has sought to ascertain how the power of movement
was affected on either side. This examination was comprehensive. He
took note both of the performance of voluntary actions, such as knocking
at the door, ringing a bell and swimming, and movement expressions,
such as snapping the fingers, beckoning and warning, as well as the
rehearsal of these movements from memory. He tried to exclude cases
in which the internal capsule was implicated, limiting his studies to the
effects of the lesions of the cerebrum.

Dr. Liepmann found that in 20 out of 41 cases of left-sided paralysis
movements were duly performed with the unaffected right arm, while
in right-sided paralysis the motor functions of the left arm were also
impaired, although in a lesser measure. In other 21 cases, the motions
were not sufficiently precise to allow conclusions to be drawn therefrom.
In 20 patients, with paralysis of the left side, 14 had also motor aphasia
with injury to the performance of movements of the left arm. In the
remaining 21 cases, there were only 4 in which the use of the left arm
was noticeably impaired. The author took precautions not to confound
cases of helplessness of the hands with sensory ataxia or with deafness.
He found that in his cases the memory of the movements, as tested by
rehearsals, was also affected. In four cases, where an examination was
held, the author could find no changes in the area assigned for the left-
hand centre nor in Broca’s convolution. In these four cases examined,
there are no lesion of the cortex noted in two of them; there was
extensive injury to the corpus callosum. The author is disposed to
place the lesion on one side of the centrum ovale through which the
projection centre (Flechsig’s) and the fibres of the trabs going to the
right sensomotorium should be interrupted.

Dr. Liepmann comes to the conclusion that, in those motor impair¬
ments which followed the lesion in the left hemisphere, the movements
of expression, as well as the performance of actions by the hand, are
both affected. The rehearsal of movements is also impaired, but the
understanding of symbols may remain. In the case of sensory aphasia,
however, the awkwardness of movements may be owing to the impair¬
ment of the conceptions of time and space. This impairment of motor
power in the left side following right-sided paralysis displays the pre-

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1907.]

eminence of the left hemisphere consequently on the preferred use of
the right hand. The left hemisphere is taking a greater part in the
motions of the left side of the body than is generally thought. Dr.
Liepmann considered that, through a greater practice in the use of the
other hand, the right hemisphere would be less dependent upon the lead
of the left one, which would be an advantage to patients affected with
lesions of the left brain. Moreover, it appears from the author’s experi¬
ments, that the loss of motor impressions is an important deficiency in
dementia. It is also conceivable that the possession of motor images
in both hemispheres might heighten their liveliness, or that the relief of
work thrown thereon on the left hemisphere, by the increased cultivation
of the right one, might allow of the performance of higher functions.

William W. Ireland.

2. Physiological Psychology.

The Mechanism of Attention [Le Processus et le Mecanismt de VAtten¬
tion], {Rev. Sclent ., April 7 th , 1906.,) Nayrac .

The author appears to have made no experiments of his own, but
attempts to explain attention on the basis of recent researches (espe¬
cially those of Francois Franck) concerning the organic phenomena
which accompany attention. There are four theories of attention—
(1) the motor theory (Ribot, Ward, Stout, and most contemporary
psychologists); (2) the sensorial theory (Bastian); (3) the mixed or
sensori-motor theory (Waller) ; (4) the theory of reduction or simplifi¬
cation (James, Richet). It is the last which Nayrac accepts and seeks
further to develop. According to this theory attention is mainly
central; it is “ a general tension of mental activity,” “ a unique force
determined by the combined play of all the energies of the individual.”
It is thus a general property of the nervous system, to be assimilated
to effort and to will; “ there is no will without attention, and there
cannot be attention without will.” The question of the mechanism of
attention is also thus found to be the same as that of the mechanism
of the emotions, which the author resolves in a contrary sense to James
and Lange. The brain, according to Nayrac, is the first agent of atten¬
tion, and the peripheral phenomena follow the central. This is the
theory usually termed “ idealist ” or “ psychological,” but Nayrac argues
that it is just as physiological as the peripheral theory. The author’s
main point, however, is that attention cannot be regarded as an isolated
phenomenon, but rather as “ our great faculty of mental adaptation,
which as soon as it wishes to come into action makes an appeal to the
whole of our organism.” It adapts its forces to the end to be attained
and cannot be adequately explained unless we admit that the pre¬
ponderant part in it is played by the brain in general and the cortex in
particular. He further considers whether attention obeys a motor or
an inhibitory mechanism, and finally concludes with the following pro¬
visional psycho-physiological definition of attention : “ The feeling of
psychic tension which arises in part from the action of cerebral phe¬
nomena and in part from the general tonic contraction, voluntary or in-

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EPITOME.

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voluntary, of our muscles. It is always manifested at the outset by organic
or cerebral phenomena, accompanied by peripheral phenomena. It is
conditioned by an inhibito-active mechanism. United to effort and will,
it constitutes our faculty of mental adaptation.”

Havelock Ellis.

Some Psychiatric Experiences in Support of the Doctrine of Human
Bisexuality [Einige Psychiatrische Erfahrungen als Stiltze fur die
Lehre von der Bisexuellen An/age des Afenscheh]. (fahrbuck f. Sex.
Zwischenstufen, Jahrgang viii, 1906.) Nacke>P.

The doctrine that in every individual there is an organic foundation
of latent bisexuality, which in a few cases comes to the surface in
various more or less pronounced degrees, moulding the instincts and
impulses, has of late made considerable progress. It has been adopted
by various writers whose opinion carries weight, and Nacke now sup¬
ports the same view in an interesting contribution from the psychiatric
side. He starts from the principle that, both physically and psychi¬
cally, everyone has a bisexual endowment, and that it is the plus and
minus modifications of this endowment which result in men and
women. If this is so, Nacke proceeds, we must ask ourselves whether
there is really only one kind of normal sexual impulse, or whether
sexual impulse directed towards persons of the same sex, though a
much less frequent form, is not to be regarded as abnormal because it
is rare. “ Up to the present there is no scientific evidence to prove
that the homosexual, as such, are degenerates.” Those who have
argued that they are have usually been neurologists and alienists only
acquainted with pathological cases of homosexuality. Even patho¬
logical cases may, however, furnish evidence in support of the pro¬
bably congenital character of the bisexual tendencies, and Nacke
proceeds to record in careful detail the nature of the sexual, and espe¬
cially the homosexual, manifestations in a series of insane patients, and
concludes that such manifestations can best be explained by the theory
of bisexuality.

It is interesting to note, it may here be added, that this theory also
finds support in an investigation recently issued from a very different
quarter. Shattock and Seligmann have been studying hermaphroditism
in the domestic fowl and the causation of allopterotism, as they term
the assumption of the plumage of the opposite sex; they reach the
conclusion that the phenomena may best be accounted for, not by the
theory of atrophy of the sexual glands, which proves to be inadequate,
but by the hypothesis that the sexual glands of such birds are really
bisexual or hermaphroditic (Path. Soc. Trans. t vol. lvii, Part I,
1906). They conclude that, even among the higher vertebrates,
hermaphroditism, instead of being abnormal, may be regarded as a
reversion to the primitive ancestral phase in which bisexualism
was found. “ The occurrence of true hermaphroditism in man
being established, the question arises whether lesser grades do not
occur, and whether the fairly common cases in which the human
female, after the cessation of menstruation, acquires hair on the face
may not indicate that the retrogression of the ovaries has been suc¬
ceeded by the progression of some quiescent male tissue. Still more

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PHYSIOLOGICAL PSYCHOLOGY.

179

remote evidence of bisexuality in the human subject may, perhaps, be
afforded by the psychical phenomenon of sexual perversion and in¬
version met with amongst both civilised and savage peoples.”

Havelock Ellis.

On the Pathogenesis oj some Impulsions, ( Journ . Abnormal Psychol .,
April , 1906.) Janet , P,

A large number of patients have impulses to perform certain useless,
bizarre, and even dangerous acts, not generally, however, very important
acts; when it is a question of dangerous acts the patient is apt to feel
himself drawn towards them rather than actually impelled to accomplish
them. The mechanism of the impulsion is not always the same. Some¬
times it is analogous to that of suggestion; at other times the impulsion
appears to develop subconsciously, entering the field of a retracted
consciousness too late to be easily controlled. Beyond these and other
causes there is, Janet believes, a mental disposition common among the
^ obsessed and impulsive which plays an important part in many cases.

To illustrate the factor in question five cases are briefly narrated, all
in young women. One is a case of periodical dipsomania, the attacks
occurring at intervals of a few weeks or months and being followed by
repentance and despair; another of the rarer impulsion to eat, the
patient feeling a constant need of support; the third of dromomania,
or the mania for walking, the patient not beginning to feel at her ease
until she has. walked over forty kilometres along a public highway, so
that no sanatorium can be found sufficiently spacious for her; the fourth
must tear out her hairs one by one and eat them, and has thus lost
a luxuriant head of hair; the fifth is never happy unless she tortures
and wounds and bruises herself. These impulsions, though apparently
different, have common clinical characteristics. They are periodic and
irresistible, while their satisfaction is followed by good but useless
resolutions.

In all these cases, the essential part of the psycholeptic crisis, Janet
believes, is played, not by the impulsions, but by the period of depression
and the sense of incompleteness which are in every case found to pre¬
cede the crisis and to be expressed in the same terms and in the same
metaphors by every patient. The impulsion is merely a way of escape
from this intolerable state of mind. Thus the girl who wounds herself
is far from having any desire for self-mortification. “ It is my parents
who believe that,” she says, “ but it is absurd. It would be a mortifi¬
cation if it brought any suffering, but I enjoy this suffering; it gives me
back my mind; it prevents my thoughts from stopping; what would
one not do to attain such happiness ? ” The other patients bear testi¬
mony to a similar effect.

These absurd acts are passionately sought, not from any insane
notions, but because they really are stimulating, and really do tend to
dispel the depression from which the patient is suffering. So far,
therefore, from being truly morbid, these impulsions are rational thera¬
peutic measures, the mistake being that the patient employs them in
excess, and also fails to realise that there are other equally effective
methods of obtaining relief. We must always remember, Janet con¬
cludes, that the cause of the impulsion is in the underlying attack of

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EPITOME.

180

[Jan.,

depression, and it is the latter which we have to combat, for the
psychological analysis of pathological symptoms is not only interesting
from a scientific point of view, but of great importance in its practical
application. Havelock Ellis.

A Plethysmographic Study of Attention. (Amer. Joum . Psych,, Oct.,
1905.) Stevens, If. C.

In this elaborate and important investigation, carried on in the
Psychological Laboratory of Cornell University, and not easy to sum¬
marise briefly, the author shows reason to believe that the method of
expression as applied to the study of the feelings— i.e., the study of the
organic concomitants of emotive phenomena—has failed. Many of the
results were found to be equivocal, and there were different kinds of
reaction in different kinds of experiment. The author accounts for
the failure by psychophysical processes in the sensation, unless we are
to speak of visual, auditory, and tactual attentions, as we speak of
memories. It is maintained, as regards volume—the only factor that
was at all uniform—that every sensory stimulus tends to produce a
fall in volume; the supposed correlation between rise of volume and
pleasantness is declared not to be established by previous investigation.
Changes in rate of pulse and respiration are brought about by the
psychophysical process of respiration, and inhibited respiration was
found to characterise attention. Both pulse and respiration seem to
respond less readily to visual stimuli than to tactual and auditory stimuli.
The author concludes that “ the plethysmograph will never serve as a
psychoscope for the diagnosis of affective processes. And if by any
means the method is rehabilitated, it will require more vigorous rules of
use than have yet obtained to secure results of any degree of certainty.”

Havelock Ellis.

The Negative Aspect of Hallucinations {Amer. foum. Psychol., Jan.,
1906). Town, Clara.

According to Stoddard, in hallucination there is dissociation of the
affected sensory centres from the neurons which normally conduct to
them stimulation from the sense organs, so that every hallucinatory pro¬
cess has two sides—a positive, resulting in the hallucinatory image, and
a negative, preventing simultaneous perception by the same centre. The
author, who is resident psychologist at the Frankford Friends’ Asylum,
has tested Stoddard’s theory by studying a series of insane patients. She
finds that in many cases the negative factor is evident, in many more it
is difficult to determine, in a few it is unmistakably absent. An adequate
hypothesis must, however, explain equally well a hallucinatory process
possessing the negative characteristic and one that does not, and should,
moreover, demonstrate why this negative factor is sometimes present
and sometimes missing. The facts call for some other explanation than
that offered by the theory of dissociation of peripheral tracts, and the
author suggests that such an explanation may be found in the variability
of the degree and span of attention. If the visual or auditory centre is
in a state of great activity initiated by central stimulation, the whole
attention may be absorbed to the exclusion of all other sensations; this

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I907.] .ETIOLOGY OF INSANITY. l 8 l

condition would be the result, not of physiological dissociation, but of
concentration and limitation of attention. It is analogous to the con¬
dition of a normal person when engrossed in a book, only carried a stage
further. Normally the mental content is so complex that it is difficult
for one idea to absorb the mind exclusively; in insanity certain brain-
centres are constantly active, while others are sluggish or inert. Halluci¬
nations may thus depend on an abnormal activity of certain brain-centres
coupled with diminished activity of other centres, or, in psychical terms,
a concentration and limitation of attention. A hallucination, According
to this theory, is simply a normal mental process in evolution, un¬
inhibited by other mental processes, and the isolation is produced, not
by dissociation, but by narrowing of the field of attention.

Havelock Ellis.

3. Etiology of Insanity.

Etiology of General Paralysis [Contribution d 1'itude de Ntiologie de la
faralysic progressive ]. ( Clb . fur Nerven, und Psyche March,

1906.) Mongeri, L.

The author bases his conclusions on cases occurring in his
Constantinople practice. These cases are of exceptional interest from
the etiological point of view in that (1) the patients comprise representa¬
tives of various nations; (2) these nations, owing to differences in
religion and mode of life, vary greatly in their liability to syphilis and
alcoholism.

After a preliminary description of the social and economic conditions
prevailing in Constantinople the author applies the postulates thus
gained to his 144 cases, and deduces the following conclusions :
General paralysis is invariably preceded by syphilis. Instances where
this cannot be proved may usually be accounted for either by the early
exaltation of general paralysis, leading the patient to deny the existence
of previous disease—the prevalence of pederastia, whereby infection
may have taken place without leaving any discernible trace—or,
finally, by the existence of hereditary syphilis. Syphilis alone is, how¬
ever, incapable of producing general paralysis. Other accessory causes
are requisite, of which by far the most important are heredity and
alcoholism. A possible explanation of these facts is to be sought in the
functional failure of the liver, involving loss of its poison-eliminating
power. Out of thirty-eight cases examined from this point of view
thirty-six had some organic or functional defect of the liver. It has
been shown that toxins diminish the amount of glycogen; if the
glycogen re-forms, recovery ensues; if not, the organism succumbs.
On this theory the part played by alcoholism in the genesis of general
paralysis is easily discernible. It is probable that heredity and intel¬
lectual overwork act in a similar manner.

General paralysis is, therefore, to be regarded as the result of an
ensemble of causes. Its comparative limitation to civilised countries
is explained by the fact that the necessary causes, though found
singly, do not occur in combination amongst savage nations.

Bernard Hart.

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EPITOME.

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On the Etiology of Mongolian Idiocy [Mongolidiotiens jE tiology ]. (Nyt
Tidsskrift fur Abnormvcesenet , 9 Hefie , 1906.) Bodil Hjorth.

Dr. Bodil Hjorth, who is Assistant Physician to the Kellers Institution
in Copenhagen, found that out of 750 imbeciles 30 presented the
characters of Mongolian idiocy. The proportion is the same in England
and Sweden. In Germany, he tells us, it is from 1 to 2 percent.

Mongolian idiocy is so marked and specific a form that one might
expect it to have a determinate cause. The author has collected
information about the parentage and birth of twenty-one Mongolian idiots,
which he gives in a statistical table. The observed conditions assumed
as possible causes are phthisis in the parents or grandparents, neuro¬
pathic heredity, and alcoholism. None of these occur so often as to
show a preponderating influence. There is no record of syphilis in any
of the cases. Twins, both presenting the specific characters, are noted,
the father a day labourer, set. 41, the mother aet. 42. These children
were the eighth and ninth of a family of ten. Out of 21 cases, 12 of
these Mongolians were the last children in the family.

William W. Ireland.

Clinical and Statistical Study on Deaths from General Paralysis. (Ann. di
Freniat ., June , 1906.) Margaria.

Dr. Margaria, studying the cases of general paralysis in the University
of Turin, finds that this malady is rapidly increasing. During the ten
years from 1894 to 1903 there were 42 deaths in the first five years and
49 in the second. He thinks that the province of Turin is one of
the most predisposed to paralysis, education being diffused and intel¬
lectual exertion being necessary in the hard struggle for existence,
which renders the nervous system more disposed to morbific in¬
fluences. As a cause, he finds the use of alcohol the most potent
(27*87 percent.), after that lues (11*40 per cent!). These two causes
were united in 8*3 per cent. General paralysis is found to begin from
the age of twenty to that of seventy years; it is most frequent between
forty-one and forty-five years, 20 per cent, of the cases falling through
this period. It is more common with men than with women, in the
relation of 1 to 3*6 per cent. There is a great variation in the duration
of this disease within ten years, but the larger number of paralytics die
between eighteen months and two years.

William W. Ireland.

4. Clinical Neurology and Psychiatry.

Mental Symptoms in Amyotrophic Lateral Sclerosis [Troubles Men faux
dans la scllrose laUralt amyotrophique\ (Arch, de NeurolJune,
1906.) Cullerre , A.

Considerable diversity of opinion exists as to the frequency of mental
symptoms in amyotrophic lateral sclerosis. Marie states that demential
symptoms, with exaggerated emotivity and puerilism, are of common
occurrence. Raymond, on the other hand, regards these phenomena
as exceptional.

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1907.] CLINICAL NEUROLOGY AND PSYCHIATRY.

183

The author—after a detailed description of several cases—arrives at
the following conclusions : Amyotrophyic lateral sclerosis may be accom¬
panied by various mental disturbances—ranging from a slight degree
of dementia to the extreme dementia of general paralysis—from simple
psychasthenia to complex psychoses, suicidal melancholia, and systema¬
tised delusions. The delusions, however, usually resemble those occur¬
ring in senile cases. Exaggerated emotivity is common. The demential
symptoms may be regarded as a consequence of the organic lesion, the
delusions and other active manifestations as a consequence of the
individual predisposition. It is probable that the causal toxins attack,
simultaneously or successively, various portions of the nervous axis
which are structurally or functionally defective, thereby engendering an
association of spinal, bulbar, and cerebro-psychic symptoms. This
opinion is supported by the pathological researches of Duprd, who
found an extension of the disease process by way of the pyramidal
tracts to the cortex, and occasionally also to the corpus callosum.

Bernard Hart.

Stereotypy in Dementia Prcecox \Atude elinique sur la stiriotypie des
diments precoces], {Arch, de Neurol, , March , 1905.) Dromard, G.

Stereotyped movements are not limited to dementia praecox, but
occur in secondary dementias, and also in some systematised delusional
states. Many followers of Kraepelin, however, would bring these last
largely under the head of dementia praecox.

1. Classification:

(a) Akinetic stereotypy, —Attitudes, either of the whole body or of an
individual member. Refusal of food, and mutism—though usually
referred to negativism—are sometimes examples of akinetic stereotypy
— eg,, a patient who refuses to eat, but who offers no resistance when fed
with the nasal tube.

(b) Kinetic stereotypy, —Movements, which may be further subdivided
into stereotypies of (1) speech — e,g , 9 neologisms, constantly recurring
words and phrases, modes of intonation ; (2) writing; (3) expression —
c.g., grimaces ; (4) walking ; (5) complex stereotypies — e.g., special modes
of sitting, eating, or dressing. Masturbation is sometimes to be referred
to this group.

2, Evolution ,—The stereotypies of the acute stages of the disease
must be distinguished from those of the terminal period.

(a) Primitive stereotypies, —The prolonged attitudes and repeated
movements of katatonia. The failure of physiological plasticity, the
impeded psychical process of the katatonic, are probably of toxic origin.
The movements are angular, jerky, awkward, like those of a mechanical
toy. This type of movement tends to disappear in later stages.

(b) Secondary stereotypies, —Those of the terminal period. These are
not to be correlated with a functional failure in the cells, but with ^n
organic defect, the result of the previous toxin. These movement
therefore arise from imperfect intercellular connections—that is to say,
a state of disaggregation. Secondary stereotypies are the residue of acts
which, though once adapted, conscious, and voluntary, are now purely
automatic. The original idea is often to be found in the hallucinations

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EPITOME.

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and delusions, accompanied by profound emotional colouring, which
occur in the early period of the disease. “ Professional ” acts also fre¬
quently form the basis of subsequent stereotypies, but some automatic
movements must be regarded as of fortuitous origin.

Although the secondary forms imply a more advanced stage of disease
than the primary, they nevertheless may occur comparatively early,
often contemporaneously with the latter. This is analogous to the co¬
existence in a tissue of inflammation and sclerosis.

Secondary stereotypies tend to become reduced in number as time
goes on, those remaining being usually those first formed.

3. Clinical value .

To preserve the value of stereotypy as a clinical sign, the meaning of
the word must be strictly limited. A repeated action is not stereotypy
if it is still joined to an idea. Acts committed under the influence of
obsessions, the conjurations of paranoia, etc., must therefore be
excluded.

Stereotypy is far commoner in dementia praecox than in other forms
of mental disease. Primitive stereotypies are more frequent in kata-
tonia, secondary in hebephrenia and dementia paranoides. Stereotypy
serves to distinguish the excitement of dementia praecox from that of
manic-depressive insanity and general paralysis. It occurs early in
dementia praecox, late in systematised delusional insanity. It is also of
service in distinguishing the terminal stages of dementia praecox from
other terminal dementias.

As regards prognostic value, secondary stereotypies are of grave
import; in primary stereotypy the outlook is less gloomy, especially if
other signs of active katatonia are present. Nevertheless, in the so-
called “ cured ” cases of dementia praecox a tendency to stereotypy per¬
sists. This tendency may be utilised in teaching the patients simple
machine-like occupations. Bernard Hart.

On the Phobias [Des Phobies ]. {Prog. Mid., August 11th, 1906.) Terrien .

The thesis put forward in this paper is that the phobias or obsessional
fears are not invariably symptomatic of the condition of degenerescence,
but may also, though no doubt more rarely, originate from hysteria. In
support of this view the author briefly records twelve observations of
phobias—six in hysterical patients and six in non-hysterical degenerates.
In the hysterical variety the onset of the symptom is usually sudden,
and it can, indeed, be induced in a typical form by suggestion, and is
very amenable to treatment by the same method. The phobias of the
degenerate, on the contrary, are slow in their evolution and are almost
always refractory to every method of treatment. W. C. Sullivan.

The Time of some Mental Processes in the Retardation and Excitement of
Insanity . (Amer. Joum, Psych., January, 1906.) Franz , S. T.

To what part or parts of the nervous system may we refer the
increased and decreased psychomotor activity usually found in depressed-
maniacal insanity (in Kraepelin’s sense)? Six subjects were chiefly
used in the research—two normal, two depressed (retarded), two
exhilarated—all willing, and some anxious, to do their best in the tests,

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which were carried out at intervals during a period of fifteen weeks.
The tests were made as simple as was consistent with accuracy, and
covered time of rapid tapping, time of simple reaction to sound, time of
choice reactions to sound, rapidity of reading, etc. When the results
of all the experiments are considered, the excited patients do not show
any consistent increase in speed over the normal or the depressed,
indicating that the maniacal condition is not increased motor ability,
but merely increased motor diffusion. The retarded subjects were slow
at the beginning of all the series, but in the more complex mental pro¬
cesses (involving choice) they took proportionately a shorter time than
for simpler acts. The maniacal patients tended to keep the normal
relations. In the retarded patients there was considerable improvement
with practice, tending to show that such patients may be improved by
systematic exercise. The author believes that if the retardation is due
to lowering of irritability, such lowered irritability is not in the brain,
but rather in the peripheral parts of the body, particularly the nervous
system. In only a few cases are the average variations for the insane
greater than for normal subjects. Havelock Ellis.

On the Growth of Nails in States of Mania and Mental Depression
[FAccressimento Ungueale nella Frenosi Maniaco depressiva\ (Ann.
di Freniat.,June y 1906.) Falciola .

Dr. Falciola has collected a large number of papers upon the growth
of the nails and the changes noted after disease, which he has tested by
his own observation. He is not disposed to agree to the assertion of
Parisot and Paget that the state of the nails is an index of trophic
alterations in the body, although he admits that their growth is affected
by a general disturbance in the economy of the organism. He found
that in melancholy the growth of the nails is slower. The increase of
the nails is somewhat irregular, being greater at one time than another,
and differing in each finger, although there is a general equality in growth,
which is more marked in the three middle fingers. The nails of one
hand do not grow at exactly the same rate as in the other. He fails to
find either marked acceleration or slowness of growth in states of
mental depression or mania. In general he finds that the study of the
growth of the nails in insane patients appears to support the views of
Kraepelin on the clinical unity of all those types of mental disease
which writers generally wish to treat as distinct, but which, in truth,
only represent different episodes of one fundamental malady.

William W. Ireland.

On Insanity from Occupation \Berufspsychoseti\. (PsychiatryNeurol.

Wochenschrift, Nos. 17, 18, and 19, 1906.) Hellpach .

Under this title Dr. Willy Hellpach, of Karlsruhe, includes some
studies of the mental derangements which beset men’s callings. The
conception in these three essays seems better than the execution. He
has nothing new to say about the “ Caesarenwahnsinn,” the insanity of
power. It appears that in Germany the apothecary is regarded as often
eccentric and abnormal. Dr. Hellpach observes that the strain of
responsibility in which apothecaries exercise their calling is liable to

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EPITOME.

[Jan.,

produce a nervous state which is frequently complicated with the abuse
of alcohol and morphia. I am not aware that such peculiarities have
been noticed amongst apothecaries in Great Britain, nor am I surprised
that the pharmaceutical journals in Germany have protested against this
honourable profession being so libelled by Dr. Hellpach.

The author is more successful in his study of collectors. As he
remarks, it is very common in young persons to make collections of
one kind or another. The desire to collect seems to be the main
thing, the object only a means to gratify it. With the cares of life this
taste passes away or is kept under; but in a few instances making a
collection of curiosities becomes a passion which people will gratify at
the expense of the welfare of their family, and in disregard of moral and
legal considerations. I knew a worthy clergyman of antiquarian tastes
who used to say “ All collectors are thieves.” Several bold pieces of
robbery under the desire of acquiring relics of antiquity are known to
me. Dr. Hellpach asks, Is fanatical collection the cause of this mental
perversity or is it only the expression ? He does not decide the ques¬
tion, though he evidently leans to the affirmative.

The collection of trifles is a very common habit in lunatic asylums.

The actor is very liable to have his mind deranged by his vocation,
which leads him to throw his thoughts and feelings into a mental world
not his own. The capacity to do so is no doubt born with him, but the
reaction upon his own character increases with his employment. The
boundary between the original and the artistic ego becomes effaced and
the assumed character has an unhealthy action on the mind like a
foreign substance on the body. The author points out the resemblance
between acting and hysteria; in fact, hysterical girls are born actresses,
and delight in making an exhibition of their feelings. The mental
derangements of actors have been very well treated by the late Dr. W. A. F.
Browne in a paper which deserves to be reprinted.

William W. Ireland.

5. Treatment of Insanity.

Sedatives and Narcotics in tJuTreatment of the Insane . (.Dublin Joum . of
Med. Sci. y September , 1905.) Cullum , S. J.

This paper is the reprint of a thesis read by Dr. Cullum for the
Degree of M.D., Univ. Dubl., July, 1905.

The writer remarks at the outset that from the myriad sedatives and
narcotics available at the present time a very small number may be
selected that are really serviceable. The modern treatment of the
insane is opposed to the extensive use of drugs, and the perfect
sedative, which shall be harmless, rapid in its action, easily adminis¬
tered, and not giving rise to habituation, remains to be discovered.
The drugs we have at present at our disposal may be roughly classified
as general sedatives, pure hypnotics, drugs lessening reflex irritability,
and motor depressants.

(1) The general sedatives useful in the treatment of the insane are

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sulphonal, trional, and cannabis indica. The first is very insoluble,
and therefore very slow in its action, but precisely for this reason it is
useful in certain patients suffering from motor excitement—noisy, dan¬
gerous, and unmanageable. Hence sulphonal is largely used in asylum
work, but from its tendency to accumulate it must be used with great
discretion. Trional is more soluble, and therefore more prompt and
also more transient in its action than sulphonal. Being much more
expensive, it is less used in pauper asylums. Cannabis indica is a
powerful but uncertain sedative in noisy, irritable, and fractious patients,
especially senile dements. (The author omits to discuss the question
whether the uncertainty of this valuable drug is not chiefly due to
variations in its quality. It is much to be regretted that the search for
the active principles of Indian hemp has not been more successful.)
In acute mania the drug sometimes calms when all else has failed.

(2) The pure hypnotics discussed by Dr. Cullum are paraldehyde,
alcohol, veronal, and chloral hydrate. Drugs of this class are pre¬
eminently needed in the treatment of the sleeplessness almost invariably
present in the early stages of insanity. A useful caution is, however,
given by the writer, who points out that in many cases if no drugs are
given natural sleep returns on the third or fourth night after the patient
is admitted to the asylum, and as he justly says, “ this natural sleep is
well worth the waiting for.” But should it fail to appear the use of
hypnotic drugs is inevitable. Of pure hypnotics, in Dr. Cullum’s
opinion, paraldehyde “takes an easy first.” The principal draw¬
back of the drug is well known. It has a nauseous taste and smell,
and as it is very volatile, and is excreted by the lungs, the breath
of the patient taking it has a characteristic odour. So much is
its taste disliked that after the first dose the nasal or oesophageal
tube has, in asylum practice, commonly to be employed in its ad¬
ministration. But the natural character of the sleep which it induces,
and the improvement in mental condition and appetite which fol¬
lows its use, lead the writer to prefer it, notwithstanding these draw¬
backs, to all other hypnotics. In the insane he employs doses far
larger than those mentioned in the pharmacopoeia, two drachms as an
initial dose, rising to four or six drachms, and in selected cases even as
much as an ounce. Its effect is increased and its action is hastened
by the admixture of an equal quantity of brandy or whisky. Alcohol
in the form of toddy, containing one ounce of brandy or whisky, is
considered by Dr. Cullum to be a most useful occasional hypnotic in
the irritable sleeplessness of senile dements. Veronal, with the use of
which we have become widely familiar during the year and a half since
the thesis under review was compiled, receives favourable mention from
the writer. Its price, however, is high, and when given continuously it
unquestionably gives rise to ataxia and to other symptoms of accumu¬
lation. Its principal use is in the sleeplessness common in the early
stages of melancholia. In mania it is practically useless, its action
being too slow, whereas paraldehyde in the doses above mentioned
will commonly insure sleep in a few minutes. Of chloral hydrate
Dr. Cullum has nothing new to tell us. He considers it especially
useful in acute alcoholics, here best combined with bromide, in
paroxysms of excitement and sleeplessness occurring in epileptic

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EPITOME.

I 88

[Jan.,

patients, and, above all, in the status epilepticus , in which it should be
given by rectum in double the ordinary doses.

(3) Drugs lessening reflex irritability .—The drugs treated of in
this section are the bromides and opium. The writer’s account of the
bromides relates chiefly to their use in epileptic cases. Opium he has
come to use exclusively in the form of the tincture, and that in
considerable doses. He thinks that there is one type of melan¬
cholia, and one only, in which the use of opium is advantageous.
These are cases occurring in either sex, above the climacteric age, and
affected with premature atheromatous changes in the arteries ; they are
depressed, restless, noisy, and frequently exhibit active and distressing
delusions. The state of cerebral irritation is presumed to be due to
atheroma of the cerebral arteries, this disease being obviously present
in the peripheral blood-vessels. In large doses (Jij in twenty-four
hours for an initial dose) opium dilates the peripheral vessels and
lowers general blood-pressure, and at the same time in the cases
described there is great improvement in the mental condition, and the
management of the cases becomes much easier. The drug is given
at intervals only, not continuously, to avoid habituation. The writer
rightly insists on the more even sedative effect produced by laudanum per
os as compared with morphine administered hypodermically. Finally,
in cases of recurrent mania with regularly occurring periods of excite¬
ment and exaltation the writer employs a mixture of morphine and
chloral hydrate “ with the most beneficial results.”

(4) Motor depressants .—In this class Dr. Cullum alludes to two

drugs only, viz . hyoscine and tincture of hyoscyamus. He has nothing
new to tell us regarding the use of the former drug in cases of violent
mania. He cautions against the use of a larger initial dose hypodermi¬
cally than a grain, and has seen death result from of a

grain. Tincture of hyoscyamus is indicated in cases difficult to manage
on account of a large “moral” element in the insanity, and more
especially in women, who are worse in this respect during thd catamenial
periods. A drachm or two drachms should be given at bedtime, often
advantageously combined with other hypnotics.

Dr. Cullum concludes his thesis with a number of maxims derived
from his experience of the use of sedative and narcotic drugs in the
insane. The most important of these are the following :

When giving any such drug frequently, make repeated physical
examinations, and pay particular attention to the ratio between waste
and repair, as shown by the weight-record.

When insomnia is associated with delusions of a visceral nature keep
watch for actual disease of the organ supposed by the patient to be
affected.

Dispense with all sedative and narcotic drugs as far as possible,
since all have a deleterious effect on the tissues of the body.

Never give a hypnotic in the daytime. M. Eden Paul.

General Therapeutics of Mental Disorders \Journ . de Med . de Bord 1 ,
October 15 th and 22nd , 1905]. R/gis , E. (Extracts from the
chapter on the above subject in Dr. Regis’ Pricis de Psychiatric.)

The methods of treating mental disorders are classified as : (1) General

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I 907 -] TREATMENT OF INSANITY. 189

Methods, all of which are various modes of isolation of the patient, his
removal to a fresh environment; (2) Physical Methods, comprising
(a) rest in bed (or clinotherapy), (b) balneotherapy and hydrotherapy ,
{c) electrotherapy, (d) massotherapy ; ^3) Surgical Methods, comprising
(a) operations , (b) counter-irritation, (c) venesection , (d) serotherapy , (e)
gastric lavage; (4) Pharmaceutical Methods (including the employ¬
ment of animal extracts). The following matters are either novel or
of especial interest in the author's detailed discussion of these various
methods.

Dealing with general methods of isolation and change of environ¬
ment, he lays considerable stress on the danger, already pointed out
by Esquirol, of sending to asylums under an error of diagnosis those
transient forms of toxaemic insanity which are due to some acute
infective disorder, to alcoholism, or to grave organic disease. In this
connection the following recommendations are made :

(1) It is absolutely necessary that a medical man, before signing a
certificate, should satisfy himself that the mental disorder is not due to
acute specific disease.

(2) Postpone sending the patient to an asylum if he has pyrexia or
albuminuria, if he is suffering from asystole or other grave organic
disease, or if he is in a condition of advanced cachexia.

(3) Be prudent above all with regard to certification of cases of
hallucinatory confusion of mind with nocturnal excitement.

(4) Exercise caution in certifying persons of advanced age, who are
commonly affected with serious organic lesions, and many of whom
exhibit delirium only as a result of pulmonary, cardio-vascular, or renal
disease.

(5) There is a definite need for the foundation of special institutions
for the reception of cases of acute delirium—the delirium of infective
fever, of intoxication, of senile cachexia—which can no longer be kept
in their own houses. Thus we should avoid the necessity for the
certification of persons either suffering from a speedily curable disorder
or destined to early death.

Perhaps the most interesting section of the paper under considera¬
tion is that devoted to the use of prolonged baths in the treatment of
mental disorder—immersion for many hours, many days, even several
weeks. Special arrangements are needed in these cases for the regular
renewal of the water of the bath, for the provision of food and sleep,
and for immediate succour should malaise or syncope result.

It seems that patients, even when much excited, submit readily to
prolonged bathing. They sometimes get out of the bath, but since those of
either sex are dressed in a long bath gown with flowing folds, their move¬
ments out of water are incommoded and they are chilled by the wet cloth,
and they are often glad to get back into the water as soon as possible. The
skin does not suffer from the prolonged immersion beyond maceration of
the thick skin of the palms and soles—and this even can be, to a large
extent, avoided by keeping the skin rubbed with oil. On the other
hand, it is definitely asserted that excited patients are calmed, and that
sleep is promoted, by the baths. Various temperatures have been re¬
commended, ranging from 82° to 97 0 F. Success for this treatment
Has been claimed more especially in cases of maniacal excitement. On

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EPITOME.

[Jan.,

190

the other hand, a discussion on prolonged bathing took place at Rennes
in August, 1905, and the majority of the alienists who took part in it
condemned the treatment on the ground that it was, in fact, a form
of mechanical restraint worse than the straight waistcoat , and a means
whose employment could not be justified by trifling hypothetical thera¬
peutic advantages.

The author quotes Letulle and others, who give extremely favourable
reports of the effect of cold baths in cases of delirium tremens. Letulle
(1896—1899) employed baths at a temperature of 64° F., in which the
patient remained until calmed, an immersion lasting six to twelve
minutes commonly having this effect. In many cases violent delirium
suddenly gave place to perfect lucidity. The great danger is excessive
fall of temperature. The duration of the bath should never exceed a
quarter of an hour, and the patient should be very carefully watched.
After removal from the bath he should be well rubbed and wrapped up
in a blanket. Salvant, who has also employed this method with
success, regards it, not as a merely symptomatic and empirical mode of
treatment, but as one rationally based, which strikes at the cause, by
preventing the auto-intoxication on which the delirium depends.

M. Eden Paul.

Psychotherapeutics: Suggestion and Persuasion {Rev. Scient., February
and March , 1905). Bernheim.

This is a reply to recent criticisms of his books, De la Suggestion et
de ses Applications a la Therapeutique and Hypnotisme , Suggestion ,
Psychotherapie , and a reaffirmation of the doctrines enunciated in these
works. In Bernheim’s view, “ ail the phenomena classified as mesmerism,
animal magnetism, braidism, hypnotism, etc., are no more than a normal
faculty of the human brain, varying in intensity and mode of manifestation
in different persons, namely, suggestibility —that is to say, capacity of the
brain to receive an idea, and a tendency on the part of the brain to trans¬
form that idea into an action. This is a physiological peculiarity of
which we are able to avail ourselves independently of suggested sleep or
the hypnotic state. . . . We have to do, not with hypnotism, but

with suggestibility; not with an exceptional state, found only in
exceptional organisations, but with physiological qualities inherent
in the normal brain.” . . . “Every idea awakened in the brain,
every phenomenon of consciousness, is a suggestion; . . . every
idea has a tendency to realise itself in action.” The last proposition
embodies Bernheim’s Law of Ideodynamic Transformation. On the
views thus epitomised are based what Bernheim regards as the two
principal recent advances in psychotherapeutic procedure: first, the
recognition of the fact that suggested sleep— i.e., hypnotism proper—
is not a necessary part of psychotherapeutics; and, secondly, the proof
that suggestion has a large share in producing the beneficial results
obtained from all therapeutic measures; for, as he says, “anything and
everything competent to arouse in the brain directly or indirectly the
psychical image of healing, constitutes a therapeutic suggestion.”

The critics to whom Bernheim is replying in the paper under review
are Dubois, of Berne {Les Psycho ntvroses et leur Traitement Moral), and

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TREATMENT OF INSANITY.

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MM. Camus and Pagniez (Isolement et Psychothirapie; Traitement de
FHysteric ct dc la Neurasthenic ; Pratique de la Riiducation Morale et
Physique). The criticism offered is largely based upon the view that
suggestion is an improper psychotherapeutic method, and that persuasion
is the only psychic influence which it is permissible to employ : 41 sug¬
gestion makes its way along the tortuous paths of insinuation, persuasion
addresses itself loyally to the reason of the patient; the one appeals to
a blind faith, the other to accurate ratiocination.” If the dispute was as
purely verbal as this at first sight appears to be, it would hardly be
necessary to allude to it; but the attack further involves the assertion
so often made that the suggestive method substitutes another’s control
for that of the patient’s own will, and thus weakens his quality as an
independent agent. There may be some justice in the latter allegation
as regards the subjects of the hypnotic exhibitor; but it can hardly be
said to apply to the proper employment of psychotherapeutic suggestion.
Moreover, Bernheim appeals to facts of observation; and he declares
it to be such a fact that in suggested sleep, however profound, pure
automatism is never observed. And the frequent discussions as to the
possible use of hypnotic suggestion for criminal purposes have clearly
established that there is a strong tendency to resist suggestions which
are not approved of by the moral consciousness of the subject. In
fact, as Bernheim says, the moral consciousness in such cases makes
counter-suggestions, which inhibit the subject from acting on those of
which he disapproves.

The author reports a number of interesting cases in which psycho¬
therapeutic suggestion was the principal curative measure employed;
several of these confirm his assertion that to employ verbal persuasion
alone, addressed to the patient’s reason, is 44 to restrict within far too
narrow limits the scope and the efficiency of psychotherapeutics.”

Persuasion, continues Bernheim, is, in the ordinary sense of the
term, the introduction of ideas into the brain of another by the inter¬
mediation of speech. It is, in fact, one of the modes of suggestion.
Suggestibility, in cases in which verbal persuasion is employed, depends
upon two elements: first, the aptitude of the brain for the reception of
the idea—that is to say, the credivity oi the subject; secondly, the aptitude
of the brain for the transformation of the received idea into action—that
is to say, his ideodynamic excitability . One of his critics, M. Dubois,
has asked why he says credivity , and not credulity . In answer, he draws
a valuable distinction. We all possess a certain degree of credivity,
which impels us to believe what is affirmed to us, without demanding
in every case rational or moral proofs of the truth of the affirmation.
And the faculty is a most important one in human social life, for
without it there would be no tradition, no history, no business, no
social intercourse. Imagine the consequences if we should demand
logical proof when informed by a trusted friend that our house is on fire
or our child in the act of drowning, before proceeding to summon the
fire brigade or to run to the child’s rescue ! In the absence of definite
proof the mind would remain fixed in a condition of philosophical
suspense—to believe without credivity would be as impossible as to see
without vision. Credivity is a normal faculty of the brain. When it is
exercised in excess, it is called credulity . The distinction between

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192

EPITOME.

[Jan.,

credivity and credulity is that between a physiological and a patho¬
logical state. Moreover, since there are two elements in suggestibility,
namely ideodynamic excitability in addition to credivity, it does not
follow that one who exhibits credivity to the pathological degree—who is,
in fact, credulous—is therefore of necessity extremely suggestible; he
may be lacking in ideodynamic excitability, so that the idea suggested
to him is not translated into action. On the contrary, in a subject in
whom the ideodynamic excitability is strong a very moderate degree of
credivity will lead to the active acceptance of a suggestion. And this
is why suggested sleep—the hypnotic state—though not indispensable
to the therapeutic employment of suggestion, is yet often advantageous ;
in the mental isolation thus produced, ideodynamism is often far more
active, and the subject's suggestibility is greatly enhanced.

In the latter part of his paper Bernheim answers certain other
criticisms which have been repeatedly directed against the “ Nancy
school ” in general and himself in particular. “ I have been reported
as having said that suggestion is everything, that electrotherapy, hydro¬
therapy, massage, and even materia medica, act only by suggestion, that
the most diverse therapeutic procedures are nothing, but that the
human imagination is everything. I never said anything so absurd. I
said, not that suggestion is everything, but that suggestion has a share
in everything. And it is precisely because no attempt has, as a rule,
been made to determine how great is the share that suggestion has had
in the cure, that the reports of different authors regarding the thera¬
peutic value of other methods of treatment are so vague, so confused,
and so conflicting.” Again, to the accusation that he has declared that
suggestion will cure everything, Bernheim replies that he has never
asserted that suggestion will kill the Bacillus tuberculosis , that it
will arrest the development of locomotor ataxia, that it will cut
short an attack of enteric fever, or that it will cure pulmonary emphy¬
sema. But what he has repeatedly asserted, and what he now reiterates,
is this, “ that suggestion^psychical treatment , is directed towards the relief
of the psychical element in disease ; and that such relief can be given
when we have to deal with a mere functional and auto-suggestive disturb -
ance , a disturbance not arising from any organic toxic or infective
change in the brain, such as meningitis, uraemia, or degeneration of
brain-tissue. These latter conditions are not amenable to psychothera¬
peutics. But the most diverse maladies can give rise to a psycho¬
neurotic disorder, to a simple reflex disturbance without lesions ; such
a factor may constitute the entire disease, it may outlast an organic
disease which has given rise to it, or it may accompany such a disease
and modify or exaggerate its symptoms.”

The control of this functional pschyoneurotic element in disease is
the province of psychotherapeutics. M. Eden Paul,

6 . Pathology of Insanity.

Hcematoma Auris in the Insane [Otcematoma nei malati di mente]. (fi
Manicomio , anno xxi, No. 3, 1905.) Baccelli.

In a short review of the literature of the subject the author refers to

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1907 .]

the observations of Pellizzi, who in 1892 isolated from the fluid contents
in four cases of haematoma auris a micro-organism morphologically
similar to the Streptococcus pyogenes , which he regards as the patho¬
genic agent in this condition. Subsequent investigations have given
discordant results, some observers confirming Pellizzi’s views, while
others have either failed to discover any organism constantly present or
have found the fluid entirely sterile.

As a contribution to the settlement of the question Baccelli has
made a bacteriological examination in three cases. In two of the
observations, one a case of senile melancholia and the other diagnosed
as the catatonic form of dementia praecox, the haematoma followed a
blow on the ear ; in the third case, occurring in a cerebropathic idiot,
there was no evidence of injury. Repeated culture experiments were
made on the usual media with the fluid contents and with scrapings
from the wall of the tumour, but in every instance the results were
negative. Inoculation of the fluid on the guinea-pig’s ear, with and
without preliminary bruising, also failed to produce any inflammatory
reaction. In two of the cases a microscopic examination was made of
the skin over the haematoma, and it was ascertained that the blood¬
vessels showed evidences of chronic inflammatory and degenerative
changes. W. C. Sullivan.

Contribution to the Study of Cerebral Morphology in the Criminal [ Con¬
tribute alio studio della morphologia cerebrale nei delinquenti\
(Arch, di Psichiat ., vol. xxvii, fasc . ;-/*/, 1906.) Tovo.

This paper contains a fairly full account of the morphological
anomalies observed in the cerebrum of a criminal whose brain is pre¬
served in the Museum of Criminal Anthropology at the University of
Turin. Beyond the statement that the subject was twenty-five years
of age at the time of his death, no particulars are given regarding
his history. Of the unusual characters noted in the surface anatomy
of the cortex the most important were: (1) lessened obliquity in the
direction of the fissure of Rolando and relatively smaller development
of the pre-Rolandic cerebrum; (2) presence of a third horizontal sulcus
in the frontal lobe; (3) deep situation of the first annectant occipital
convolution and resultant distinctness of the external occipital fissure,
reproducing the appearance of the Affenspalt (4) interruption of the
ascending frontal convolution in two places by transverse sulci; (5) inter¬
ruption of the fissure of Rolando at the junction of the upper third with
the lower two thirds, an annectant convolution at this point joining the
ascending parietal to the ascending frontal. The first three anomalies
were visible on both sides, the fourth and fifth in the left hemisphere
only. The author emphasises the atavistic significance of these
characters, particularly of the Affenspalt appearance in the occipital
lobe and the interrupted fissure of Rolando, and founds on their
presence in the brain of a criminal an argument in favour of the
doctrines of the Lombrosan school. The paper* is illustrated by two
photographs which show very satisfactorily the anomalies described in
the anterior region of the brain but are rather blurred towards the
occipital pole. W. C. Sullivan.

LIII. 1 $

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EPITOME.

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On Changes in the Bones in General Paralysis [Ueber Knochenveran -
derungen bei progressiver Paralyse ]. (Cbl. fur Nervenheilkunde u.
Psychiat., Sept . 15 th, 1906.) Reichardt.

Dr. Reichardt had occasion to observe general paralytics who suffered
from spontaneous fractures. The bones were found to be light and
porous. He does not think that this condition is owing to marasmus,
or lues, or general weakness, but to be the result of the affection of the
brain and spinal cord in general paralysis. There is no doubt, he
observes, that changes in the condition of the bones attend some
nervous diseases—for example, in hemiatrophia facialis progressiva, and
in the deficient growth of the limbs in porencephaly, and the occurrence
of spontaneous fractures in uncomplicated tabes and syringomyelia.
The question may be asked what part of the nervous centre may be
held to influence the growth or diseases of the bones. Reichardt is
disposed to localise this function in the medulla oblongata. He entirely
dissents from Gudden’s remark that fractures in asylums are owing to
external violence; no doubt with greater care their numbers may be
lessened, but with such alterations in the structures of the bones
spontaneous fractures will occur. This fragile condition is not
cortimon in the bones of cranium. The author combats the assertion
that general paralytics have unusually heavy brains and thick skulls,
but he has observed that where there are persistent frontal sutures and
Wormian bones there are often unusually heavy skulls, owing to osteo¬
sclerosis, or to thickening with normal specific weight. He has observed
general paralysis in two microcephales. He denies the assertion that, in
atrophy of the brain, there is an accommodative concentric thickening of
the cranial vault. At the end of his article, he prints a letter from Pro¬
fessor Schmidt, of Strasburg, who holds that in thickening of the skull
it is impossible to distinguish whether this was owing to a natural or
diseased process. William W. Ireland.

On Artificial Atrophy of the Brain and Skull [Experimentell erzeugie
Gehirn-Atrophieund damit verbundene Schadel-Atrophie\. (Cbl. fiir
Nervenheilkuttde u. Psychiat., Aug., 1906.) D'Abundo.

Professor G. d’Abundo, Director of the Clinique for Nervous and
Mental Diseases in the University of Catania, published, in 1901,
some researches on atrophy of the brain. Since then, he has been
making experiments upon new-bom dogs and cats, in which he prac¬
tised openings of the skull. He found that, when these lesions extended
to the white matter, the growth of the brain as well as that of the skull
was diminished. With lesions on one side, there was hemiatrophy,
though the growth of the whole brain was affected. The result of the
experiment induces him to believe that the skull ceases to grow after
the brain is affected in infantile life, and not, as some people have
imagined, that the deficient growth of the skull hinders the increase of
the brain. William W. Ireland.

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7. Sociology.

The Problem of Responsibility [Examen de Quelques Questions Touchant
la Responsibility. (Rev. de Psychiat., July % 1906.) Toulouse and Crinon.

Will is “ the resultant at every moment of a person’s tendencies and
ideas,” as constituted by the environment in conjunction with the
subject’s own organisation. By virtue of this organic factor of will,
enabling a choice to be made among the directions presented, the
individual may be said to be psychologically free. Even if this psycho¬
logical factor be not held sufficient to involve freedom, it is still necessary,
from the social point of view, to postulate freedom. On this basis
responsibility exists when—(1) there is a sufficient consciousness of the
act and its consequences and (2) a sufficiently powerful and ordered
voluntary effort.

The authors do not undertake to define the nature of crime or of the
social reaction against it, though on this point they appear to be in
harmony with the modern positivist school, and they remark that the
protection of society is much better guaranteed if, instead of regarding
“punishment” as a method of correction, we regard it as “above all a
measure of treatment.”

As responsibility is based on lucidity of consciousness and capacity
for voluntary effort, which vary as we pass from normal to abnormal
individuals, punishment (if the word is still to be used), to be just, must
vary correspondingly, according to the psychological conditions. Thus
it comes about that the medical expert is asked to declare the state of
an individual’s “ responsibility.”

At this point there is a division of opinion. Some authorities assert
(and it might have been added that the assertion has never been dis¬
proved) that the idea of “responsibility” is not a medical or even
scientific conception, that the medical expert who expresses an opinion
on this matter is going beyond his own field, since he is only justified
in stating the actual medico-psychological facts which he can find in the
individual presented to him. The authors do not share this opinion,
and consider that they have solved a difficult question with the very
dubious assertion that “ the problem of penal responsibility is a psycho¬
logical problem.” If that is a fact, it is a fact of which psychologists
themselves seem to be ignorant. So far, however, as our authors are
concerned the difficulty is mainly verbal; if we substitute for “ examina¬
tion of the responsibility of criminals ” the phrase “ examination of the
mental state of criminals ”—which is what Toulouse and Crinon are
really concerned with—the difficulty falls away and the conclusions of
the authors may be accepted with unqualified approval.

The current methods of psychiatrical observation, they declare, are
altogether insufficient, being superficial, narrow, and involving no
elements of exactitude. It is by the systematic application of experi¬
mental methods that we can alone learn precisely how far an individual
is abnormal in intelligence and aptitude for voluntary effort, how far he
is capable of education, and what treatment he requires. Italy, the
authors believe, is now leading the way along these paths, and they refer
especially to the medico-legal methods used by Tamburini.

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196 EPITOME. [Jan.,

A purely psychiatric preparation no longer suffices to equip an expert
in this field, the author concludes. It is necessary, but is not sufficient;
familiarity with the methods of the psychological laboratory is also
required. This is all the more important since criminals must not be
divided beforehand into vicious and insane. Every inculpated person
should be examined by an expert. This is necessary, not merely to
discover those who are, in the ordinary sense, insane, but for the more
difficult and important end of ascertaining how far those who are not
technically insane are susceptible of medico-psychological treatment.
The authors incline to think that all criminals should receive sentence
(although their actual presence in court might in some cases be dis¬
pensed with); for it is for the judge, representing society, to determine
what persons are in their present condition unfit for society, but for all
serious offences the indeterminate sentence is the only one that should
be permitted. In all cases, also, there should be a preliminary period
of observation before the method of treatment is decided and the
offender classed. The prison must be a hospital. The medical expert,
however, would remain only an expert, and it would be for the judge
to sanction or not his recommendations. Not all these ideas, the
authors remark, are yet realised, but they are meeting with less and
less opposition, and it is becoming generally recognised that simple
criminals and insane criminals are not essentially different

The paper is a clear and vigorous presentation of some of the most
recent tendencies in alienism as it affects criminals.

Havelock Ellis.

A New Classification of Criminals founded on Psycho-pathology \Nuova
classificazione dei delinquenti fondata sulla psichopatologia\. (II
Manicomio , annoxxi, No. 3, 1905.) Ingegnieros .

Defining crime as “ a human action which transgresses the conditions
of the struggle for existence that are normal to the social milieu,” the
author considers its scientific study under three aspects: (1) the eti¬
ology of crime; (2) clinical criminology, investigating the forms of delin¬
quency and the characteristics of the criminal; and (3) the therapeutics
of crime.

The causes of crime are of two orders, endogenous or biological, and
exogenous or dependent on the social or physical environment. The
study of the former class constitutes criminal anthropology, which is
again divisible into criminal psychopathology and criminal morphology.
The investigation of the exogenous factors of crime, which is the pro¬
vince of criminal mesology, is also to be considered under two heads—
viz., criminal sociology, which deals with the causes belonging to the
social environment, and criminal meteorology, which has to do with the
influences of the physical environment. The two orders of factors are
always associated in the causation of crime, but in proportions that vary
widely in different cases; in the instinctive criminals and the insane
criminals, for instance, the predominance of the biological factors is
evident; while in the category of the occasional criminals the chief part
belongs to the influence of the environment.

Of the three modes of function under which the psychic activity,

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SOCIOLOGY.

197

itself one and indivisible, becomes manifest, namely the intellectual, the
emotional, and the volitional, one or other is usually predominant in the
individual personality, and determines the type of character. In the
criminal the anomaly of character, which is revealed in conduct, may be
predominant similarly in one or other of these modes of function.
Classified on this basis the psychopathic disorders of the criminal may
be represented in this scheme :

Moral anomalies (dysthimias). —Congenital: congenital criminals or
moral idiots; acquired: habitual or morally perverted criminals;
transitory: occasional criminals.

Intellectual anomalies (dysgnosias). —Congenital: criminals from con¬
stitutional mental defect; acquired : criminals from acquired insanity;
transitory: drunkards and other forms of toxic insanity.

Volitional anomalies (dysbulias ).—Congenital: impulsive epileptics;
acquired: impulsive chronic alcoholics; transitory: criminals from
passion.

To these three groups, which represent pure types, it is necessary to
add a fourth, formed by the combined types in which the loss of
functional balance affects more than one psychic sphere; thus we have
sensitivo-intellectual criminals in whom ethical defect is associated with
intellectual defect, and volitional-intellectual criminals who are lacking
in power of inhibition at the same time as they are intellectually feeble,
while again we meet with cases of extreme degeneration in which im¬
pulsiveness, absence of moral sense, and intellectual weakness co-exist;
these latter represent the psychologically complete type of the criminal.

W. C. Sullivan.

Relationships between Somatic Anomalies and the Educational Capacity
of the Senses in the Defective \Rapporti fra i caratteri anomali
somatici e feducabilita dei sensi nei deficienti\ (Arch, di Psichiat .,
vol. xxvii y fasc. i-ii, 1905.) Montesano and Selvatico-Es tense.

This very valuable paper is based on an exhaustive study of fifty
mentally defective children (thirty males and twenty females) in the
asylum of Santa Maria della Piet& at Rome. The method pursued by
the authors was to establish in each case on the one hand the number
and character of the somatic anomalies, and on the other the degree
of educational aptitude for the senses of sight, touch, and hearing,
and then to compare the two series of data. Adopting with slight
modification Morselli’s classification, they divide the physical anomalies
into (1) those of a properly degenerative type, recalling conditions found
normally in the lower races or in the primates—such, for instance, as
‘Toreille en anse,” the lemurian apophysis, the prehensile foot, etc.;

(2) those of a mixed or dubious character, probably for the most part
of pathological origin, but by some counted among the atavistic
stigmata, such as platicephaly, oxycephaly, the Gothic palate, etc. ; and

(3) those of distinctively pathological nature, depending either on such
dystrophic processes as cause facial symmetry, strabismus, etc., or on
constitutional diseases of which rickets is the most important, or on
accidental circumstances such as injury at birth or in childhood,
meningo-encephalitis, and so forth.

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[Jan.,

To investigate the degree of educability experiments were made to
ascertain (1) how far the child could be got to recognise qualitative
and quantitative differences in sensory stimuli; (2) what degree of
effort was needed to elicit such recognition (*.*., whether it occurred
spontaneously or only with (forced attention, or only when the recog¬
nition was associated with the satisfaction of appetite, as when sweets
were hidden in the object to be identified); and (3) the facility with
which the terms expressing shades of difference were acquired and
retained in the memory.

The salient facts are set out in detail for each case, and the results
are analysed from different points of view in a series of elaborate
tables which do not lend themselves to condensation.

The conclusions which the author puts forward are summarised as
follows:

(1) A complete, or almost complete, educability of the senses is
possible in a defective child even when the child presents a consider¬
able number of somatic anomalies. In one case, for instance, with
nineteen such abnormalities the educational aptitude was complete.

(2) A complete educability is also possible when the subject presents
a large number of atavistic stigmata.

(3) It is also compatible with the presence of any one of the more
notable atavistic stigmata and with a high degree of such stigma.

(4) As an indication of slight degree or total absence of educa¬
tional aptitude the dystrophic or constitutional signs have generally
more significance than the atavistic. Thus with the diminution of
educational aptitude there was a regular increase of the percentage of
subjects with a predominance of the stigmata of the former class.

W. C. Sullivan.

A Morphiamaniac on Trial for Murder: a Medico-legal Study of the
Matthews Case . (Alienist and Neurologist , vol. xxvii, No. 3,
August ; 1906.J Crothers .

The case reported in this paper is of peculiar interest as illustrating
in morphia intoxication the same medico-legal problems that so often
arise in connection with alcoholism. The subject of the report, a
medical man, set. 35, was accused of the murder of his wife. He was
known to have been a drug-taker for many years, and about two years
before the alleged crime he initiated his wife into the morphia habit.
Their relations appeared ordinarily to be very good, and on the day
preceding her death their manner towards one another was marked by
its usual friendliness. The following morning a friend called at the
house and found the woman in a semi-comatose condition, which the
husband explained by stating that the night before she had taken a
quantity of strychnine tabloids with suicidal intent, and that as a
remedy he had been giving her quarter-grain doses of morphia every
half-hour. The case was regarded as one of morphia-poisoning, and
remedies were applied accordingly. The husband, who was slightly
under the influence of the same drug, obstructed the treatment in a
silly manner, tried to persuade the physicians to leave him alone
in the room with his wife, and, failing in this, attempted surreptitiously

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SOCIOLOGY.

199

• 90 /.] *

to give her a hypodermic injection. His manner throughout was
confused and irrational, and after his wife’s death he made puerile
attempts to bribe the doctors to certify that death was due to
natural causes. When arrested he showed the same irrational and
unconcerned demeanour. The hypodermic syringe taken from him
was found to contain a mass of white powder, which after a cursory
examination at a drug store was pronounced to be strychnine. Sub¬
sequent analysis proved that it was morphia without a trace of
strychnine. No post-mortem examination of the woman’s body was
made. The family history of the accused showed a strong neuropathic
taint, his paternal grandmother having been insane, while on his
mother’s side one uncle died insane, an aunt suffered from some con¬
vulsive disease and was burned to death in a fit, and two other relatives
committed suicide. The accused was delicate and erratic as a child,
and presented further evidences of instability at adolescence, con¬
stantly changing from one occupation to another before finally adopting
medicine. While studying medicine he made an almost successful
attempt to commit suicide. From the time of his starting in practice
be was known to be addicted to the use of drugs, especially of morphia ;
and it had been noted for several months that his physical and mental
condition had greatly deteriorated, and that he had developed an
extreme instability of temper, oscillating from torpor and indifference
to irritability and impulsiveness.

Despite the medical evidence as to the effects of the chronic morphia
habit on the man’s mental state, the Judge charged that consciousness
of wrong-doing would involve responsibility, and that if there were
any blunting of the moral perceptions due to the intoxication, such
incapacity would not excuse the crime, because the intoxication was
voluntary. Dr. Crothers, who has been one of the foremost champions
of the forensic recognition of automatism in intoxication, comments
with just indignation on this reactionary attitude. The prisoner was
convicted of murder in the second degree, and sentenced to twenty
years’ imprisonment. W. C. Sullivan.

The Responsibility of Hysterics [A propos de la responsabiliti des hys-
tiriques\ ( Joum.de Mid. de Bordeaux , September , 1906.) Rigis, E.

There is an extreme variability in the mental state of hysterics, and
one must therefore assume a parallel variation in the degree of responsi¬
bility to be attributed to these patients. The most satisfactory theory
is that of “attenuated responsibility,” which alone allows a place in
criminology to the numerous intermediaries between the completely
sane and the undoubtedly insane. It is often maintained that the
practical application of this theory leads to results inimical to society.
This is not so. What is dangerous is the present judicial use of the
principle whereby punishment is diminished, while no adequate con¬
sideration is given to the question of public security. The solution of
the problem is the placing of the partially responsible in special institu¬
tions distinct from both the prison and the asylum.

Bernard Hart.

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EPITOME.

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8 . Asylum Reports.

Some English County and Borough Asylums.

Derby Borough. —The admission rate seems here to show a tendency
to become less. Dr. Macphail, as usual, gives the average respite ex¬
perienced by those who have been readmitted after discharge on
recovery. Last year this average for nine cases was six years and
eleven months. We wish that more would give these particulars, and, if
possible, add the form of mental disorder on the preceding and the
present attacks. Such information over a large area would not only
be helpful in discussing the various problems connected with the inci¬
dence of insanity from the administrative point of view, but would do
good by stirring up scientific inquiries into any marked differences in
results in various areas. General paralysis shows a large diminution in
the admissions. The duration of these cases seems from the figures to
be longer than usual, the deaths and admissions both being 5, while
the remainder on December 31st is 19.

Derby County. —Curiously enough, at Mickleover the figures relating
to general paralysis read just the other way, the admissions being 16
and the deaths 25, while the remainder is but 5. Dr. Legge notes
that more than a third of the admissions were returned as being
suicidal. Though more intimate knowledge of some cases removed
them from this category, yet the remainder formed an unusually heavy
charge. We do not ever remember noting an earthquake as an inci¬
dent in asylum life, but one was felt at Mickleover.

Dorset — Dr. MacDonald is able to point to a falling admission rate
for county cases, which he considers to be particularly satisfactory in
the midst of recognised distress from want of employment We much
appreciate the very full particulars in Table 1 in regard to the numbers
of private patients and out-county cases. Such fulness is essential to
the tables of all asylums where considerable batches of private cases
are dealt with.

Glamorgan .—A feeling of deep regret is kindled in handling the
Report of this asylum. It seems very sad that after many years of
subordinate work here Dr. Stewart should have been spared for so
short a period of full control. His death is a great loss to the service
of the locality, following as it does closely on the resignation of Dr.
Pringle, and the Association likewise has reason to deplore the loss of
an earnest and courteous member. The medical part of the Report is
rendered by Dr. Finlay, who is by no means a new-comer to Bridgend,
and whom we congratulate heartily on his succession to the superin¬
tendency. He reports that “ religious excitement ” is responsible for
21 admissions, 14 being men and 7 women. This recrudescence
of an old trouble in Glamorgan may be attributed to recent reli¬
gious revival. The latter, however, has had apparently some influence
in reducing the amount of alcoholic insanity admitted. The two

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influences together, though varying for the year, account for about as
many as they did last year. Hereditary predisposition was found in
nearly 50 per cent, of the religion cases. Solariums have been insti¬
tuted, and, though they have only been in use for a short time, they
promise to be of advantage in the treatment of tuberculous diseases.

Middlesbrough .—In commenting on a notable decrease in admis¬
sions from the borough, Dr. Geddes writes: “The decrease in the
number of admissions from the borough is unusual, and therefore
remarkable, and leads one to seek an explanation of it. It may be
that the trade depression from which Middlesbrough has suffered, and
which may presumably have been partly responsible for the increase in
the admissions in last and previous years, now operates as a cause of
the decrease, in that, having in the first place swept into the asylum
the weaklings—those most prone to mental degeneration—it has left a
hardier class—those whose nervous systems are more able to withstand
the stress of a strenuous existence. Again, the same factor may have
acted by driving from the town an appreciable proportion of the class
from which our patients are drawn. It is melancholy to reflect upon
the fact that whereas ‘ hard times ' tend to decrease the incidence of
insanity, prosperous times and high wages tend to keep our asylums
well filled.” The general paralytics provided nearly half the deaths.

London County Council Asylums .—The volume issued oy the
Council does not decrease in size nor in interest and value. As we
have said before, in all parts of the Report there is evidence of intense
earnestness and intention to take up worthily a great, continuous, and
increasing responsibility. The Committee gives figures to show that though
there is, as must be expected, an absolute increase in the number of
patients, that increase has been for two years past a diminishing one.
But it is wise not to attempt to draw any conclusions from such a
meagre period. At the same time, the same tale is told in many other
places, and our impression after reading many asylum Reports for the
year is that there is less urgent demand made for accommodation over
the country. The Committee again refers to the inconvenience of
having two important bodies regulating the insanity of one area. It
shows that while in the last sixteen years it has increased its percentage
of total accommodation for the insane of all kinds by 1091, the per¬
centage of that provided by the Metropolitan Asylums Board has
decreased by 8*34. The workhouses and friends receive now a smaller
proportion than they did. Then in one of the tables it is shown that
some parishes have many more in asylums of one Board than in those
of the other. The Committee seems to be justified in concluding that
the explanation of the inconvenient arrangement must be found in the
method of certification. We believe that we have in former pages
hinted at the same thing, but it is not so long ago that in a legal inves¬
tigation it was shown that relieving officers had a freedom of choice as
to where patients should be taken that could not be supposed to make
for the most efficient utilisation of available room. It is stated in the
Report that 4201 applications for beds were received, while only
3627 were allotted during the year. The admissions to the CommiUee’s

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EPITOME.

[Jan.,

asylums seem to be also on the descending scale, but of course without
knowledge as to what Leavesden, Caterham, and similar asylums are
doing no certain conclusion can be drawn about the occurrence of
insanity in the area. A curious fact is pointed out: the proportion
of the chargeable insane on the north side of the Thames is 5’66 and
4*69 on the south side, in each case per mille. The explanation
suggested is that the more crowded areas which are typically lunatic-
producing are to be found to the north of the river. The readmissions
of patients discharged as recovered bear a percentage in the recoveries
of between 27*42 and 29*18 during the last eleven years when the
recoveries during the whole of those years are taken into consideration.
But of the recoveries during the same eleven years between 1174 and
13*47 were readmitted within twelve months of their discharge. It
would be of immense service if the original form of mental disease
in these relapses could be given and summarised. We are very glad to
see that the Committee has resolved to adopt the scheme of statistical
tables now brought out by the Association. It is possible that in some
respects these tables are open to criticism; in fact, it is inconceivable
that with such extensive and intricate points to work up and decide
there should be complete agreement as to the best method of dealing
with such a complex subject; but harmony is preferable under any circum¬
stances to discord, and we feel sure that if the tables are worked in
each asylum in general harmony the lunacy statistics of London will
acquire a value that they never have had and that cannot be surpassed
elsewhere. The Committee points to the undoubted necessity of
getting reliable information as to causation, and complains of the
paucity of information supplied by the authorities of Poor Law in¬
firmaries when patients are transferred from them to the asylum. This
should not be, and it would not be if those responsible woke up to the
fact that the heaviest burden that comes on the rates can only be
successfully attacked by getting to the root of the matter. Curiously
enough, what appears to us to be the best suggestion for meeting the
difficulty comes from one of the Committee’s own officers, Dr. Stansfield,
who thinks that an experienced medical officer could well be allocated
to this work for two years or so.

Building still goes on apace. The Report contains useful drawings
of the new Long Grove Asylum, to which Dr. Bond has been lately
appointed, to the hearty contentment of the Association. His appoint¬
ment may be taken as a practical endorsement of the Association’s
choice of him to follow Dr. Robert Jones. One principal feature of
the design of Long Grove is the employment for the main building of
connecting passages simply covered and not enclosed. There are
many villas included in the plan, which, in general, follows Messrs.
George T. Hine & Co.’s lines. At Bexley a hospital is being built
for male admissions. At Colney Hatch several villas are being planned
to take the place of the unhappy iron buildings. These are all to be
specially allotted, chiefly to diseases—phthisis, dysentery, general
infirmities, etc.—and one for acute cases. An eleventh asylum is
called for, and preparations are being made for its erection. This
is to be built on the vacant space at Horton. On the part of that
estate which has been allotted to Long Grove a considerable

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amount of work has been executed in the shape of gardens, etc., by
a body of the “ unemployed.” It was not to be expected that the
value per man of these workers should be as great as would be the
case with outdoor labour, but there must be some benefit attaching to
the system when looked after properly.

With regard to the financial side of the management of their huge
trust the Committee has taken what appears to us to be a very wise
step in suggesting that the services of the Council Comptroller should
be given towards independent audit and checking of accounts, stores,
etc. It will take a large amount of responsibility off the shoulders of the
Committee, while the checking by a professional checker cannot but
tend to close, economical, and honest work. At the same time, the
Committee points out that the powers of report which the Finance
Committee of the Council propose to ask for will not absolve the Com¬
mittee itself from fulfilling its statutory duty to the Guardians from
whom the maintenance rates are called up by it.

The Commissioners* reports are now for the first time grouped
together, instead of being put under the head of the respective asylums.
There is nothing in them calling for special comment.

The reports of the Medical Superintendents are grouped in the
same convenient manner. In them are points of interest as follows :

At Bexley Dr. Stansfield has had a complete personal and family history
made, as far as possible, in each of the 494 admissions. In practically
three fifths a complete history was obtained, in another fifth the history
was only incomplete, and in the remaining fifth no history at all could
be obtained.

Dr. Stansfield finds that out of the 302 histories 56*9 showed either
insane or neurotic history, and he is satisfied that even this large pro¬
portion falls short of the truth.

“ There is a floating mass of degeneracy in the population which is
constantly augmented by the victims of social vice and its satellites,
syphilis and drink, and from this mass we derive the bulk of our asylum
population, fill our prisons, and supply our ‘ unemployable *; and that
this is increasing at a faster rate than the normal population is, I think,
indicated by the statistics of the Lunacy Commissioners as to the
relationship of certified insane to the total population, which show that
the increase of population in the nine years ended January 1st, 1905,
was io*8 per cent ., whilst that of the number of certified insane has been
24*2 per cent . in the same period. I believe that one important factor in
the disproportionate increase is the lowering birth rate of practically all
classes except these degenerates.”

He points out that the upper and middle classes are driven by
motives of ease or economy to limit production, while the degenerates
care not for consequences. We do not think that perhaps the most
mischief is done by degenerates marrying or cohabiting with degenerates.
The more this occurred, the greater would be the tendency to extinction
of the class. It is the half-degenerate marrying either his equal or even
his superior that will in the end produce a larger number of undesir¬
ables. He hints at the question of sterilisation becoming more pressing.
Sterilisation is a splendid abstract principle, but the application thereof
to practical purposes is many generations off. There is a very extensive

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EPITOME.

[Jan.,

etiological table given by him that would rejoice the heart of the late
Statistical Committee. The correlations of fifty-six factors with each
other are set out and form an interesting study. Another very useful
table gives the factors which were assigned on admission of those cases
which recovered. Very full statements and correlations of the causes
of death are likewise produced.

Dr. Robert Jones also adverts to the history difficulty. “Thedifficulty
of obtaining full and correct 4 family histories * in cases of insanity can
only be fully appreciated by those engaged in the work. Such
histories are fragmentary and often apocryphal, and when obtained are
difficult to classify. The fact that the human organism is a series of
complex units, and that each of these may be either dominant or reces¬
sive, shows the necessity for a scheme of classification in regard to
heredity which will give the history of collaterals as well as o£ ascendants.”

He emphasises the importance and quantity of the training work done
among the attendants, and he quite rightly points out that the higher
the scope of such training the more likely is it that the brighter minds
will come in under it.

Dr. Bryan alludes to the unfortunate murder case at Horton,
which has already been dealt with by Dr. Mercier (October No., 1905,
p. 790, et seq.).

“ The jury said that they 1 desired to add a recommendation that care
should be taken that such letters as those written by the woman should
not be allowed to go out of the asylum.* The learned Judge said 4 that
he was most anxious in any remarks he made not to say a word against
any individual, and he was sure the jury did not mean to cast any
reflection on any individual. The letters, however, should not have got
out, and the proper authorities should make careful inquiries into the
matter and see that it did not occur again.*

44 The question of the suppression of patients* letters has always been
a difficult one, and the modern practice in this respect is, and rightly so,
to give the unfortunate patients the fullest facilities for writing to their
friends, and, indeed, it has even been questioned by the highest
authorities whether any patient*s letters whatsoever should be suppressed.
Apart from this altogether, letters written by the patients to their
friends are of great value as affording them information as to their state
of mind, and all former experience would have tended to show that the
receipt of letters of similar character to those in question would have
produced even increased care and vigilance on the part of friends when
visiting. It is extraordinary that, although the contents of the letters
were apparently known to the relatives, other than the husband, no
information was given by them that these letters were having any effect
on him, and no request was made that they should not be sent. In any
case, however, the question of interception of patients* letters is
approached by every asylum medical officer with the greatest care, and
only those who are intimately connected with asylum management can
form a correct judgment in the matter. I see no justification in sup¬
pressing a letter from a wife to her husband, who, as has been well said,
has surely a right to know from her letters in what state of mind she is,
and in this opinion I am supported by my colleagues throughout the
country.**

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At the Colony Dr. Bond has prepared some special tables which
afford valuable information about his epileptic charges. With regard to
hereditary predisposition, we are somewhat surprised to see that in the
cases where history could be got of the antecedents of parents and
grandparents the proportion of those relatives in the ascending line
who had been insane or epileptic to those who had been neither insane
nor epileptic is as 19 to 185. The proportions for the parents only are—
for the father 7 to 42, for the mother 4 to 40. We should have looked
for more evidence of direct transmission. Apparently the two disorders
have about equal causative value, while heredity of alcohol ranks at
about half of either. Personal alcoholism was found in about 18 per
cent. In the larger number of the cases the duration of epilepsy previous
to admission was considerable, more than half being over fifteen years.
But of course this might be an accident depending on the selection of
the cases for admission. Apart from congenital cases, about two thirds
of the admissions were those whose epilepsy commenced before the age
of twenty. Dr. Bond gives a full table of correlations of etiological
factors on the lines of the Association’s Table B, 8. In time value
must attach to this as supplying means for ascertaining what effect (if
any) is caused in the incidence of factors by the prevalent element of
epilepsy.

Dr. Mott’s pathological report is in the main a record of facts, and
does not contain the suggestive remarks on moot points which have
conveyed valuable teaching in former years, He analyses in consider¬
able detail the death returns and the post-mortem findings at Claybury.
We attach much value to a table in which he shows all the notable
pathological appearances that were discovered post mortem in the cases
examined. This table and the formal record of a single cause of death
(presumably the primary) in each case, together bear some comparison
with the new system of recording the etiology of the insanity admitted;
we have one principal and as many associated factors as may be found.
It is thought that the new system of death return, divided up in the
same way into principal and contributory, will tend to obviate incon¬
venience and possible error. The Report before us shows us an instance
of possible error. In the first single cause table, out of the 186 deaths
only 5 are returned as due to general paralysis. Yet the second table
shows pathological appearances of general paralysis in 43 cases, which
latter total corresponds, after allowance for a different commencement
of the year of record, with that given in the old Statistical Table 5 on a
later page. Taking the former table, as one very well might under
present circumstances, as the true guide to the principal cause of death
a reader might quite erroneously conclude that Claybury received very
little general paralysis. No doubt the apparent want of harmony arises
from the old high-and-dry question as to what primarily killed a man—
the grave but remote or the recent and otherwise insignificant. The
ejection of the terms “primary” and “secondary” in favour of “principal”
and “contributory” will surely make things easier to the scrupulous
certifier. In 98 out of 185 cases no sign of tubercle was found in
either acute or obsolescent form. Very full tabulation is provided for
ascertaining the history of each asylum for several years past in the
matter of dysentery. In time to come these records must prove to be

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EPITOME.

[Jan.,

of immense value in tracking down this fugitive malady of uncertain
genesis. The returns of last year show some recrudescence at Bexley.

In the report of Mr. Clifford Smith, the engineer, we note, among
other matters, that he valued at ;£n66 the labour of patients placed at
his disposal by Dr. Stansfield at Bexley. He states that the standard of
interior repair is being more effectively maintained by reason of such
labour being available, and he looks for a reduction in the cost of such
repairs in the course of the next few years. He finds that the new
pumping plant at Colney Hatch has delivered water at 3d. per 1000
gallons, this sum including repairs to machinery. It is about id. under
his estimate. At the central station the 1000 gallons cost about 6id. 9
after knocking off the rates, taxes, and insurance.

The average weekly maintenance per patient in the county asylums
works out at 10s. 11*3 d.

The Committee refers with great regret to the retirement on account
of ill-health of Dr. Alexander from the control of the Hanwell Asylum,
which he has held for many years. The Association will feel the same
regret, we are assured. A full pension appropriately backs up the kindly
words in which the Committee speaks of his service.

Somerset ( Cotford ).—The most noticeable matter in this Report is
the production of the year’s statistics mostly in the new tables adopted
by the Association, and we must congratulate Dr. Aveling on his being
the first of the English county and borough asylum superintendents,
as far as we know, to tackle the system. It must have meant a large
amount of trouble to work all the material up before the way was cleared
by new registers and other means. Of course it is quite too early to
review or criticise the changes in tabulation which the Committee
supposed would be followed by advantage. There are fresh points,
however, that may repay consideration. For instance, in the table
showing the duration of particular forms of insanity on admission before
death intervened, it is curious to find that the record of longevity
attaches to a congenital with epilepsy who counts over fifty years of
mental deficiency and is followed by a case of acquired epilepsy of over
forty-five years’ insanity. The table from which this is taken (D 3)
would appear to further the inquiry into the “expectation of life” in
insanity, of which a good deal was heard when Sir William Gowers
started a debate on the subject.

Stafford (Cheddletoti ).—The Commissioners note that in 173 deaths
no bed-sore was found post mortem. Again we say that no record of
general nursing can possibly show anything better than this evidence of
care bestowed day by day and night by night on paralysed, resistive,
and apathetic mortals in asylums like this. Dr. Menzies, after careful
inquiry, is enabled to attribute almost 50 per cent, of the admissions to
social vice, comprising syphilis and alcohol. In 144 cases in which a
history could be taken the former contributed twenty-seven and the
latter thirty-five instances of direct causation. In discussing the incidence
of tuberculosis, Dr. Menzies gives the result of careful examination of
647 cases, in many of which several examinations have taken place.
Positive physical signs of tubercle were found in 123 and doubtful signs

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I 907 .] ASYLUM REPORTS. 207

in 133. A large number were injected with Koch’s old tuberculin “with
the surprising result that only 8*8 per cent failed to give positive re¬
action.” A parole navvy gang has been organised among the convales¬
cent patients, which has been most successful. These men work, for
the final month or so before recovery, the ordinary full labourer’s hours
without the supervision of an attendant, but under the general instruc¬
tions of the foreman ganger. They begin the day with a good meat
breakfast, and have other privileges, especially that of going home from
Saturday to Monday. Consequently, when they are discharged they are
already in good training for hard labour instead of being fat and flabby.

East Sussex .—After several months of complete immunity from
dysentery, a female patient who had been in the asylum for a year
developed this disease, which ran a rapid course to death. No other
case occurred within reasonable time either before or after, and Dr.
Taylor considers that a case with such a history as this suggests that
there must be some other method of contracting the disease besides
direct infection. He is convinced that the only way to prevent out¬
breaks is the immediate and permanent isolation of any case that has
been once attacked. The satisfactory recovery ratio, which would have
been greater but for the removal of private patients before recovery was
actually established, is attributed to the hospital permitting more indi¬
vidual attention being given to recent admissions. The appointment
of a training mistress for the children has proved a considerable success,
the work, which is carefully graduated to the intelligence of each child,
apparently serves to slowly develop what understanding there may be.

Worcester .—Here, too, the Commissioners note the entire absence of
bed-sores. Dr. Braine-Hartnell divides, quite properly we think, the
hereditary etiological influences into two: direct, which he terms
“hereditary influence,” and indirect or family predisposition. The
ratios for these respectively are 12 and 18 per cent . He adds a column
of ratios of incidence for all causes, which is very useful. Among the
admissions were two little girls, aet. 4 and 5. There must be some¬
thing wrong if no more appropriate place than the asylum can be
found for such little tots.

Wiltshire .—Here there has been a steady fall in the admissions for
the past five years, those for last year being 141 against 189 in 1900.
This has not resulted from the insane of the county being detained
elsewhere, with friends or in the workhouses, etc. Dr. Bowes notes
that the type of the insanity on admission tends less to the maniacal
and more to the delusional, the prospects of recovery being correspond¬
ingly prejudiced. He entirely declines to take on nurses from other
asylums, and he thinks that if all superintendents pursued the same
practice beneficial discouragement would be given to the spirit of rest¬
lessness which all deplore among the junior female staff. Being asked
by his Committee to make a report on the insanity of the county in
relation to the needs for accommodation, Dr. Bowes goes into the
matter in a separate document His Report contains some interesting
points. The population of the county has increased by about 3k per

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EPITOME.

[Jan.,

cent . in the ten years 1891—1901, while the insanity in the same time
has increased 20 per cent . The most remarkable increase is in the large
borough of Highworth and Swindon, where, while population increased
in the ten years about 25 per cent, , the number of the chargeable insane
was more than doubled. One would think that a careful inquiry on the
part of the local authorities might lead to some suggestion of a cause
for this. At all events, some approach could be made to a decision as
to whether the increase was due to administrative reasons, such as
longer detention or greater inpouring of senile dements, or, on the other
hand, to actual increase of occurring insanity. It is possible to think
that as this is a town that has grown under the eyes of many still living,
that as it is a town that has grown rapidly but evenly under satisfactory
hygienic circumstances and that as in it exists a continuous industry
which forbids anything like distress to the bulk of inhabitants, a
thorough inquiry into the history of each case from year to year for
some time back would amply repay the trouble taken.

We are quite with Dr. Bowes when he makes the following suggestion,
and we hope that should it be accepted in his time he will do his best to
keep the hospital sacred to mental disease, and not let it be muddled up
with physical infirmities. In speaking of chronic dements he says :

“ For these and other reasons one cannot but feel they are better off in
large institutions containing special arrangements conducive to their
future good; but in place of building special institutions for their accom¬
modation, the right and apparently preferable course to adopt would be
to appropriate existing asylums to the housing of the incurable class,
and the provision of small mental hospitals, equipped with every appli¬
ance and convenience, for the treatment of acute mental disease.
Special hospitals now exist for nearly every special disease, and that it
will come to the establishment of such hospitals for the treatment of
insanity, one of the most to be deplored of all diseases, there can be no
doubt.”

Some Registered Hospitals .

Bootham Park .—Dr. Hitchcock relates with gusto that on last Boxing
Day he saw a man whom he thought to be a stranger sitting by the
fire in one of the wards, smoking his pipe with the patients, and seem¬
ing to be very pleased with himself and his surroundings. He turned
out to be a former patient, who lived some forty miles away. He had
given his men a holiday, and finding it dull by himself, had come over
to spend the evening with his old friends. He also finds that ten of
his nurses and nine of the servants have left to be married in the last
two years. His head attendant has been presented with the Asylums
Workers Association’s gold medal for forty-four years’ good service.
Other attendants have put in thirty-seven, thirty-three, twenty-nine
years, etc. We should imagine that there are elements of comfort
here for both patients and staff. The recovery rate is high on both
sides—sixty-nine and fifty-seven.

Wonford House .—The Committee and Dr. Deas are to be much
congratulated on the last payment in extinction of a heavy debt having

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1907.]

been made during the year. Some time back we adverted to the
burden thus thrown on the management. The amount so released
will be available for increasing the already large amount of assistance
given to the needy insane. The Committee refer in generous terms
to the fact that Dr. Deas has now given them twenty years* splendid
service. Referring to the large proportion of melancholia cases which
he took in last year, he adverts to the unsatisfactory nature of the
cases that are both insane and hypochondriacal. He had eight of
them with suicidal tendencies. This is the chief difficulty; with
purely melancholic cases we know where we are ; they must always be
treated as such. But with the other class, especially when we suspect
that a good deal more than necessary is being made of the illness, it
is quite easy to be deceived as to the reality of the tendency to self-
destruction, attempts at which are generally the result of a fit of
temper.

The Retreat , York .—Scarlet fever is always a most unpleasant visitor
in an asylum, but is more so when the Medical Superintendent is taken
with it. This was Dr. Pierce’s fate, he and four others falling to it on
the same day. Thanks to strict measures, all did well, and no other
case followed. As usual, rigid inquiry failed to discover the source of
infection. We are glad to see that Dr. Pierce has worked out his
statistics for 1905 on the new lines. He produces an almost complete
set of the tables lately adopted. Dr. Pierce, like Dr. Robert Jones, finds
that strict training tends to improve the standard of applications for
employment, but chiefly because it discourages those who are not
serious in their intentions.

Some Scottish District and Chartered Royal Asylums .

Aberdeen (.Kingseat ).—It is, indeed, most sad that after the writing
of this the first Report of a new asylum, Dr. Angus should have been
cut off in his prime; but the numerous entries made by his Committee
and the Commissioners show that he has left behind him, as a memorial,
an institution of a novel character that apparently leaves nothing to be
desired in efficient and easy management. It is true that much the
same ideas that are found at Kingseat are to be found elsewhere.
Alt Scherbitz has impressed itself in other areas as well as in this; but
it is something for the Committee to say that this new asylum on a new
principle will cost but ^250 per bed for land, buildings, equipment, etc.
To this end Dr. Angus must have helped much. Then it is recorded
that the cost of the staff is less than the average for Scotland in spite
of the presumed relative expensiveness of the segregational system.
The secret of this no doubt lies, as is pointed out, in the larger employ¬
ment of women, who are content with less pay than that which their
male colleagues accept. The general cost for other matters is not
above the average. The future of this asylum will be watched with
much interest, as it is the first of the kind that has been opened. The
principal building is, of course, the hospital, which holds fifty of each
sex. It is intended for the physically sick as well as for recent cases.

LIII. 14

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EPITOME.

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It appears to be admirably designed for convenient working. The only
point of criticism that we offer (beyond, perhaps, a suggestion that it
would have been advisable to give a separate entry to the ward for
excited cases instead of a passage through that for the depressed) is the
attachment of small infectious wards on each side to the building itself.
We know that this is a common occurrence in Scotland, but we cannot
believe that any amount of disinfectants would form an efficient barrier
to the passage of microbes, say of smallpox, at such close quarters.
These wards are but ao ft. distance from other wards or a main
corridor. We note that one of the Commissioners recommends that
they should be used for cases of phthisis till they are wanted for their
special purpose. He adverts to the desirability of segregating all
tuberculous patients. What would occur, then, if the phthisical in¬
habitants of the wards were to be suddenly dispossessed by a fever
case ? One would think that it would be better to keep these wards for
phthisis and to erect a small isolation hospital in the grounds. To
one remark of a Commissioner visiting the asylum we must take exception.
While praising the rigid economy of the Committee who had charge
of the building, he states that the main cost of asylums, as of other
buildings, is in the external architecture, and not in the finishing or
furniture. This probably is the case in the North, but it certainly is
not so in England. We know several of the later asylums farther South
which have a quite unpretentious outside, but have cost much per bed.
As we have pointed out not long ago, the final cost must be settled by
the amount spent for good reason on outside matters, such as cottages,
by the sinking of capital with a view to saving yearly repairs. Without
a full statement of all “associated conditions” the price per bed is
likely to be somewhat fallacious for purposes of comparison.

Argyll and Bute .—Here there is a steady fall in the admission rate.
This has been going on since 1898. There does not seem, however,
to be any notable decrease in the average number resident Sixteen
were readmissions after an average period of absence of four years and
one month. It is not stated how many of these were recovered on the
first discharge. In no case is alcohol assigned in any form as a pro¬
bable cause.

Crichton Royal Institution .—The directors do the honour to Dr.
Rutherford of stating that in his absence on account of severe illness
they were unwilling to proceed with the important work of completing
the new pauper asylum. No less than 10 per cent of the admissions
were those of voluntary patients, whom Dr. Rutherford encourages,
while setting his face steadily against dipsomania cases. He asks
himself the question whether the large number of patients that he
sends out recovered are likely to remain well. He takes inheritance
as the chief guide in that matter. He lost one old lady, aet. 96, after
sixty years* residence. She was the last of those nominated by the
original foundress of the institution. The recently provided sanatorium
for tuberculous cases is held to have done good work in reducing the
amount of that disease in the asylum. Dr. Rutherford finds that re¬
covery among the pauper admissions is not only promoted but expedited

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ASYLUM REPORTS.

21 I

1907 .]

by the reception hospitals, into which the majority of cases go direct.
There are only ordinary handles to the doors in these houses, no locks
being used.

Royal Edinburgh Asylum. —Dr. Clouston, after a period of critical
hesitation, announces in his Report his entire acceptance of the microbe
theory of general paralysis evolved by Dr. Ford Robertson and Dr.
M’Rae. Since he has had every opportunity of inspecting the work of
these two pathologists on the spot, his adherence to the new belief will
be taken as a valuable support to it, for many men who have neither
time nor opportunity for examination themselves will be quite content
to rely on Dr. Ciouston’s deliberate judgment. What a vista the
theory opens up ! Dr. Clouston with all justice claims credit for the
work carried on for some years now by the Scottish Asylums Labora¬
tory. He states that 20 per cent, of his pauper and 10 per cent.
of his private admissions are traceable to alcohol, and he asserts
that education is the best remedy for the evil. He recommends
that children should be taught more of the effects of alcohol as a branch
of knowledge that will help in future life. One has only to see the
immense good done by voluntary bodies working among the young,
such as Bands of Hope, to feel sure that the recommendation of a
routine instruction in this matter is absolutely sound. The total of
general paralytics admitted is very heavy—64 in 428, but the fact that
females number 38 to 26 of the males must be a record.

Glasgow (Gartloch). —Fifty.cases have been boarded out, and to that
extent accommodation has been saved. But Dr. Parker points out
the fact that this discharge of the quiet and harmless removes so much
useful padding which would obviate much friction between irritable and
excitable cases. He advocates the trial of a system of boarding out in
village groups under proper supervision, so that a due proportion of
these latter cases should be sent out for the good of themselves and
their irritability as well as for that of those whom they would leave
behind. The number of cases with active tubercle have diminished so
much since the institution of a sanatorium that this building has been
devoted to general paralytics and other such folk, while smaller isola¬
tion wards have been found elsewhere for the phthisical.

Govan .—A very noteworthy matter in this Report is the abolition of
Table X of the old series and the substitution of what is practically a
modified admission register devised by Dr. Watson. Though Dr.
Watson states in his Report that these new registers (there being one
for each sex) are intended to take the place of the etiological tables,
they go very much further than this. Against the serial number of each
admission are given, in the following order, age, date of admission, date
of discharge, and death (if it has occurred before report, together with
in the case of discharge the state of mind on discharge), social condi¬
tion, form of insanity, heredity, associated conditions—(1) existent, (2)
pre-existent We have no hesitation in saying that this is a very
great step forward. It is admitted that for purposes of scientific
inquiry the ideal is a register giving certain information about each of a

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212 EPITOME. [Jan.,

class of individuals and letting those who care to do so elaborate the
recorded facts. But to make the ideal generally convenient there must
be use of certain terms of a certain individual value and meaning, all
agreed upon generally. Now, Dr. Watson pointedly rejects “ cause”
and “etiological factors” and adopts “associated conditions.” The
Statistical Committee seems to have been more chary of rejecting all
idea of etiology, but it apparently recognised that there were several
“ conditions ” often accompanying insanity, which, though they might
not be classifiable under strict etiology, might be taken to have some
possible influence. A middle course is taken in the Association’s tables
therefore. It is possible that as Dr. Watson’s register stands one might
work its contents out on the lines of the new table B 8, but it would
not be possible to adjust it to B 7, in so far that Dr. Watson avoids
putting any etiological pre-eminence in value to anything, whether factor
or condition. Can an expert never say that in any case a given factor—
alcohol for instance—has been the chief element in a breakdown?
We fancy that Dr. Clouston, for instance, has strong ideas on this point
If no attempt is made to confer a pre-eminence it follows that any
given term must acquire a fixed value wherever it appears, unless
specifically qualified. Dr. Watson has evidently felt this difficulty, for
he almost invariably qualifies alcoholism as being excessive and con¬
tinuous, moderate but continuous, and so on. As a fact, in looking
over his long lists we note that in the great majority of alcoholic cases
drink, in one or other degree, stands by itself as an associated condition.
Does not this invite a reader to regard drink as being responsible for
the breakdown in these cases ? One would say that no other conclusion
is possible. Then why should not the medical man who makes the
return and has the facts and history before him take the responsibility
of declaring that drink did in a certain number of cases act as the
determining factor ? And it is the same in all other directions ; if no
prepotence in individual cases is to be assigned to a given factor or
condition, it must assume a constant value. It will follow that sooner or
later all factors or associated conditions will have the same value in
relation to each other—lowered health and drink for instance—one
condition, one value. The only point for determination will be the
frequency with which associated conditions recur in examining a series
of cases. Taking the two conditions mentioned above, which is to be
found more often in our patients, alcoholism or lowered health ? And
which is really the more important factor ? Some differentiation between
conditions is implied by the use of the terms “existent” and “pre¬
existent,” but this does not seem to extend beyond the idea of time and
cannot be of any service in the elucidation of causation, unless some
non-natural meaning is to be read into the terms. Even this differentia¬
tion must lead to some confusion, because it would be difficult to say
that the effect of, for instance, syphilis, mental worry, etc., began or
ended at such a date as to be pre-existent and not to be existent, or
the converse. We imagine that if these two terms were withdrawn the
register would be at least as useful, and possibly less open to misreading.
But still we venture to say that the register does not help to answer fully
the question, How does insanity come ? That is a question which will
very properly demand from each and all of those who have knowledge

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ASYLUM REPORTS.

213

aod opportunity every endeavour to find an answer. After all no one
pretends that any answer of absolute accuracy can ever be given, but
the world does think that asylum superintendents can get a bit nearer
truth than it can itself, and looks for something like a definite opinion
from each of us according to our lights. Few are more fitted to express
such an opinion than Dr. Watson. One sympathises a good deal with
those who find a conscientious difficulty in making an attempt with
insufficient or questionable material to supply each case with a cause.
But it is possible, we think, to begin at the other end and take causes
or factors or associated conditions and endeavour to see how many fell
under their influence and in what degree. If Dr. Watson, then, were
to add to his register a simple statement that in such or such a pro¬
portion of admissions he believed that a particular condition, or event,
had appreciable influence in bringing about attacks of insanity, then
we think that his registers, plus such a statement, would very nearly
approach the ideal. We are, indeed, very anxious that none of these
remarks shall be considered as carping or depreciatory, for such an
attitude would be highly improper in view of the thought and trouble
which Dr. Watson must have given to devising and working out this,
the most important private addition that has been made of late to our
statistical inquiries.

James Murray's Royal Asylum .—The statistics of insanity are per¬
haps more lacking in precision of terms than are those relating to any
other human affairs. Chief among the elastically uncertain stands the
term “ recovery.” Yet on it depends the true history both in the posi¬
tive and negative sense of our fight with the disease. Dr. Urquhart
gives his interpretation of the term, and we consider that it is as fair
and accurate as can be looked for :

“The number of readmissions (15) was unprecedented in the his¬
tory of the asylum, and the number of those suffering from recurrence
of mental disorder (22) was also disproportionate. In these obser¬
vations the word ‘ recovery * is used to indicate those in whom there
is re-establishment of mental soundness permitting of the return of the
patient to his place in the world without requiring the care and super¬
vision of others. The ‘ lucid interval ’ may prove to be of lifelong
duration, it may last for years, or only for months. Doubts have been
expressed regarding the propriety of liberty in many of these cases. It
has been represented as a wrong to the lieges. This is a new phase of
opinion. For many years we have been accustomed to accusations of
undue detention in asylums, elaborate safeguards have been devised to
protect the insane from that evil, and now the tide of opinion seems to
be setting in the contrary direction. As the law stands there is no
longer authority for the detention of a person after he ceases to be
insane; and, in the great majority of cases, it would be an intolerable
hardship to be detained indefinitely because of a possibility of untoward
remote consequences. No doubt there are those, including many who
have never been under custodial care, who should be limited in liberty
of action under revised legal enactments; but the advocates of ex¬
treme measures will have to be content with less Spartan remedies than
they formulate. The practice of discharge on recovery, or even on

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NOTES AND NEWS.

214

[Jan.,

improvement, may entail occasional hardships, but on the whole it is
appropriate to existing conditions.”

Roximrgh. —Dr. Carlyle Johnstone is to be congratulated on the
completion of his male hospital, which with smaller additions and
alterations on the other side will finally relieve him and the Committee
from all the drawbacks of overcrowding. The hospital will contain
ninety-five patients. Its cost, including furnishing, works out at about
^216 per bed. The infirmary, designed for eighteen patients, will be
staffed by night as well as by day with female nurses. The readmissions
were fifteen out of sixty-six admissions. The average period of respite
was nearly eight years, a longer absence than usual.

Part IV.—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT
BRITAIN AND IRELAND.

A Quarterly Meeting was held at 11, Chandos Street, London, W., on
Thursday, November 15th, 1906, Dr. Robert Jones, President, in the Chair.

Present. —Drs. H. T. S. Aveline, Fletcher Beach, G. Fielding Blandford,
C. Hubert Bond, David Bower, A. N. Boycott, F. St. John Bullen, James
Chambers, W. C. Clapham, R. H. Cole, Maurice Craig, Thomas O'C. Donelan,
F. W. Edridge-Green, F. H. Edwards, J. Alfred Ewan, C. H. Fennell, Bernard
Hart, W. H. Haslett, H. E. Haynes, C. K. Hitchcock, G. H. Johnston, Robert
Jones, Richard Legge, W. H. C. Macartney, P. W. Macdonald, A. MacDougall,
T. W. McDowall, W. F. Menzies, C. A. Mercier, C. S. Morrison, H. Hayes
Newington, E. S. Pasmore, R. N. Paton, M. Eden Paul, W. Rawes, G. M.
Robertson, J. Scott, H. Smalley, R. Percy Smith, P. C. Smith, J. G. Soutar, R. H.
Steen, W. C. Sullivan, T. Seymour Tuke lohn Turner, Frederick Watson, L. A.
Weatherly, E. B. Whitcombe, T. Outterson Wood.

Apologies from Drs. J. F. Briscoe, T. S. Clouston, A. R. Turnbull, and A. R,
Urquhart.

Visitors. —Drs. Purves Stewart and T. A. Williams (Washington, B.C.).

The minutes of the last meeting, having been printed in the Journal , were
taken as read.

The President made feeling reference to the loss by death of the Association’s
former President, Dr. Oscar Woods, of Cork. He would be remembered as a
distinguished and able past-President of the Association, and one who conducted
its affairs with dignity. He was very friendly, and would be missed very much at
the meetings. He (the President) had taken upon himself the responsibility of
writing to his widow, on behalf of the members, to convey their sympathy with
her in her sorrow. Mrs. Woods, in her letter of acknowledgment, said the death
of her husband was an irreparable grief to her, coming as it did so soon after the
loss of their eldest daughter, which occurred just previously to her husband’s
decease. The Association, he said, had lost also by death two other members,
namely. Dr. Craddock of Gloucester, who was the President’s old fellow-student
at St. Bartholomew’s Hospital, and was well known as an excellent asylum super¬
intendent and administrator; and Dr. R. S. Stewart, of Glamorgan, one of the
most promising of the younger members of the Association and a very ardent
student of social science. The Council had decided to convey to the relatives of
those gentlemen the Association’s sympathy with them in their sorrow. The
President said that he was also reminded that Dr. Spence, a former President, had
met with great grief in the loss of his wife, who was personally known to the

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NOTES AND NEWS.

215

I907-]

President as an amiable and able lady. Those melancholy events had happened
since the annual meeting, at which occasion he had been pleased to be able to
state that for twenty years not one of the Association’s Presidents had died.

Statistical Tables. —Dr. Hayes Newington announced that the new registers, as
proposed by the Association and adopted by it, had received legalisation in England
and Wales by having been laid on the table of the House for a sufficient time.
The forms were therefore now statutory in this country, and no doubt members of
the Association would receive information from the Lunacy Commissioners on the
subject.

Election of new members .—The following candidates were elected ordinary
members of the Association (Drs. R. H. Steen and D. J. Thomson acting as
scrutineers): Baird, Harvey, M.D., Ch.B.Edin., Assistant Medical Officer, London
County Asylum, Colney Hatch (proposed by W. S. Seward, Robert Jones, and
H. Hayes Newington ); Clague, Henry John, L.R.C.S., L.R.C.P.Edin., Assistant
Medical Officer, Glamorgan County Asylum, Bridgend (proposed by J. McGregor,
H. Hayes Newington, and Robert Jones); Eager, Richard, M.B., Ch.B.Aberd.,
Assistant Medical Officer, Devon County Asylum, Exminster (proposed by Arthur
N. Davis, H. Hayes Newington, and Robert Jones); Fielding, Saville James,
M.B., B.S.Durh., Bethel Street, Norwich (proposed by D. J. Thomson,
S.J. Barton, and R. H. Steen); Forster, Reginald Arthur, M.B., Ch.B.Aberd.,
Assistant Physician, The Royal Asylum, Aberdeen (proposed by H. de Maine
Alexander, H. Hayes Newington, and Robert Jones); Fortune, John, M.B.,
Ch.B.Edin., Senior Assistant Medical Officer, Devon County Asylum, Exminster
(proposed by Arthur N. Davis, H. Hayes Newington, and Robert Jones);
Hannan, George James, L.R.C.P.&S.Edin., L.F.P.S.Glasg., Assistant Medical
Officer, County Asylum, Chester (proposed by A. Lawrence, G. H. Grills, and
Robert Jones) ; Leggett, William, B.A., M.B., B.Ch.Dubl., Assistant Medical
Officer, Kent County Asylum, Maidstone (proposed by H. Wolseley Lewis, H.
Hayes Newington, and Robert Jones) ; Lowry, James Arthur, M.B., B.Ch., B.A.O.,
R.U.I., Assistant Medical Officer, Middlesex County Asylum, Napsbury (proposed
bjr T. j. O. Donelan, A. E. Patterson, and H. R. Steen) 5 McDowall, Colin Francis
Frederick, M.B., B.S.Durh., Assistant Medical Officer, City Asylum, Newcastle
(proposed by T. W. McDowall, Mary O’Brien, and G. R. East); Moore, Francis
Joseph, L.R.C.P.&S. Ireland, Assistant Medical Officer, London County Asylum,
Banstead, Sutton, Surrey (proposed by D. Johnstone Jones, Robert Jones, and
H. Hayes Newington); Phillips, Nathaniel Richard, M.R.C.S., L.R.C.P.Lond.,
Assistant Medical Officer, London County Asylum, Banstead, Sutton, Surrey
(proposed by D. Johnstone Jones, Robert Jones, and H. Hayes Newington) ;
Rowan, Marriott Logan, B.A., M.D., R.U.I., Assistant Medical Officer, Derby
Countv Asylum, Mickleover (proposed by Richard Leggc, A. C. Nash, and Bedford
Pierce); Scanlan, John, L.R.C.S.Edin., Assistant Medical Officer, Devon County
Asylum, Exminster (proposed by Arthur N. Davis, H. Hayes Newington, and
Robert Jones); Sievwright, Henry Gates, M.R.C.S., L.R.C.P.Lond., Assistant
Medical Officer, Monmouth Asylum, Abergavenny (proposed by J. Glendinning,
H. Hayes Newington, and Robert Jones) ; Turner, Frank Douglas, M.B.Lond.,
M.R.C.S., L.R.C.P., Medical Officer, Eastern Counties Asylum for Idiots,
Colchester (proposed by C. Caldecott, H. Hayes Newington, and Robert Jones).

Report on the International Congress on the Care op the Insane,
held at Milan in September, 1906.

The President said it would be within the recollection of members that an
International Congress on the Care of the Insane was held at Milan in the
autumn. Dr. Percy Smith was a member of the committee in England to arrange
for papers to be read and for inviting a certain number of British members to take
part in the Congress. Dr. Percy Smith was present at that gathering, he held
several meetings at his house preparatory to the Congress, and papers were pre¬
pared by members of our own Association and were read at Milan. Dr. Percy
Smith had kindly consented to communicate a short account of the Congress and
its doings.

Dr. Arcy Smith then read a report of the proceedings at the Congress.

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216

NOTES AND NEWS.

[Jan.,

Presentation of an Illuminated Address to the President.

Dr. Outterson Wood said that before passing to the consideration of the next
item on the agenda, he would like to ask the attention of members to a matter of
which no notice had been given. When Dr. Jones was elected President of the
Association, it conferred upon him the highest honour it was in its power to
bestow. But it was felt that some further recognition was due to him for his
long and valuable services as General Secretary. It was accordingly resolved
that he be asked to accept some more tangible proof of the very high appreciation
entertained by the members of all the excellent work done by him during the past
nine years. And it was decided that it should take the form of an illuminated
address on vellum. Unfortunately, it was not ready in time for the last meeting,
but he had now much pleasure in presenting it, on behalf of the Council and
members whom the President had so well and faithfully served. They trusted
that as the ever-rolling tide of time bore him along to what it was hoped would be,
for him, a happy and prosperous future, he would look upon that token of regard
and esteem, and remember with feelings of satisfaction the sincere and hearty
good wishes of every one of his fellow-members which accompanied it. (Applause.)

(Dr. Outterson Wood then handed the address to the President.)

The President said, in response, that he felt deeply touched by the very kind
remarks which had just been made by Dr. Outterson Wood concerning his
(Dr. Jones's) services to the Association. He had no idea that anything of the
sort was either on foot or was about to be presented to him, and therefore it had
come as an extremely happy surprise to him. He was quite certain he did not
deserve it. (No, no.) He had arrived, through members' kindness and considera¬
tion and confidence in him, at the highest point of honour which the Association
could confer, and he could only say that in his own humble way he would
endeavour to do justice to their choice. He could say that for nine years he had
not missed a single meeting of the Association or a single Council meeting, with
the exception of one annual meeting—that at Cork, which he was unable to
attend owing to what was known in the asylum service to require his special
attendance, vs*., an adjourned inquest, which happened to be fixed for the particular
day of the Association meeting. From the bottom of his heart he thanked Dr.
Outterson Wood and the members generally for the kind way in which they had
considered his very humble services. He would be able to keep the address with
feelings of very considerable pleasure and satisfaction, and he would not forget
the verv kind words in which the presentation had been made. (Applause.)

Dr. R. Welsh Branthwaite (H.M. Inspector under the Inebriates Act) read
a paper entitled “ Drunk and Disorderly,” which was subsequently discussed by
the President, and Drs. G. H. Savage, Outterson Wood, Mercier, Scott, Sullivan,
Seymour Tuke, G. M. Robertson, Crochley Clapham, and Tom A. Williams
'Washington, B.C.).

Dr. Purves Stewart contributed a paper, illustrated by lantern slides and a
microscopical demonstration, on “ Diagnostic Value of Examination of the Cerebro-
Spinal Fluid.” It was discussed by the President and Drs. D. J. Thomson, Cole,
and Mercier.

Representation of the Association on the Royal Commission upon
the Care and Control of the Feeble-minded.

The President stated that at the meeting of the Council that day the extension
of the scope of this Royal Commission was considered and four names of members
of the Association were selected for submission to the Home Secretary, with a
request that one or more of them should represent the interests of the insane,
through the Medico-Psychological Association, on the Commission. He thought
that some medical superintendents of asylums might be preparing evidence for
submission and would be interested in knowing that the Council continued to be
active in all matters concerning the welfare of the insane.

In the evening between thirty and forty members and their friends dined at the
Cafd Monico.

At the Council meeting, which was held at 1.30 p.m., the following members

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1907 ] NOTES AND NEWS. 217

were present: H. T. S. Aveline, Fletcher Beach, C. Hubert Bond, David Bower,
F.St John Bullen, James Chambers, Maurice Craig, Sam. Edgerley, J. A. Ewan,
Robert Jones, P. M. MacDonald, T. W. McDowall, H. F. Hayes Newington,
Bedford Pierce, G. H. Savage, R. H. Steen, D. G. Thomson, John Turner, and
T. Outterson Wood.

SOUTH-EASTERN DIVISION.

The Autumn Meeting of the South-Eastern Division was held, by the courtesy
of the Governors, at the Bethel Hospital, Norwich, on Wednesday, October 17th,
1906.

The members present were Drs. M. T. Archdall, Sami. Barton, N. J. H. Gavin,
C. Rodney Huxley, Sydney H. Long, C. A. P. Osbume, D. G. Thomson, and
K. H. Steen (Hon. Sec.)

Apologies were received from Drs. Robert Jones (President), Outterson Wood,
Ernest W. White, Tidbury, Haynes, Crookshank, and Kidd.

The wards and grounds were inspected, and subsequently Dr. Fielding enter¬
tained the members to luncheon.

The minutes of the last meeting having appeared in the Journal , were taken as
read and confirmed.

The invitation of Dr. Tavlor to hold the spring meeting of the Association at
the East Sussex County Asylum, Hellingly, on April 17th, 1907, was unanimously
accepted with much pleasure.

Dr. James Fielding, in place of reading a paper, presented, with the compliments
of the Governors, to each member, a, copy of a beautifully bound and illustrated
History of the Bethel Hospital , Norwich.

On the motion of Dr. D. G. Thomson, seconded by Dr. Osburne, and carried
unanimously, the Secretary of the Division was instructed to write a letter to the
Governors of the Bethel Hospital thanking them for the generosity of their gift.

Dr. Samuel J. Barton read a paper on “ An Epidemic of Sore Throat at the
Bethel Hospital.”

The Honorary Secretary gave a short account of an exceptional case of
cancer.

A vote of thanks was unanimously passed to Dr. J. Fielding for so hospitably
entertaining the Division.

After the meeting the members were taken to the Norfolk and Norwich Hospital
by Dr. Samuel J. Barton, Senior Physician, who generously gave up his valuable
time to personally conduct a party through the wards and museum of this up-to-
date institution.

NORTHERN AND MIDLAND DIVISION.

The Autumn Meeting of the Northern and Midland Division was held, at the
invitation of the Committee of the David Lewis Colony, at the Colony, Sandle
Bridge, near Alderley Edge, on Thursday, October nth, 1906.

In the morning members were shown over the colony and visited the various
villa residences for epileptics under the guidance of Dr. Alan MacDougall, the
Medical Director, and afterwards lunched together, at the invitation of Mr. Helm,
the Chairman of the Committee. Mr. Royle, on behalf of the Committee, welcomed
members to the Colony.

There were present fourteen members, viz. Drs. Colcott, Edgerley, Kay,
T. W. MacDowall, Alan MacDougall, Mackenzie, Nixon, Owen, Pierce, J. M.
Rhodes, Sheldon, Sutcliffe, and Trevelyan, as well as eight visitors.

Dr. Alan MacDougall presided.

The minutes of last meeting were read and confirmed.

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218 NOTES AND NEWS. [Jan.,

Drs. Hitchcock, MacDowall, and MacPhail were re-appointed members of the
Divisional Committee.

The Secretary was instructed to write to Dr. Macleod expressing the regret of
the members that he had retired from his post at the East Riding Asylum owing
to ill-health, and was unable in consequence to invite the meeting to Beverley, as
arranged.

It was decided to cordially accept Dr. Perceval’s invitation to hold the Spring
Meeting at Prestwich Asylum.

Some Remarks on Obsessions and Imperative Ideas.

Dr. Ernest S. Reynolds read a paper on “ Obsessions and Imperative Ideas.” He
mentioned the simple examples found in every-day life, such as the idea that the
gas-tap has not been properly turned off. In the shape of fixed delusions impelling
to some action they are common in the insane. But he. specially alluded to those
occurring in the purely neurotic patients, and related short accounts of such cases
which could be classified as (a) instances of over-caution often combined with the
insanity of doubt; (b) those occurring in hypochondriasis as syphilophobia;
(c) some of the fears of neurasthenia; (d) those impelling to homicide or
suicide.

Dr. T. W. MacDowall said that Dr. Reynolds’ paper brought back to his mind
a conversation with Dr. Hack Tuke many years ago. Dr. Tuke related the case
of a young schoolmaster who had struggled against an impulse to commit indecent
acts with pupils if these happened to wear knickerbockers. If the boys were dressed
in trousers the morbid impulse did not occur. The schoolmaster deplored the
impulse, begged that he might be saved from it, and asked Dr. Tuke to save him
from the commission of acts which he knew would cause him ruin and probably
lead him to prison. Dr. Tuke advised the patient to abandon his work in this
country and seek refuge in a colony with a very scattered population. This advice
was followed, but with what result he did not know.

Dr. E. Vipont Brown, of Manchester, a visitor, said it so happened he could
give the conclusion of the story. The schoolmaster did actually commit an indecent
assault and had to leave the country, and he went to a large school in one of the
colonies. Here his health broke down, he lived a hermit life for some years and
died of general paralysis.

Dr. Bedford Pierce related two cases of imperative ideas, via, a man who said
he had “ double thought ” and uncalled for ideas which arose when an object pre¬
sented itself— e.g. t the sight of a hammer suggesting a blow on the head. The
other case was a man who had an impulse to murder his child, and who made a
good recovery as a voluntanr patient in an asylum.

Dr. Sheldon and Dr. Finney joined in the discussion and Dr. Reynolds
replied.

The Etiology of the Epileptic.

Dr. Alan MacDougall read a paper on “ The Etiology of the Epileptic.” He
considered that several of the unpleasant characteristics of the epileptic are the
result of treatment, not symptoms of the disease. He urged that treatment
should not be directed solely, or even principally, against fits; but that the chief
aim should be to keep the patient, in spite of his fits, as much like his neighbours
as possible. He ascribed the benefit of colony treatment to the fact that at a
colony the epileptic can regard himself as a normal member of the community
in which he lives.

In the discussion which followed Dr. J. Milson Rhodes stated that it had
been found that epileptic patients were generally worse on Mondays, from which
it might be inferred that work and regular occupation was beneficial to them.

Dr. J. S. Reynolds dwelt upon the difficulty in persuading parents that work is
an essential for the epileptic.

Dr. Trevelyan spoke of the discouraging results of the treatment of epilepsy,
and especially referred to the injury frequently resulting from the administration
of bromides.

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NOTES AND NEWS.

219

1907 .]

The Increase in the Number of the Certified Insane, and the Decrease
in the Mortality from Diseases of the Nervous System.

By J. Milson Rhodes, M.D., J.P.

The statistics of the number of certified lunatics in our asylums, as disclosed
by the sixtieth Report of the Lunacy Commissioners, has raised a considerable
amount of alarm in the public mind, an alarm largely due to certain sensational
articles in the press, most of them evidently written by writers with an elementary
knowledge of the science of statistics; e.g., one writer states that *' insanity is
rapidly on the increase, for statistics compiled in 1859 showed that the per¬
centage of insane persons then was one in every 536 of the total population and
to-day the percentage had increased to one in every 385, nearly doubled.”

I was always under the impression that one in 385 was a ratio and not a per¬
centage ; but leaving that aside, the statistics of the Commissioners prove that the
number of the certified insane under the control of the Commissioners has
increased and nothing more. The assertion made is about one of the most
outrageous examples of the non sequitur order of fallacies that I have ever come
across. To show the absurdity of the statement, take the case of a City sana*
torium with which I am acquainted. The cases of scarlatina in 1894 and 1904
were as follows:

In Cases

Year. hospital, notified.

>894.»4i5 39<53

1904 . 3314 3988

The number of cases in the hospital rose by upwards of 700, but the number of
cases notified fell by nearly 1000.

The returns of the Metropolitan Asylums Board prove that the same change of
opinion is taking place in London. How great the change has been is seen from
the following statistics of the percentage of admissions to notifications.

Disease
Scarlet fever

1891

4684

1901

• 7889 .

Diphtheria .

2507

74*85

Enteric

27*34

4534

Typhus

70*37

850

Smallpox

55*5

9729

The public are now accustomed to make use of what are really State hospitals
for the treatment of physical disease, and there can be little doubt that the same
is true in regard to those suffering from mental disease.

I am quite aware that during the last ten years the Registrar-General’s return
shows a very considerable rise in the mortality from insanity; the figures are :

1880 1885 1890 1895 1900 1904

65 - 99 • 93 • ”9 • ! 3 <> l2 7

But if you turn to the deaths from softening of the brain and reverse the order
of years, you find some very suggestive figures:

1904 1900 1895 1890 1885 1880

67 70 . 90 120 . 124 . 127

If you add the mortality from insanity and softening together, you get the
ratios as follows:

1880 1885 1890 1895 1900 1904

192 . 223 . 213 . 209 200 194

No alienist would assert that softening of the brain had really fallen by 50 per
tent, during the last quarter of a century. Another cause must be found, and that
cause is the fact that the cases of so-called softening are now sent in large numbers
to the asylum, and so come under their proper classification in the returns instead
of under their former omnium gatherum. A reference to the (Commissioners’
Reports strongly supports this view; taking at random the forty-seventh and
sixtieth, we find the following ratios:

65 and

Years. Under 15 15— ao— *5— 35— 45— 55— upwards.

1884—1888 . 3 . a*8 J*8 8*6 10*9 . in . io‘i 9*0

1900—1904 3-3 . 6*a . 9*0 . 11*9 . 13*3 . 13*1 . 14*8

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220

NOTES AND NEWS.

[Jan.,

It is true that the ratio of patients admitted has risen from 5*4 per 10,000 to 6*5,
but a glance shows that the really serious rise in numbers takes place after forty-
five years of age. What a serious matter this is for the ratepayers is shown by
taking the totals for the same periods :

Year*

Under 15

15 —

30 —

* 5 —

35 —

45 —

55 —

65 and upwards.

1884—1888

. *98

7*3

1 359

3*99

3331

*4*0

*554

1188

1406a

1900—1904

. *66

975

1938

474 *

4747

3834

*555

2 * 5 *

*1298

Population

“ 3 *

+ * 5 *

+ 569

+ * 44 *

+ i3*6

+ * 4*4

+1001

+ 1064

+ 7*36

>o.S 45 *

3*46*

31*0*

5 * 55 *

3996*

*36**

* 943 *

* 5 * 7 *

3 *» 5 * 7 *

* 000 omitted.

Another powerful cause of the increase of the number of certified insane is the
extended gathering ground from which we now draw our cases. In 1859 the
number of private cases was 4679; in 1904 the number of private cases was 9551.
It had taken forty-five years to double the number of cases in private asylums, and
that in spite of the fact that the population had risen from nineteen to thirty-three
millions. If we turn to the pauper class, we find that the numbers in county
asylums had nearly doubled in 1879, only twenty years, and had trebled by 1899.

Anyone who will carefully study the figures can come to no other conclusion
than that a considerable number of cases that fifty years ago would have been sent
to the private asylum are in these democratic days sent to the county asylum, or
in some cases even to the workhouse.

That diseases of the nervous system are on the increase is an assertion often
made, and on asking for the proof of it we are referred to the number of cases in
the asylums. My opinion as to the alleged increase is very much that of Betsy Prig
in regard to the existence of Mrs. Harris. The Registrar-General's Report certainly
does not show an increase, as the following figures prove:

Causes of Death Showing an Increase.

Per million.

18 8 $ 189 $ 1904

General paralysis and insanity, not puerperal . . *99 119 127

Locomotor ataxy, paraplegia, and diseases of the spinal

cord.63 75 80

Causes Showing a Decrease.

Meningitis, inflammation of brain.313 248 186

Softening of brain.124 90 67

Chorea.5 4 4

Epilepsy.116 93 86

Laryngismus stridulus.27 20 12

Other diseases of nervous system.171 113 108

We often hear a great deal about the increased worry and stress of life, but the
pressure is far greater amongst the upper and middle classes than in the case of
the labouring classes ; yet amongst the former there is certainly no “ enormous
increase,” and why there should be amongst the latter I fail to see, because they
are better housed, better clothed, better fed, and work shorter hours of labour,
under enormously improved sanitary conditions, to what they did formerly.

The increase in the number of the insane in our asylums is due (1) chiefly to
the accumulation of the cases in the asylums. Few people take the trouble to
reckon how rapidly this takes place. For example, you admit 100 people to a new
asylum; 37 recover, 10 die. If the admissions, recoveries, and deaths continue at
the same ratio in three years the number of cases in the asylum will have doubled
without any increase in the prevalence of insanity.

(2) The enormously increased confidence of the public in the treatment of the
mentally and physically sick in our State institutions as compared with what they
were and what they were thought to be a quarter of a century ago. I well
remember an old lady blaming me for sending a case to an asylum, because she
asserted “ if they are bad cases they smother them under feather beds.” You do
not hear such nonsense now; the nonsense you hear is more about castration to
prevent the increase of the unfit.

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NOTES AND NEWS.

221

1907.]

(3) The difference in the distribution of the people now and ten years ago.
During that time the rural population of England and Wales only increased from
7,257,000 to 7,469488. The urban in the same period rose from 21,745,000
to 25,058,000. There is no necessity to point out that a case of harmless
dementia that could be easily tolerated in a thinly populated rural district becomes
sometimes an intolerable nuisance to the neighbours if in an urban district and
addicted to certain habits. Again and again 1 have been consulted about such
cases by aggrieved parties. The cases that used to be kept at home are no longer
seen. " The moping idiot and the madman gay ” are both in the asylum now.

(4) Another powerful factor is the change of opinion that has come over the
public in regard to what justifies you making use of the asylum for your friend if
of unsound mind. The fact that you had a friend in an asylum when I was a boy
used to be looked upon almost as a discreditable thing—a skeleton in the closet, to
be concealed if possible. That is to a great extent changed, and we are looking
upon the insane as far more probably possessed of toxins than possessed of devils.

(5) The alteration in the standard of mental disease required by the profession
to justify a medical practitioner in certifying a case as insane and suitable for
asylum treatment. I can very well remember the time when experienced men
were very reluctant to sign a certificate unless the case was “ dangerous to himself
or others.”

These are some of the causes of the apparent increase, and, after many years’
attention to this question, I have come to the conclusion that Sir Arthur Mitchell
and the late Sir John Sibbald were right when, in their Report, they said, 11 The
facts and figures afford no ground for a belief that insanity is to-day more
prevalent than when we entered upon our functions, over thirty-six years a^o.”
The fact that the last four years have seen a decrease in the number of admissions
affords ground for hoping that we are not far off the time when the question of
bow to increase the accommodation for our insane will cease to be the ever-bunu
ing question of the County Councils that it is to-day.

Discussion.

Dr. Ewan said that the figures in Lincolnshire bear out what Dr. Rhodes had
said in respect to the increase in the number of certified patients. The increase
there has been due to accumulation— i.e. t the admissions were more numerous than
the discharges and deaths. As to the aged dements in country districts, there is
no place else for them than the county asylum.

Dr. MacDowall asked about the statement as to the deaths from insanity; in
his opinion such were very rare.

Mr. Roylb and Dr. Bedford Pierce also concurred in the views expressed by
Dr. Rhodes.

A small party of members dined at the Midland Hotel after the meeting.

SOUTH-WESTERN DIVISION.

The Autumn Meeting of the South-Western Division of the Medico-Psycho¬
logical Association was held at Kingsdown House, Box, on Friday, October 26th,
1906, by the kind invitation of Dr. MacBryan, who entertained the members to
luncheon and showed them over the asylum afterwards. There were present at the
meeting:

Members. —Drs. P. W. Macdonald, H. T. S. Aveline, Manning, Aldridge,
Bullen, I. L. Baskin, Soutar, Pope, MacBryan, Eden Paul, Bowes, L. A. Weatherly,
and Millar.

Visitors. —Drs. Whitbv, Fleming, Llewellyn Jortes, and J. B. Walters. Letters
of apology were received from Drs. Robert Jones and Brayn.

Dr. P. W. Macdonald was voted to the chair.

Votes of condolence .—After the reading of the minutes the Chairman alluded in
feeling terms to the loss the Association had sustained in the recent deaths of Dr.
Craddock of Gloucester, and Dr. Stewart of Bridgend, and proposed that the Hon.
Secretary should be requested to convey their sympathies to the relations. The
meeting assented without any formal resolution being taken.

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[Jan.,

Dr. Sidney Bazalgette, L.R.C.P., M.R.C.S., Assistant Medical Officer to the
City and County Asylum, Fishponds, Bristol, was unanimously elected an
ordinary member. The proposers were Drs. Marnan, Aveline, and W. F. Mac¬
donald.

The next business was to elect a representative member of Council in place of
Dr. P. W. Macdonald, President-Elect. Drs. Soutar and Bowes were appointed
scrutineers, and declared Dr. Bullen unanimously elected.

Dr. R. Llewellyn Jones then read a paper on “ The Relation of Rheumatoid
Arthritis to certain Diseases not uncommonly associated with Mental Disorder,
namely Raynaud's Disease, Graves' Disease, and Myxcedema.”

We hope to publish this paper in a future issue of the Journal.

Remission in General Paralysis op the Insane.

The Hon. Secretary read some notes on two cases of remission in general para¬
lysis of the insane. He prefaced his remarks by saying that authorities were
almost unanimous in agreeing that recovery from general paralysis was practically
unknown, and that the nearest approach to that state was the incident of the disease
known as a “ remission.”

The two cases described came within the definition of a “ remission ” as given
by Bianchi: “ We may have in the course of progressive paralysis periods of im¬
provement, during which almost all the somatic and psychic disturbances dis¬
appear, sometimes to such an extent as to simulate recovery. There always
remains a certain degree of depression of the various mental activities, but on the
whole there is established a condition that is generally satisfactory and very like
recovery.”

Both cases exhibited the expansive type of the disorder, and in each the “ remis¬
sion ” lasted only a few months and did not lengthen the total duration of the
disease.

The improvement appeared gradually, while the relapse was sudden and was
followed by rapid dissolution.

In one of the cases, as well as in a similar one recorded some years ago by Dr.
Bonville Fox, there was a history of syphilis. In both these improvement followed
the employment of antisyphilitic remedies, offering an inducement to give such
remedies a further and more extended trial, and above all to continue their use
over a longer period after the improvement, if any, had been obtained.

Dr. Lionel A. Weatherly said it had been interesting to hear of those two
cases, for he was sure they must have all met with more or less similar cases.
From the point of view of the private asylum superintendent they were not only
very interesting but very difficult and trying cases. He well recollected not so
very long ago that of a doctor who was placed under his care. He had a fleeting
practice, which he recommended should be sold at once, and it was. He stayed
with him for some weeks, but the case was too noisy and violent, and he had to
be transferred to a neighbouring institution. He was intensely surprised to hear
one day that the patient was quite well and back in Bristol, which was the town
from which he came, and he (Dr. Weatherly) was having an unpleasant time of
it at his hands. He was represented as having ruined him. He was in Bristol,
stranded, with nothing to do, and he (Dr. Weatherly) was the cause of his
practice having been sold. He took the position of ship’s surgeon, and made a
trip, during which he performed his duties with perfect success, but within six
months he was back in the asylum again, and very soon died. His was a definite
remission. But the most interesting case of remission that had come across his
experience was one that Dr. Aveline, when he was his (Dr. Weatherly’s)
assistant, might have had something to do with. The patient had many
grandiose delusions, and this went on for some time, when a succession of fits
took place, and he became bedridden. He went downhill fast, had very little
use in his hands and arms, and became hopelessly bedridden. Bed-sores de¬
veloped, and an operation subsequently took place. His mental symptoms
disappeared, and he mended in a remarkable way, although his friends had been
to see him and say good-bye. He went out driving, attended horse shows, and
thoroughly enjoyed life. He became intensely religious, and was to a certain
extent unreasonable, because he wrote sheets upon sheets out of the Bible for

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NOTES AND NEWS.

223

1907.]

circulation among the poor, under the impression that they could not afford to buy
the written Word of God. Later he developed the idea that he was the Holy
Ghost, and that it was his bounden duty to bite out the testicles of anybody he
could find to save them from ultimate perdition. Finally a state of acute mania
developed, and he died.

Dr. Avbline stated, in reply to Dr. Paul, that the dose of iodide of potassium
which he had prescribed in the case alluded to was 10 grs. three times a day,
continued over a period of some months.

At the close of the proceedings the Chairman said he had the pleasurable duty
of offering their kind host their thanks for having received them so hospitably.

Dr. MacBryan, in reply, assured the members that it had been a great pleasure
to him to have received them that day. It would interest them to know that
Kingsdown House was said to be the oldest licensed house in England, dating back
to 1792.

The members dined together at Messrs. Fortt's restaurant, Bath, in the evening.

SCOTTISH DIVISION.

A meeting of the Scottish Division of the Medico-Psychological Association
was held at Perth District Asylum, Murthly, on Friday, November 2nd, 1906.

The following members were present: Drs. Alcock, Carlyle Johnstone, Easter-
brook, Goldie Scott, Gostwyck, Keay, Kerr, Macdonald, Mcllwraith, Mackenzie,
Marr, Parker, G. M. Robertson, J. M. Rutherford, and L. C. Bruce, Divisional
Secretary.

Dr. Carlyle Johnstone was called to the chair.

Letters of apology were intimated from the President and Dr. Watson.

The minutes of last meeting were read, agreed to, and signed.

The following nominations were made: Drs. Turnbull and L. C. Bruce to be
Representative Members of Council; Dr. Hamilton C. Marr to be Divisional
Secretary; examiners in psychological medicine, Drs. Easterbrook and Oswald.

Dr. Bruce showed a case of melancholia, and illustrated the disease process by
charts; (1) of the urinary excretion of urea as against the nitrogen ingested in
the food; (2) leucocyte charts, comprising that of the melancholic patient with
charts compiled from sane persons who were at the time of observation suffering
from known disease processes; (3) charts of opsonic indices in similar cases of
melancholia to the patient shown, and in whom bacteria had been isolated to
which the serum of the patients gave a definite agglutinative reaction ; (4) charts
of the opsonic indices in a case of chronic rheumatism and in a case of fissure of
the tongue—both sane persons—were also shown and compared with the indices
in the cases of mental disease.

An interesting discussion followed.

The Division appointed Drs. Ireland, Urquhart, and Ford Robertson, with
powers to add to their number, to represent the Division at the International
Congress for Psychiatry and Neurology to be held at Amsterdam in September, 1907.

The project of a joint meeting with the American Medico-Psychological Society
was mentioned, and a letter was read from Dr. A. E. Macdonald.

The meeting terminated with votes of thanks to the Chairman and Dr. Bruce.

The members afterwards dined at the Station Hotel, Perth.

IRISH DIVISION.

The Autumn Meeting of the Irish Division was heldjon Monday, November 5th,
1906, at the Royal College of Physicians, Dublin, by the kind permission of the
President and Fellows of the College. Dr. Conolly Norman occupied the chair,
and there were also present Drs. G. T. Revington, F. E. Rainsford, G. F. West,
T. Drapes, E. D. O’Neill, R. L. Graham, J. Mills, R. R. Leeper, W. Graham,
J.J. Fitzgerald, M. J. Nolan, H. M. Eustace, and W. R. Dawson (Hon. Sec.).

Dr. Norman said that before the minutes were read he would ask the permission
of the meeting to propose the following resolution: “ That this meeting desires

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NOTES AND NEWS.

[Jan.,

to express the sorrow felt by every member of the Association at the death of our
distinguished colleague Dr. Oscar Woods, ex-President of the Association. We
desire to convey to Mrs. Woods and the other members of our lamented friend's
family our sincere sympathy in the irreparable loss which they have sustained.'*
He was sure that he spoke the mind of the whole Association in this expression
of condolence.

Dr. O’Neill, in seconding the resolution, said that the Association could ill
afford to lose Dr. Woods. He was a conscientious man, a hard worker and a
good friend, and his death was an irreparable loss to the profession and his family.

The resolution was passed unanimously in silence,

The minutes of the previous meeting were read, confirmed, and signed.

The Secretary reported shortly on a matter arising out of them.

It was proposed by Dr. Rainsford, seconded by Dr. Revington, and carried,
that the next meeting of the Division be held at Portrane Asylum, on the second
Thursday in April, 1907, as the members were of opinion that this date would be
more convenient than Monday, April 22nd, the date originally fixed, the
President’s consent to the change to be secured.

Referring to the recent Report of the Viceregal Poor Law Reform Commission,
Dr. Nolan thought it satisfactory that the Commission had adopted the recom¬
mendations of the Committee appointed by the Irish Division, so far as to advise
that all lunatics should be placed in asylums and looked after by a resident
medical officer.

Dr. West then read a paper on “The Utilisation of Asylum Sewage,” in
which he advocated the employment of a filtration system and the use of the
solid products for manure.

The Chairman called on Dr. Revington to give the results of the system in use
at Dundrum.

Dr. Revington said that the precipitation system there produced a good
effluent which did not decompose and was free from smell, but that the manure
would only grow green vegetables, not potatoes, being a “cold manure.” It
would also grow grass, but of poor quality. The fluid was also useless as
manure. He had tried cow-manure and human manure on potatoes side by side.
The cost of working was 4 d. per week per head for the population of 200.

Dr. Drapes had obtained poor results from the use of cesspool contents as
manure. He alluded to the rapidity with which sewage was sterilised in a river,
but had found the drinking of such water unsafe. Spreading sewage on land had
been tried at Waterford Asylum, but discarded owing to the smell.

Dr. Dawson thought that the human manure having already been decom¬
posed, the conditions were not the same as with cow-manure.

Dr. Leeper had found the septic tank system work well, but had not tried the
products on land.

Dr. Rainsford said that fresh sewage had been tried as manure at Bristol
Workhouse, but found unsatisfactory owing to the smell. The infectious tract in
a river extended at least fifteen miles below the point of sewage discharge.

Dr. Graham read an interesting paper entitled “The Psychology of Christian
Science.” He traced the growth of the cult in spite of argument and ridicule,
and expressed the view that, though seven tenths of the so-called recoveries must
be rejected, there existed a grain of truth in Mrs. Eddy’s teachings, that grain
being the power of the mind to control the bodily state, a power recognised by all
who practise suggestion.

After some remarks by Drs. Norman, O’Neill, and West, Dr. Drapes agreed
that suggestion explains a good deal, though he thought that certain facts related,
for example by Crookes, contravene physical laws. He mentioned an instance, of
a man suffering from hay fever who improved after writing to a Christian Science
expert, but relapsed on finding that the latter had not received his letter.

Dr. Nolan thought there was a further element which could not be quite under¬
stood, and related the case of a tabetic patient who was judged by an eminent
medical man to be dying, but who walked into his study three weeks later after a
visit to St. Winifred’s Well. A neighbour said to have been similarly affected
also went and was improved.

Dr. Rainsford alluded to the large nervous element in disease as explaining
Christian Science “ cures.”

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NOTES AND NEWS.

225

Dr. Norman thought that the interest, other than metaphysical, of the new
faith consisted in the vogue it had attained. Cases like that quoted by Dr. Nolan
sometimes improved greatly without aid at all, as shown in that of a tabetic
general paralytic of fifteen years' standing, who was quite helpless and suffered
from bed-sores, but began to get better and recovered power of walking. Evidence
of the dependence of well-marked physical disease on mental causes was accumulat¬
ing—e.g., some cases of Bright’s disease.

Dr. Graham, in replying, said he had heard a Christain Scientist claim that a
tumour had been cured.

Dr. Nolan brought forward a study of a case of melancholic Folie raisonnante .

Dr. Rainsford substituted for the paper on the agenda one entitled “ Clinical
Notes of Four Cases of General Paralysis of the Insane/’

The meeting concluded with a vote of thanks to the President and Fellows of
the Royal College of Physicians for the use of the college hall.

In the evening the members dined together at the Shelbourne Hotel.

THE MILAN INTERNATIONAL CONGRESS.

Reported by W. W. Ireland, M.D.

The second International Congress for the Assistance of the Insane was held at
Milan from September 26th to the 30th. The different chambers of the Univer¬
sity Bocconi had been arranged for the use and comfort of the visitors. The
meetings were held in the great hall, a circular chamber well lighted and adapted
for acoustic purposes. In the upper story there were some interesting models
and plans of asylums. Dr. Augusto Tamburini, of Reggio-Emilia, discharged the
duties of President with his usual address and ability, and much of the success of
the Congress was owing to the unwearied energy and courteous attention of the
secretaries, Dr. G. C. Ferrari, of Bologna, and Dr. P. Gonzales, of Milan. There
were about three hundred adherents on the list of the Congress, but the attendance
was seldom greater than fifty or sixty. Although the larger number was composed
of Italians, there were physicians from every country in Europe and America.
There were official delegates from France, Germany, Austria, Hungary, Holland,
Belgium, Portugal, Greece, Roumania, Sweden, and Luxembourg, who were
entertained at a banquet by the Committee. After the opening address of the
President, Dr. Frank, of Zurich, read a paper advocating the formation of an
International Committee to collect information about the causes of insanity with a
view to prophylaxis. He expressed the hope that this would lead to the formation
of an International Institution to ascertain and combat the causes of insanity. Pro¬
fessor Zuccharelli, of Naples, stated that he had already made a similar proposal
to the International Congress for Criminal Anthropology at Amsterdam. Dr.
Easterbrook had communicated to the Milan Congress a scheme for International
statistics of the insane. Professor Lombroso considered that little would be
gained from such an assembly, but Dr. Frank’s proposal, supported by Professor
Bianchi, Dr. Percy Smith, Dr. Cassaves, and Dr. van Deventer, was eventually
carried. Dr. Lombard offered the use of his chateau on Lake Lugano for the meetings
of the Committee. The subjects discussed at the Congress included the general
care of the insane and idiotic epileptics, criminals, and drunkards. There were
eight sittings; besides Italian the French, English, and German languages were
allowed.

As the number of papers read or communicated was considerable, we can only
indicate some which strike us as more interesting. Much attention was given to
the family treatment of the insane, which, it was hoped, would afford a relief to
the expense of building new asylums for the ever-increasing number of lunatics.
Dr. Agostoni, Superintendent of the asylum at Perugia, stated that the out-of-door
treatment of harmless lunatics in Umbria had been given up. The subsidies were
ill-spent, and the use of spoiled maize in the dietary was a cause of danger and
degeneration.

In a communication by Drs. Tamburini and Guicciardi it was stated that, in
spite of the obligatory instruction of attendants and guardians, the family care of
the insane had not been attended with the desirable success save about the asylums
L 1 II. I s

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226 NOTES AND NEWS. [Jan.,

of Reggio-Emilia and Lucca. In the Canton de Vaud the Grand Council had
authorised two years ago the placing of harmless chronic lunatics in the country
under certain conditions, which Dr. Ladame states has already given good results.

Dr. C. Hubert Bond, Superintendent of the Colony for Epileptics at Ewell, ex¬
plained the arrangements for the admission, case-taking, and treatment of different
classes of lunatics according to their symptoms and degrees of excitement in the
most modern English asylums.

Dr. van Deventer gave the results of his arrangements for the treatment of
lunatics at Amsterdam. He found that in some cases the infermihres had a whole¬
some influence upon the male patients, though precautions were needful.

Communications were also made by Dr. Menzies (Chedleton) and Dr. MacDonald
(Hawkhead), who read his paper in Italian, and Dr. Percy Smith communicated a
description of the new asylum ^t Hellingly by Drs. Hayes Newington and Percival
Taylor. There also came from Dr. Easterbrook a description of the new infirmary
of the Ayr Asylum.

One of the most interesting communications was the report of Dr. Ladame, of
Geneva, upon the Swiss Society for the Help of the Insane. The first of these was
founded forty years ago at St. Gall. An appeal was made by the medical men of
that canton to their fellow-citizens to form themselves into a society to afford
succour to those discharged from the asylum, so that they should not fall into
unfavourable conditions from poverty or lack of suitable employment. At the
outset the Society counted 344 members; now it has nearly ten times as many,
with an accumulated capital of 105,000 fr. The Society spends 5000 francs a year
in aid of patients and their families. There are now societies of this kind in
twelve cantons, counting above 33,000 members ; a small sum qualifies for
admission. The object of all these societies is to afford assistance to lunatics and
their families before, during, and after their treatment, and to diffuse correct ideas
about the causes, prevention, and nature of insanity.

Madame Marie, the wife of Dr. Marie, the Superintendent of the Asylum of
Villejuif, gave an account of similar efforts in France for the assistance of con¬
valescents, and Dr. Jules Morel, of Belgium, read a paper on ** The Character of
the Societies for the Assistance of the Insane, what they are and what they ought
to be.” Dr. Percy Smith presented a complete account given by Dr. Fletcher
Beach of what was being done in England for abnormal or for epileptic children,
and Dr. Gourjon gave a similar report from France. He considered that the
return from the Minister of the Interior of 31,791 such abnormal children had need
to be multiplied by four; in round numbers there are 120,000 of them. There are
known to be 4453 under age in the asylums; 1448 of these are under thirteen. In
the course of his report he paid a well-deserved compliment to Dr. Bourneville,
who, in a labour of thirty years, has modernised and completed the methods of
Seguin; Bourneville has organised his department at the Bic6tre by the pro¬
vision of new buildings and the training of teachers and attendants, the necessary
funds having been obtained from the Government. Having passed the age
limit, Bourneville has had to leave his post at the Bicfetre, though he still retains
the direction of the Fondation Vall£e.

On the 28th the whole Congress went upon an excursion to the asylum of
Mombello, eleven miles in the railway from Milan. The asylum buildings are
placed upon an eminence which rises above the waveless plain of Lombardy. It
was opened for the reception of the insane forty years ago. In 1879 the number
resident was 1481, the admissions 403. In 1905 the number resident was 2600,
the number of admissions 857. The recoveries during the last five years were
2216—males 12*95, females 41 39 per cent.

Upon a total population of males 4456, females 3763, the death-rate has
remained about the same, between ten and eleven per cent.

It was new to us visitors from the North to see cases of pellagrous insanity.
From 1879 there were admitted 2858, 1509 males and 1349 females, suffering from
this malady. Sometimes collapse supervenes so rapidly that the patient dies
before he can be borne to the asylum. From 1901 to 1905 there died in Mombello
fourteen patients from “ tifo pellagroso.”

About this time there were no less than eight congresses which the Milanese,
sagaciously taking advantage of the International Exhibition, had got to assemble
on questions of jurisprudence, sociology, and medicine. Amongst these was a

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I907.]

“Congresso pellagrologico ,s to devise further measures for the prevention of
this disease, the scourge of Lombardy, which is known to be caused by the use
of spoiled maize. In Italy about ten per cent, of the cases of pellagra become
insane. This Congress, after hearing a report from Dr. Probizer, or Rovereto,
went to visit the Pellagrosario of Insago, a charitable institution, at which they
were received by the President, Senator Facheria. The admissions for pellagrous
insanity at Mombello were in 1879, 89; in 1905 they were 62, from which we
may infer that the disease has become less frequent.

Unhappily, the admissions from insanity following alcoholic intoxication,
which bears some resemblance to pellagrous insanity, are increasing in Lombardy,
though the Italians are on the whole a sober people.

Restraint is not used at Mombello; 37 per cent, of the inmates were
at work on the grounds or in the workshops and laundries. The asylum is
made op of twenty-six separate buildings; the bigger blocks enclose a square
court in the centre with a pillared verandah, as is customary in large houses, in
Italy. To one accustomed to the asylums in Great Britain, where so much stress
is laid upon decorations and furnishings, the large rooms looked bare and dismal;
in fact, there was no furniture to be seen save the beds, which were sufficiently
comfortable. There seemed to be no heating apparatus for the four cold months.

It is proposed that Mombello should be set apart for chronic lunatics to the
number of 1500, and that a new asylum should be built near Milan for the
treatment of curable cases. Although a thoughtful and vigorous administration
may overcome many inconveniences, Dr. Verga has clearly shown in his able
report that the quiet, order, and hygiene of the establishment suffer from the too
great contiguity and overcrowding of the patients in some of the large storied blocks.

After a sumptuous luncheon, with flowing wines and fluent speeches, the
Congress returned to Milan in time for an evening sitting.

Fresh impulse has been £iven to the care of the insane by the promulgation in
1903 of a new law regulating the organisation of the asylums throughout Italy,
which clearly defined the power of the medical superintendents and added to the
number of assistants. Italy is anxious to learn from the experience of other
countries, while possessing in herself a fund of original vigour.

The Congress closed with a most pleasurable excursion to the Swiss Asylum of
Mendiisio, on Lake Lugano. This beautiful asylum was opened eight years ago.
It is made up of a number of handsome blocks spread over wide grounds amongst
plantations of pine and cypress. It occupies an eminence in a picturesque valley
surrounded by high peaks of the Alps ; the number of patients is 219—males 128,
females 91. The number of inmates has doubled since 1899. The medical labora¬
tory and apparatus for research were finely equipped, as was the case in all the
Italian asylums I have visited. After a plenteous breakfast in the open air, the
company walked down to Lake Lugano, where a steam-boat was waiting to convey
them to the town of Lugano. In the evening they were entertained at a splendid
banquet in the H6te! Bristol, given by the Cantonal Government of Ticino. They
returned to Milan about eleven o’clock at night. Next day the members of the
Congress separated, each being supplied with a permit to travel on all the railway
lines of Italy at a reduction of 60 per cent. They were also furnished with a large
map indicating the situation of all the asylums which they were invited to visit.

THE BETHEL HOSPITAL, NORWICH.

The Governors of this hospital have just issued a history of this institution,
which was commenced bv the late Sir Frederick Baleman, for many years the
consulting physician, and has been completed since his death by the eminent
Norfolk antiquarian Mr. Walter Rye.

The book is a quarto volume, containing the portrait of the founder, Mrs. Mary
Chapman, and of seven other worthies associated with the history of the hospital,
all admirably executed. A full plan of the present hospital is given, together with
a number of illustrations of its various parts.

The historical part of the work is very thoroughly done and of great interest,
showing the handiwork of the skilled antiquarian. The volume will be added to
the library of the Association.

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NOTES AND NEWS.

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CORRESPONDENCE.

Private Asylums.

To the Editors of the * Journal of Mental Science.*

Gentlemen, —The defence of private asylums in the last number of the Journal
is certainly convincing, for it shows that the percentage of recoveries in provincial
licensed houses was higher last year than that in any other class of institutions for
the insane. But, in addition to this, it may be pointed out that the true recovery
rate in private asylums— i.e. the ratio of the number who get well to the number
who die or become chronic—is higher than the apparent recovery rate estimated
by the ratio of recoveries to admissions. The cause of this is that many patients
are removed from licensed houses, for pecuniary or other reasons, without being
given the chance of getting well. This is not the case to an appreciable extent in
public asylums; about registered hospitals I am ignorant. The patients thus
removed swell the number of admissions without being afforded an opportunity of
adding to the number of recoveries. In public asylums practically all the patients
admitted either recover on the one'hand, or, on the other hand, die or become
chronic; hence the percentage of recoveries may reasonably be expressed by the
ratio of recoveries to admissions. But in licensed houses the existence of a large
third class—those who are taken away for monetary or other motives—vitiates
this method of computation. The larger this third class is, the more unfair does
the use of the above ratio become.

The Commissioners in Lunacy have recognised that this method of estimating
the recovery rate is unsatisfactory, but they have shown that there is no other
practicable method that is not even more so. It would be well, however, if they
would indicate that the use of the ratio of recoveries to admissions bears hardly
upon licensed houses.

The unfairness is not so great as it might seem at first sight, for the patients
who are thus removed rarely include the most acute and curable cases, so that the
percentage of recoveries amongst them would not be high. Still, I have known
acute cases removed when progressing rapidly towards convalescence, and even
among the others some would get well. It is probable that some private asylums
would have their recovery rate raised 4 or 5 per cent. t or possibly even more, if it
were not for these cases.

It may be said that, on the other hand, public asylums labour under a dis¬
advantage that affects their recovery rate, in that the poor do not send their insane
friends till they are practically compelled to do so. But neither do the richer
classes as a rule. Indeed, the case is even worse with these, for they take the
patient to a consultant who too often has no experience of asylum treatment, and
who pronounces him to be insane but not bad enough for an asylum. In the same
manner one might tell a man with a broken leg that he has a fracture but is not
bad enough to wear splints. I use this simile advisedly. The action of asylum
life on an unbalanced mind appears to me to be analogous to that of a splint on a
fractured limb. Quite as important as the healthy life, the skilled care, and the
isolation from home surroundings is the routine existence which keeps the unsteady
mind in artificial grooves, so to speak, and thus furthers powerfully the return of
steadiness. In addition to this there is the strong “ suggestive” action due to
being surrounded by others who all lead the same routine life. These most
important factors of cure cannot be found in “ private care.” There are other
advantages of asylums, but they were clearly proclaimed some years ago by Prof.
Clifford Allbutt, who spoke with authority, being one who for a time gave up to
lunacy what was meant for the benefit of medicine as a whole.

I am, Gentlemen,

Yours faithfully,

P. C. Smith.

Tunbridge Wells,

October 30th, 1906.

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1907.]

OBITUARY.

William Lloyd Andriezen.

We much regret to have to record the death of Dr. Andriezen at the com¬
paratively early age of thirty-six years. Borne of Cingalese parents, he came to
this country to study medicine. During his student career he obtained many
medals and distinctions, amongst which was the Medical Entrance Exhibition of
University College.

In 1888 he was appointed Demonstrator in Physiology. He was Exhibitioner
and Gold Medalist in Organic Chemistry at London University in 1889, and
obtained the Liston Gold Medal for Original Research and Pathology in
1891. He graduated as M.B.London with First Class Honours in 1891, and
M.D.London in 1893.

He held the post of Pathologist and Assistant Medical Officer at* the West
Riding Asylum, Wakefield; also Deputy Medical Superintendent at the Metro¬
politan Asylum, Darenth ; and latterly he was Assistant to the Director of Cancer
Research in the laboratories of the Middlesex Hospital.

In 1893 he contributed to the Internat. Monats. f. Anat. u. Physiol, an article
on “A System of Neuroglia Fibre-cells surrounding the Blood-vessels of the
Brain.”

In 1894 he wrote a long account of the " Newer Aspects of Pathology of Insanity,”
which he published in Brain.

He contributed to the British Medical Journal an article on “The Neuroglia
Elements in the Human Brain ” and another on “ The Pathogenesis of Epileptic
Idiocy and Imbecility.”

In 1899 be submitted to the Medico-Psychological Association a paper on “ The
Bases for Scientific Psychology and Classification of Mental Diseases.”

In 1903 he published in the Journal of Mental Science an article on “ Stereo-
plasm of Nerve Cell: a Study in Nerve Dynamics,” and in 1905 another paper on
"The Problem of Heredity, with special reference to the Pre-embryonic Life.”

During the last year or so of his active life he devoted himself to investigations
in connection with the causation and pathology of cancer.

Dr. Andriezen was well known to the members of the Neurological and Medico-
Psychological Associations of Great Britain. His work in connection with neuro¬
pathology was know in every country. He was a man of wide reading and an
earnest thinker in many departments of biological science. He lived a strenuous
life of hard work and but little recreation. All his time and inclination seemed to
be centred upon his work and his books, and he appeared to wish to cultivate but
few friends. In debate, as in private life, he was always courteous, earnest, and
just, and few could but admire his indomitable energy and his mental grasp of the
various theories and advances in psychology and neuro-pathology.

His last illness was of one year’s duration, and he was laid to rest on Friday,
November 23rd; his funeral was attended by Dr. Robert Jones and Dr. Hyslop.

Charles Angus.

We much regret to have to record the death of Dr. Charles Angus, late Medical
Superintendent of the Aberdeen District Asylum, Kingseat.

A native of Aberdeenshire, Dr. Angus had the benefit of an excellent preliminary
and secondary education. He entered the University of Aberdeen in 1883, as a
medical student, and soon took a distinguished position in the various classes he
attended. His favourite subject was anatomy; and he was regarded by the late
Sir John Struthers as one of his most exemplary and distinguished students.
Thus, on graduating in 1887, he was at once appointed Demonstrator and
chief assistant to the Professor of Anatomy. In this position he displayed
the same ability and thoroughness which characterised him as a student. During
the fourth year of his curriculum he attended a course of clinical lectures on
insanity at the Aberdeen Royal Asylum, and for three successive years acted for
lengthened periods as locum tenens for one or other of the resident medical
assistants. On these occasions he showed much aptitude for and was himself so
greatly interested in asylum work that he determined to throw aside his excellent
prospects as an anatomist and devote himself to the study of insanity. He was

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NOTES AND NEWS.

[Jan.,

appointed Junior Assistant Physician to the Royal Asylum in 1889, and a year
afterwards was promoted to the senior assistantship, a post which he held for over
seven years. He was then appointed Medical Superintendent of the Aberdeen
Royal Infirmary and Convalescent Home. During the five years he occupied this
post he gained the complete confidence of the Directors, who were not slow to
recognise his great powers of organisation and administration. While attending
to the duties and work of the infirmary he continued to maintain his interest in
the study of mental disease, and kept himself fully conversant with the most
recent literature and practice. He made a special study of asylum construction
and administration, and for the purposes of investigating the villa system he
visited the asylum at Alt Scherbitz, with the methods ana working of which he
made himself familiar.

The District Board were fortunate in securing Dr. Angus as the first Medical
Superintendent of Kingseat Asylum, and their judgment was fully justified by the
excellent service he rendered in connection with the equipment and organisation
of the new institution. There were many problems to be faced in connection
with the inauguration of an asylum on new lines, and to the Lunacy Board Dr.
Angus’ experience and administrative capacity were invaluable. He was able

? [uickly to complete the organisation and staffing of the institution. The satis-
actory and efficient manner in which this was accomplished, and the recognition
which his ability had obtained from those most competent to judge, are shown
in the Annual Report of the Commissioners in Lunacy , which contains the
following reference to the late Superintendent: “ By his zeal and ability be
quickly organised the administration of the asylum at its opening, and made it
thereafter one of the best managed institutions for the insane in Scotland.”

In the management of his patients Dr. Angus was seen at his best. He always
seemed to intuitively recognise and adapt himself to their various mental pecu¬
liarities. An all-round athlete himself, he took an active part in promoting the
recreations and amusements of his patients. In his relations with the members of
his staff, and with all the employees of the institution, he was particularly happy:
while never relaxing discipline, he was able to secure the most loyal service and
co-operation.

Dr. Angus was a unique personality. He was a man of ability, shrewdness, and
tact; endowed with a most genial temperament, a man whose cheery optimism
made it always a pleasure to meet him, no matter under what circumstances.
Moreover, he had that enviable gift, a keen and ever ready humour, which
could always be counted on, and which was a frequent source of enjoyment to his
friends. He made several contributions to the literature of mental diseases and
was an expert microscopist. His untimely death has cut short a career of great
promise. He leaves a widow and two daughters to mourn his loss.

Frederick Hurst Craddock.

It is with much regret that we have to record the sudden death on October 14th
of Mr. Craddock, Medical Superintendent of the Gloucester County Asylum.

A comparatively young man, he was only fifty-five, Mr. Craddock had until quite
recently enjoyed good health, and had been able to carry on his work as actively
as ever.

Some rather serious symptoms of heart trouble occurred during the heat of the
past summer, and his usual autumn fishing holiday had to be interrupted owing to
a severe seizure on the river bank. He was brought home and, after a week or
two’s rest in bed, seemed to be making excellent progress. He was feeling well
and cheerful and was hopefully planning an extended holiday. But it was not to
be.

On the morning of October 14th Mr. Craddock was found lying dead on the
floor of his bedroom, having evidently succumbed during the night to an attack of
syncope.

Mr. Craddock was educated at Lincoln College, Oxford, and at St. Bartholomew’s
Hospital, and after qualifying was for six months clinical assistant at St. Luke’s
Hospital. In 1877 he was appointed Assistant Medical Officer at Powick, where
he remained, first as Junior, and afterwards as Senior, for a period of five years.
In 1882 he was selected from amongst numerous candidates for the post of Medical

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NOTES AND NEWS.

1907 .]

231

Superintendent of the Gloucester Asylum, and here for twenty-four years he carried
00 a successful work with an energy and zeal that knew no bounds.

An excellent organiser, he brought about much-needed reforms both in the
structure and the management of the asylum. He was a strict disciplinarian but
had the heart of a woman, and his kindness to both patients and staff endeared him
to one and all.

The committee have lost in Mr. Craddock a most valuable officer, and their
appreciation of him and his work may best be told in their own words:

*' They desire to place on record their appreciation of the great services rendered
by their late Superintendent, Dr. Craddock, whose sudden death on the 14th inst.
they deeply deplore. By his able management, combining firmness in maintaining
discipline with consideration and great kindness towards his subordinates and the
patients under his care, he gained in a marked degree the esteem and affection of
all who were brought in contact with him.”

Mr. Craddock was more of a reader than a writer and he was keenly interested
in the social problems that vex the soul of the present-day physician.

The funeral took place at his native village in Warwickshire, and the large
number of friends, professional and otherwise, that attended to escort the body to
the station was evidence of the esteem in which Mr. Craddock was generally held.
A memorial service, attended by members of the committee, the staff, and patients
was held in the asylum chapel on the previous day.

John Grkig McDowall.

By the death of Dr. J. G. McDowall, at the comparatively early age of fifty-five,
the West Riding of Yorkshire has lost a most conscientious, capable, and upright
officer, his large family of staff and patients a good and affectionate friend, and his
many personal friends a most loyal and lovable man.

After his graduation at Edinburgh in 1873 he had a short experience in Scottish
Poor Law work at Craiglockhart, but at an early date devoted himself to the study
of insanity, obtaining an appointment as Assistant Medical Officer at the then new
South Yorkshire Asylum, at Sheffield, in 1873, at that time under the superinten¬
dency of Dr. Samuel Mitchell; here his strong individual characteristics soon
showed themselves, and his work was marked by that careful, painstaking con¬
scientiousness which stamped everything that he undertook in later years.

In 1887, after keen competition, he obtained the appointment of Medical
Superintendent of the then new West Riding Asylum at Menston, and that
institution in its development and administration is practically a reflection of his
mind. During the early years, when the work of organisation was a severe strain,
no undertaking was too great and no detail was too small for his energies and
attention, and from morning to night, and from year’s end to year’s end, his whole
object and aim in life was the welfare, good name, and honour of the institution
entrusted to his care.

As a Superintendent he was kind, forbearing, and gentle, and had what Pliny
calls the best of all characters, namely, he was ready to pardon the errors of
mankind as if he were every day guilty of some himself and, at the same time, as
cautious of committing a fault as if he never forgave one. As a man he had a
most lovable disposition, was perfectly straightforward, even-tempered, and large-
hearted. He leaves behind many to mourn his loss, and not least important
among them are those amongst whom he lived so many years, his staff and patients.

Robert Sloss Stewart.

We much regret to have to record the death, from heart disease, of Dr. Robert
S. Stewart, on September 28th, at the early age of forty-four years.

Dr. Stewart was a distinguished student of the University of Glasgow, where in
1883 be took the degrees of M.B., C.M. “ with high commendation,” and three
years later that of M.D., also "with commendation.” Having completed his
curriculum, he acted as Resident Assistant in the Glasgow Western Infirmary, in
the wards of Sir William T. Gairdner, the late Dr. Leishman, and Dr. Alexander
Paterson. Thereafter turning his attention to the study of psychological medicine,
he obtained the appointment of Assistant Medical Officer at the Glamorgan

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NOTES AND NEWS.

[Jan., 1907.

County Asylum, at which institution he spent the remainder of his life, devoting
himself entirely to the study and care of the insane. So thoroughly were his
services and excellent qualifications appreciated by the Committee that they
immediately appointed him Medical Superintendent on the retirement of Dr.
Pringle in 1904.

Dr. Stewart was an able and indefatigable worker, an excellent statistician, and
one of our most valued contributors to this Journal . For many years he con¬
tributed to the Glasgow Medical Journal reviews of papers which appeared in the
English, American, and Continental journals devoted to the study of nervous and
mental affections. Among his contributions to medical literature may be mentioned
the following: “ Observations on the Spinal Cord in the Insane,” “ Ataxo-spas-
modic Tabes (Ataxic Paraplegia) in Case of Primary Dementia,” “The Spastic
and Tabetic Types of General Paralysis,” “ The Increase of General Paralysis in
England and Wales, 1896,” “ The Decrease of General Paralysis of the Insane in
England and Wales, 1901,” “ The Relationship of Wages, Lunacy, and Crime
in South Wales,” “ The Mental and Moral Effects of the South African War,
1899—1902, on the British People.”

By Dr. Stewart’s untimely death Glamorgan Asylum has lost an able Superin¬
tendent and the medical profession a prominent member. Of a retiring,
unostentatious, kind, and genial disposition, he was universally respected and
esteemed, and his loss is keenly felt by all who knew him.

NOTICES OF MEETINGS.

Quarterly Meeting. —The next meeting will be held, by the courtesy of Dr. A.
Molyneux Jackson, at the Notts County Asylum, Radcliffe-on-Trent, on February
22nd, 1907.

South-Eastern Division. —The Spring Meeting will be held, by the courtesy of
Dr. Taylor, at the East Sussex County Asylum, Hellingly, on April 17th, 1907.
South-Western Division. —The Spring Meeting will be held on April 18th, 1907.
Northern and Midland Division. —The Spring Meeting will be held, by the
courtesy of Dr. Perceval, at Prestwich Asylum, on April 18th, 1907.

Scottish Division. —The next meeting will be held on March 22nd, 1907.

Irish Division. —It is proposed to hold the next meeting at Protrane Asylum on
April nth, 1907.

APPOINTMENTS.

Bayley, Harry, L.S.A., Assistant Medical Officer to the Warneford Hospital for
Mental Diseases, Oxford.

Bond, C. Hubert, D.Sc., M.D., Medical Superintendent of the new London
County Asylum, at Long Grove, Epsom.

Macllraith, N. MacLaren, L.R.C.P., L.R C.S., L.D.S., R.C.S.Edin., L.F.P.S.Glas.,
Assistant Medical Officer to the Norwich City Asylum, Hellesdon, near Norwich.

MacKenzie, T. C., M.B., M.R.C.P.Edin., Senior Assistant Physician to the
Royal Asylum, Aberdeen.

Wood, T. Outterson, M.D., F.R.C.P., F.R.C.S.Edin., M.R.C.P.Lond., Consulting
Physician to the West End Hospital for Nervous Diseases, Welbeck Street, W.

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THE

JOURNAL OF MENTAL SCIENCE

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

No.221 [ M * N W o’"r] APRIL, 1907. VOL. LIII.

Part I—Original Articles.

The Morison Lectures.—On Insanity , with Special
Reference to Heredity and Prognosis . l By A. R.
Urquhart, M.D., F.R.C.P.Ed., Perth.

Lecture I.— Prolegomena.

“ There are some authors whose only design and end it is to give an
account of things that have happened; mine , if I could arrive unto it 9
should be to deliver what may come to pass” — Montaigne , Bk. I 9
Chap. xx.

In the daily routine of medical work we are called upon to
deliver what may come to pass. The constant weighing and
measuring of our observations and experience lead us naturally
to an estimation of probabilities. Recovery or death—success or
failure in the appointed strife with disease—that is the momen¬
tous question to which the physician must endeavour to find an
answer. Things have happened ; what is to come to pass ?
Much of skill in prognosis is personal, empirical, and incom¬
municable ; but, as our science advances, with the contributory
aid of all the sciences that are subordinate to the master
art of healing, so, in just proportion, our premonitions will be
determined.

In no kind of disease is prognosis more doubtful than
insanity. For long overshadowed by ignorance and super¬
stition, for long regarded as a mysterious calamity, for long

LIII. 16

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234

THE MOKISON LECTURES,

[April,

obscured by confusing issues, it is only of late years that the
fundamental truths have been disengaged from the fantastic
phenomena which formerly dominated the attention of the
observer. The tedious melancholy, the violent excitement, the
bizarre ideas, and the dangerous conduct of the insane wholly
occupied attention, and precluded the study of obscure and
elusive bodily conditions. The mere recital of aberrant talk
and morbid conduct long detained us with mere irrelevancies.
Metaphysical discussions of mental aberrations issued in a
reiterated confirmation of Bacon’s dictum— what was a question
once , is a question still. Pathological researches were not
unknown. There is no indication of the reasons which led
James Murray to devote his fortune to the humane purposes of
the Perth Royal Asylum ; but it is possible that his uncle’s
work may have influenced him at a time when Scotland had
awakened to a recognition of the public duty towards the
insane—a time when public and private beneficence flowed
strongly in that direction. His uncle, Dr. Marshall, practised
medicine and lectured on anatomy and surgery in London.
His posthumous book was published in 1815 under the title,
Morbid Anatomy of the Brain in Mania and Hydrophobia.

Since then work in this sphere has been incessant and
arduous, until, at last, there are indications that more is to be
gained by research applied to the living body rather than by
perseverance in morbid anatomy. Not that this is a new
departure, for the oldest English writer on insanity—Dr.
Timothy Bright—in his Treatise of Melancholie (London,
1586), discourses at great length on the somatic conditions,
and especially on gastro-intestinal disorders, because “ melan¬
cholic appetite is not proportional to their digestion.”

It is unnecessary to discuss the history of medical literature
dealing with insanity until the memorable publication of
Schroeder van der Kolk’s lectures on mental diseases, which
took shape about the middle of last century. He arrived at
the conclusion that much insanity is due to morbid conditions
of the great intestine. In accordance with the medical ideas
of his time he described this class of cases sympathetic
insanity . While he clearly recognised the brain as the organ
of mind, he believed that it is liable to disturbance in direct
consequence of somatic conditions influencing it in a secondary
manner.

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I907-] BY A. R. URQUHART, M.D. 235

This conclusion was widely supported, and here, in Edinburgh,
the influence of the body on the mind was definitely fixed and
crystallised by Skae’s classification of mental diseases. Dr.
Skae had the advantage of an able and clear-sighted colleague
in the late Dr. Howden, so long physician to the Montrose
Royal Asylum, and the earlier work of Schroeder van der
Kolk was thus developed along lines which are still sufficiently
familiar.

But the trammels of metaphysics were not to be readily
shaken off. Even Dr. Maudsley’s epoch-making books, tending
to freedom of thought as they did, left the position doubtful.
Professor Laycock devoted his arithmetical powers to an
enumeration of the brain cells, in order to arrive at the possi¬
bility of a sufficient number of cells capable of each containing
one idea. Futile questions are still demanded as to the intimate
nature of the thought.

The traditions of men die hard. Every now and then a case
of witchcraft is reported in the newspapers, yet it is 350 years
since Reginald Scot wrote his famous book on the Discoverie of
Witchcraft . I had occasion, some time ago, to show how
ancient beliefs survive in modern minds, and remain apparently
indelible. Quite lately an obscure book reached me, and I
make no apology for quoting part of the title-page : “ Hidden
things brought to light in reference both to the upper, middle,
and lower worlds, or the true millenium only to be enjoyed in
the new or renovated earth ; also new discoveries in antiquities,
with illustrations of those formerly discovered ; together with
a truly interesting narrative of a man under demoniacal posses¬
sion, with the discovery of a remedy for the night mare.”
Notwithstanding the old-world suggestion of this lengthy
description of contents, the book was published at Edinburgh,
in 1843, by the Rev. Andrew Small, LL.D., of Abernethy, who
set to work because “ these demoniacal possessions are come to
an alarming height, and are obviously the cause of filling the
lunatic asylums.” Needless to say, Satan had a very poor
chance with the LL.D., as is his fate in these tales of demoniacal
possession, and the cure was to be found in securely plugging
up all the holes in the walls of the chamber of the afflicted
person in order to prevent the demons from gaining access.

It is almost impossible to gain any useful information from
old asylum records. In the earliest series the recorders note

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236

THE MORISON LECTURES.

[April,

the reception of a lunatic, and briefly indicate that he was
furious or fatuous, sometimes adding an account of heroic doses
of medicaments, blistering, and bleeding, and sometimes an indi¬
cation of removal by death or otherwise. The man was mad, and
there’s an end on’t. At a later period the cases are described
as psychological curiosities—how they arrived on foot or in a
carriage, how they displayed their morbid ideas, how they
wrote, and how they behaved. But, withal, the most chary
record of physical disorders, the most elusive statements as to
family or personal history. In brief, it was the study of mind
apart from body—the psychological content. Having arrived
at the conclusion that there is no pathology of insanity, com¬
ment on somatic conditions was, of course, superfluous.

It is to be regretted that these methods persisted so long,
indeed preventing other than the baldest facts available for a
survey of the insanity of the period ; yet it would be dis¬
courteous and ungrateful to ignore the work that was done,
just as we cannot but acknowledge the excellent intentions
and practical beneficence which inaugurated and maintained
the Royal Asylums of Scotland throughout the earlier years
of the nineteenth century.

For example, the blood of the insane is the dernier cri of
the modern investigator. My predecessor, Dr. Lauder Lindsay,
so long ago as 1854 published a series of observations on the
histology of the blood of the insane, which he had made in
the Crichton Royal Institution, then under the direction of
Dr. W. A. F. Browne. He did not claim that his researches
elucidated the morbid conditions of mind, or its organ, the
brain, but rather illustrated the laws of pathology, the natural
relations of healthy and morbid states of mind and body, and,
more particularly, the reaction of physical diseases on mental
phenomena. The observations were made on 36 officials and
236 patients, the physical diseases under which they laboured
having been duly noted. The microscope used varied in
magnification from 180 to 380 diameters, and, of course, there
was then no means of accurately estimating the relative
proportion of corpuscles, although it was apparent to the
observer that the white corpuscles were present in excess in a
comparatively large proportion of cases. The rteutnd was
presented under fourteen headings, the fourth being to the effect
that a leucocythaemic condition frequently exists. As examples

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1907]

BY A. R. URQUHART, M.D.

237

of this, cases of general paralysis, acute mania, and melan¬
cholia were cited. Unfortunately, Dr. Lindsay concluded that
there was no connection between the state of the blood and
the mental condition, but that it bore a relation to the
physical disorder, debilitated conditions of the system, and
general vitiation of the blood. In fact, the time had not come
to determine the exact and significant facts which have but
recently emerged from the chaotic state of opinion characteristic
of pioneer work.

Thirty years elapsed before another systematic investigation
of the blood of the insane was undertaken, when Dr. S. R.
Macphail in 1884 won the medal of the Medico-Psychological
Association. By that time the haemocytometer and the
hxmoglobinometer had been invented, and with these instru¬
ments of precision further advance was recorded. In general
paralysis Dr. Macphail found an increase in the relative
proportion of white to red corpuscles, coincident with the
progress of the disease; he failed to find any great difference
in the proportion of white to red corpuscles in maniacal
attacks, while in a series of recent admissions the proportion
was increased. Most important is his conclusion that there
is a close connection between gain in weight, improvement in
the quality of the blood, and mental recovery.

Another prize essay on the same subject was the work of
Dr. Johnson Smyth in 1890. He inferred that the relative
proportions of white to red corpuscles were so variable as to be
of little importance. In many instances, however, he recorded
an excess of leucocytes, and stated that the blood of the insane
is in a pathological condition.

These brief references to work, which was, of course, laden
with many other details, show the tendency of the times.
From crude and elementary observations the advance has been
remarkable. Quite recently the position has been still
further developed by the researches and conclusions of yester¬
day. We can understand that Dr. Lauder Lindsay’s investi¬
gations, aided by a high-power microscope, modern staining
reagents, and precise methods of estimation, conducted in the
light of the knowledge which is daily increasing in important
directions, would now be stated with a fuller confidence and
illumined by a brighter light.

Within the last few months Dr. L. C. Bruce has published

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THE MORISON LECTURES,

[April,

his records of clinical investigations. Much of his book is con¬
cerned with observations on the blood of the insane, and
specially on the leucocytoses, which he has shown to be of
definite importance in diagnosis and prognosis. What was
dimly discerned by Dr. Lauder Lindsay half a century ago is
made clear by Dr. Bruce to-day, and especially the important
conclusion that the morbid state of the blood is a dominating
factor in the evolution of mental diseases. Sufficient has been
said to indicate the growth of medical opinion relevant to
insanity as an affair of medicine.

Similar references might be made to other somatic condi¬
tions, the true nature of which are only now intelligible and
explicable. I have referred to Schroeder van der Kolk as one
of the first to appreciate the toxic nature of insanity. He
said : “ It is evident that the brain, as the organ through which
the higher intellectual powers are immediately manifested,
must especially suffer in insanity. We should, however, be
much in error in seeking the proper source and cause of the
disease always in the brain, for the influence which many organs
exercise upon the brain is evident enough.” He thereafter,
unhappily, reduced all forms of insanity to two principal
groups, one designated Idiopathic —a stupid word which sticks
like a burr—and the other Sympathetic . By the latter he means
that the cause of insanity occurs primarily, not in the brain, but
in other parts of the body—specially in the abdomen and the
sexual system. Van der Kolk had studied the clinical sym¬
ptoms of insanity for years, and eventually concluded that
the prodromal indication is a “ venous ” congestion of the
brain owing to a pathological change in the blood, and an
obstinate constipation which leaves its traces on the colon, and
especially and commonly on the descending part, where he found
constrictions, ulcerations, and false membranes. He also
noted the intimate nervous connections of the generative organs
and the colon. Passing to the thorax, he observed that those
members of insane families who remained sane usually died from
phthisis. Van der Kolk, of course, recognised that the
diseases named are incompetent of themselves to cause insanity,
but that in such cases there must be, in addition, a peculiar dis¬
position, and a particular excitability of the cerebral system.

The Hippocratic doctrine that insanity is caused by disease
had been obliterated by the superstitions of the Middle Ages.

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BY A. R. URQUHART, M.D.

239

1907.]

Reil concluded that common sensation is the germinating soil
of insanity, and disentangled it from Locke’s narrow theory
that insanity was nothing but a change in the working of the
intellect. Jacobi, by an extensive research, established the
somatic conditions of mental disease, and finally overthrew
Heinroth’s doctrine of the common origin of insanity and sin,
which, indeed, is not yet unknown in these latitudes. Griesinger
and his school, however, in concentrating attention on the
brain led to some neglect of the position attained by Van der
Kolk, but again the tide turned towards an enlargement of
that narrower doctrine. The brain, as the organ of mind,
infinitely complex in its own proper connections, is at present
the subject of study in its relations with all pathological
somatic conditions. Thus, the sympathetic insanity of Van
der Kolk is regarded as a toxic affection, not always and
inevitably caused by the direct continuity of nervous elements,
but rather by a poisoned blood supply ; and the newer view is
the wider. The contributory causes of insanity are to be
sought in heredity, in defect and decay of organisation, in the
disordered working of the somatic mechanism, and specially in
the toxic elements which may be formed by that disordered
mechanism or introduced from without.

The trend of opinion in view of later experience is consonant
with this toxic element in insanity, which again brings the
manifestations of cerebral disorder into line with other patho¬
logical somatic conditions, and leaves the mystery of madness
on a par with the mystery of rheumatism.

For the position is, that we have to deal with a constitutional
disease, profoundly affecting metabolism, mainly originating in
hereditary defect, and issuing in a liability to repeated attacks
of insanity, of a cyclical nature, quite different from those
maladies which, like smallpox, appear to confer a future
immunity.

Dr. Ford Robertson, from this place last year, announced, as
a result of his researches on general paralysis, that the etiology
of general paralysis and tabes is to be sought in the weakening
of general and local defences, and that these diseases are
dependent upon an active bacterial toxaemia. I need not
repeat his argument for my purpose, which is to summarise
broadly the present position in respect of all forms of insanity.
It is sufficient to say that the work recorded illumines the

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THE MORISON LECTURES,

240

[April,

ancient Hippocratic doctrine and translates vague guesses into
a defensible system of opinion.

When Lister was as. yet revolutionising the practice of
surgery and driving out the demon of sepsis from his wards, I
had arrived at the conclusion that medical practice must adopt
similar methods, and that asylum wards must be cleansed in
accordance with the new ideal. It occurred to me that anti¬
septic treatment might alter the condition of the insane, and
I made a long series of therapeutical observations on the
internal use of carbolic acid, hyposulphite of soda, etc., which
were too crude and ineffective to deserve recording. Newer
drugs, such as / 3 -napthol and eucalyptus, proved more useful,
and are still valuable in certain conditions of the alimentary
tract; but bacteriology has so reformed our ideas, and so
explained our difficulties, that we now gain a higher level of
understanding, and have good reason to hope for a higher level
of treatment.

From the medical point of view mind is not a separate
entity, nor can we think of mental disorders as entities. The
mind, normal or abnormal, is but one, or rather one series of
vital manifestations, part and parcel of the individual. The
brain is the organ of mind, but it is entirely dependent upon
somatic agencies for nutrition, repair, rest, regeneration, and
removal of noxious products—in short, for the normal mani¬
festations of mind. These are elementary propositions, which
are constantly overshadowed by prepossessions which hinder
us, as the smoke of the conflagration obscures the origin of
the fire. Sir John Buckniirs aphorism that a lunatic is lunatic
to his finger-tips gains an added force related to these con¬
siderations. The psychic disorder is generalised, the somatic
disorder is generalised ; both are constitutional. Very rarely is
insanity a focal disease. Rather is it a generalised mental
reduction dependent upon generalised bodily conditions. It is
always a mental reduction, characterised by a loss of the finer
feelings, an inability to adapt, a loss of restraint on motor
manifestations; and the depth and continuance of this reduction,
the severity and pathological importance of the organic con¬
comitants, are the measure of prognosis.

All insanity is defect—at least, a degradation of function, if
not a degradation of structure. Politely, we speak of mental
affections, just as acute mania is softened to hysteria, and idiocy

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to feeble-mindedness, but it is by the recognition of defect in
the earliest stages of insanity that we may hope to recover lost
ground.

If the defect of original constitution—the inherent instability
of the neuropathic organism—is manifested in a perverted
metabolism or a failure in the somatic defences against malignant
bacteria, the aspect, the way of looking at insanity, is totally
changed. Insanity is a unity, not a fortuitous collection of
kaleidoscopic symptoms each requiring a proper name—M or
N, as the case may be. I claim some honour in having so far
spent my professional life without a single Greek synonym to
my discredit. No doubt it will always be convenient to speak
of mania and melancholia, and so on, as convenient descrip¬
tions of common symptoms, but we may now hope to pass from
these appearances to a more intimate understanding of the
underlying facts.

I shall not impose upon the College a new definition of
insanity, or a new classification. Definitions grow on every
hedge and sprout like mushrooms—for a day. For instance,
Cullen’s definition—“ a lesion of the intellectual faculties with¬
out pyrexia and without coma ”—will no longer stand the test
of the clinical thermometer. If we provisionally adopt Dr.
Hack Tuke’s definition—“ a disease of the brain affecting the
integrity of the mind, whether marked by intellectual or emo¬
tional disorder ”—the content will be a vast variety of forms,
the mere recital of the names of which would be intolerable.
There is a strong temptation to confer a special designation on
every symptom-complex, which can be agglutinated. Knowing
so little of the pathological conditions, the symptoms of
insanity have been erected into an undue importance, and
classifications innumerable have been proposed, not one of
which can be regarded as other than merely provisional. A
distinguished architect evolved a leading principle in his work,
which he repeatedly impressed upon me —simplify your plans ,
and I may be excused if I proceed no further than Griesinger
in this matter of classification—broadly founding upon promi¬
nent symptoms, for it is still convenient to speak of states of
depression, states of excitement, and states of enfeeblement—
melancholia, mania, and dementia. Of course there is the
familiar objection that melancholia and mania may alternate in
the same patient, e. g .:

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242 THE MORISON LECTURES, [April,

Observation 2286.—Female, aet. 19. Heredity of neuroses and
alcoholism. Manifested delusions of persecution and unworthiness,
with hallucinations of sight and hearing, after a prolonged period of
depression, ushered in by gastro-intestinal disturbance, sleeplessness,
and general malaise. On admission states of depression and excite¬
ment alternated in rapid succession, so rapidly, indeed, that they
appeared to be almost simultaneous. This confusional condition
merged into a dreamy state, not amounting to stupor, which again
issued in convalescence and recovery in four months.

This is an example of the evolution of adolescent insanity
from the hereditary burden of neuroses and alcoholism under
severe physical strain. I find it recorded under the heading of
excited melancholia, denoting the symptoms predominating,
although, as I have indicated, there were rapid alternations from
despair to hilarity. Cases illustrative of the predominance of
mania over melancholia could, of course, be as readily adduced.

Therefore, in this broad view of insanity, these main features
find place ; but it is also permissible to use the term circular
insanity and delusional insanity, as denoting a pronounced
mixed, alternating form, and a systematised, delusional con¬
dition, neither of which is distinctly mania, melancholia or
dementia. In fact, this simple classification is founded upon
symptoms in terms of time.

It is evident, however, that as our knowledge progresses we
are enabled to screen off from the total numbers of insane
persons certain persons affected by definite pathological forms.
I shall therefore further divide the cases under review into cases
of ordinary insanity of obscure causation , and cases of definite
pathological causation .

Just here I stand at the parting of the ways—the beaten
track has led us surely, if circuitously, to this position, where
we discern the pioneers at work clearing the jungle of doubts
and difficulties. It has long been evident that general paralysis
of the insane constitutes a distinct pathological disease. The
march of the symptoms, the pathological conclusions, are
determined and evident. It is a gross organic disease of the
brain. The evidence for a similar conclusion regarding
epilepsy has also accumulated. And, of course, the senile
degenerations of cerebral tissues are admitted. The crude
toxic action of alcoholism on the intimate structures of the
brain is so far determined as to permit of this also being
regarded as truly pathological. I shall also add traumata,

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whether isolation or violence, for Van Gieson has shown that
the effects of these injuries are microscopically identical.
There remain cases of idiocy—brains arrested in development
or pathologically and irretrievably damaged.

Therefore, on the one hand, while I regard the pathological
forms as of little moment in respect of prognosis under present
conditions, as fixed, irrecoverable, and already doomed, on
the other hand I regard ordinary insanity as uncertain, curable
and now even hopeful It may be that general paralysis is to
be lifted out of the category of reproach, that it will be fought
and conquered, as has been suggested by Dr. Ford Robertson ;
but the difficulties are, to my mind, almost insuperable, and I
do not contemplate a general vaccination to obviate the rare
event. At any rate these observations are directed to the
results of experience rather than the possibilities of the future.
And yet it is to the future we must look for relaxation of the
bonds now imposed upon us.

I propose nothing new in thus considering cases of insanity.
Indeed, it is only a year ago that Dr. Graham Crookshank
revived the memory of Dr. W. H. O. Sankey’s brilliant generali¬
sation—“ that insanity is but the process, and that the so-
called varieties are merely differentiated by non-essential
phenomena ; that all insanities begin with melancholia, and
tend to pass through a succession of stages in the order—
melancholia, mania, and dementia, a succession liable at any
time to interruption by recovery.” It is forty years since
Sankey first published these shrewd conclusions, and empha¬
sised the importance of the initial stage of melancholia or
depression, so commonly observed, and yet so little regarded.
No doubt, in his plea for simplification Sankey was carried a
little too far, for it is not in every case in accordance with
clinical experience. The facts of the initial stage of insanity
are very obscure ; they are overlooked, they are forgotten, they
are minimised. Yet it is by these facts that the true somatic
nature of these maladies are determined, and in the instant
appreciation of them that we are to find a new and more
excellent treatment.

I have said that I stand at the parting of the ways towards
which Sankey’s generalisation led, and at which the track
becomes clearer. Dr. L. C. Bruce has lately shown, by the
published account of his clinical studies, that, disregarding the

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mental concomitants, there is evidence of the toxic nature of
insanity. This evidence is of such a nature as to be appre¬
ciable by the methods of the clinic and the laboratory, to be
checked or corroborated by other observers. It is not a theory
of disease, but the direct outcome of a long, laborious, and
skilful investigation into the facts of disease, honest and unpre¬
judiced. I cannot refrain from congratulating a Fellow of the
College, and my near neighbour, upon the distinguished posi¬
tion he has won. His work opens up new vistas, and affords
new hopes. He has finally brought insanity into the category
of other somatic diseases, and established a parallel condition,
long surmised and discovered with difficulty, long obscured,
and at length distinguished by none other than the method of
Zadig.

Briefly, it would appear that the time has already come
when the conclusions formulated by Dr. Ford Robertson last
year in reference to general paralysis—the failure of the organism
to protect itself against bacterial invasion—may be extended to
forms of ordinary insanity, which hitherto have evaded the
skill of the pathologist. Whether it is consequent on a meta¬
bolic toxaemia, or on a bacterial invasion, insanity must now be
regarded as a condition of disease which demands no special
pathology, and therefore no exceptional treatment.

To resume, it is necessary to revise the opinions of yesterday,
to recognise that a neuropathic heredity is operative in the
weakening of the somatic functions and defences at an earlier
or later period of the individual existence ; that the physical
conditions are the important considerations which now, more
than ever, render insanity an affair of medicine, and finally
justify the founder of the Morison lectures in the encouragement
which he gave to these studies.

Statistics .

The statistics of insanity present grave difficulties, and pit-
falls innumerable. They are the most elusive of vital statistics.
Asylum statistics are notoriously untrustworthy, and impossible
in collation. There is no personal acquiescence in underlying
principles, and recent proposals in this direction tend to make
confusion worse confounded. There is, for instance, apparently
no possibility of general agreement as to the use of the word

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“recovery,” by which I mean to indicate those in whom there
is re-establishment of mental soundness, permitting of return to
ordinary life without need of the care and the supervision of
others. Recovery may be used to designate a partial improve¬
ment in mental condition, a lucid interval more or less
temporary’, or a discharge from asylum care and control to the
custodial care of home life. A final, permanent recovery, we
shall see, is a comparatively rare event—just as rare as a true
recovery from gout The recoveries generally claimed in
asylum statistics are referable to cases y not to persons . Even
when referable to persons they are only declared, and that
rarely, as recoveries so far as official statistics can show. No
doubt the same remarks may be made regarding the medical
results of general hospitals dealing with other constitutional
diseases of obscure causation. The persons are received and
treated, are discharged cured, and return relapsed. The vital
history can only be completed on death.

Again, the stock question put to an asylum physician is :
Do you believe that insanity is increasing? It is, of course, a
question of urgent national importance, and, therefore, has to
serve the purposes of the journalist and the pamphleteer, who
gain a more or less honourable livelihood by their writings
around the social conundrums of the day. It probably pays
best to use a large brush, and to begin with the word
alarming. It is also an opportunity for the Member of
Parliament with a question to ask. The Commissioners in
Lunacy of the three Kingdoms have done their best to inform
and reassure, but the staid and guarded results of their investi¬
gations are not effective in ending the discussion. Besides, it
is easier to ask a crisp question than to study voluminous blue
books. Imagine the popular outcry if the unrecovered persons
discharged from general hospitals had to be kept for life in those
institutions, and the resulting dread of national degeneration !

I cannot regard it as possible to answer the question until
to each insane person recorded in the registers of the
Commissioners has been assigned one number, and no more,
and until the asylums of the country use these individual
numbers in any statistical returns they may make for collective
investigation. The crime of the country—the criminal offences
committed—is a question apart from the number of persons
committing these crimes. A system of law which has regard

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THE MORISON LECTURES,

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to the crimes rather than the criminals is defective and
uninformed ; and a system of medicine which is occupied with
diseases rather than diseased persons stands condemned by its
own ineptitude.

No doubt the physician may take credit for cure, the return of
his patient to the ordinary activities of life—always under the
full understanding je le pansay , Dieu le guerist —but if we are to
see life sanely, and see it whole, we can call no man happy
until he is dead. Even in this last event suspicion may lurk.

Observation 1773. —Female, unmarried, set. 50. Admitted in 1879,
labouring under delusional insanity of an apparently intractable type.
Hereditarily strongly predisposed to mental disorder, she exhibited the
usual features of climacteric insanity of persecution. She was, as the
French say, a persecuted persecutor, and so remained for eight years,
when she made a good recovery and returned to her usual life of social
and charitable interests. Seventeen years after her recovery, at the age
of seventy-five, she returned to asylum care, a typical case of senile
melancholia. In the course of a year or so recovery was again recorded.
But for survival to the age stated she would have been regarded as a
final and satisfactory recovery. No doubt the case is somewhat ex¬
ceptional—firstly in regard to the delayed recovery from a delusional
condition, apparently fixed, and secondly, as a relapse into insanity of
a different type at an advanced age. A recurrent case is generally
more steadfast in symptoms, which, almost always, are reproduced in
unvarying succession in succeeding attacks.

It is therefore very difficult to attain such a degree of
exactitude as is desirable, and the methods of applied mathe¬
matics are placed at a disadvantage in dealing with these
problems. Further, the number of observations at my disposal
is so small that any deductions must be made with reserve.
The element of error, of course, increases as numbers diminish.
On the other hand, the studies on which these conclusions are
based have an advantage of more intimate and revised personal
knowledge than those drawn from wider sources. After deal¬
ing with patients belonging to the middle class of Scottish
society, throughout a long residence in the county of Perth, it
appears appropriate to give some account of that experience as
a retrospect.

In 1905, in the Presidential Address to the Section of
Psychological Medicine at the British Medical Association
meeting in Leicester, I laid before the Section the results of
studies in heredity, and then expressed the hope that I should
be able to follow out the histories of these cases as successes

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247

or failures. This occasion seemed suitable, and I therefore
returned to the cases reported upon at Leicester, and have
reproduced certain tables made for that purpose. The cases
submitted are those under my care during twenty-five years—
from 1880 till 1904 inclusive—and include those resident in
Murray’s Royal Asylum at the beginning of 1880.

1 have omitted voluntary patients with some reluctance.
The hereditary and other causal factors are so similar, and the
facts are so much in accordance with those observed in the
certified class, that they might well have been treated as a
whole. There is a similar tendency to relapse, and the broad
results generally resemble those of the certified class, especially
of late ; for year by year the number of voluntary patients
increases—certain persons who formerly would have been
certified preferring the less formidable arrangement. The
somatic complications, too, are practically the same. When I
gave evidence before a Departmental Committee, and entered
upon a consideration of these somatic conditions, Sir Charles
Cameron, the chairman, remarked, “ You must have got hold of
a particularly diseased lot.” That is the position I still main¬
tain ; those suffering from insanity are particularly diseased, and
if all the apparatus of our hospitals for the insane is not bent
to the elucidation and treatment of bodily disease they are
pro tanto medical failures, obvious and indefensible.

On the other hand, the introduction of voluntary patients
would have raised questions as to the relative or comparative
value of these conclusions, since it is usual to exclude them
from the annual statistics of asylums.

1 therefore find, as formerly, that the numbers under con¬
sideration are 419 men and 390 women, being a total of 809
persons. For the reasons I have already indicated the re¬
admissions are excluded. They are the same persons returned
to us for one reason or another. They may have relapsed, or
their reappearance may be due to other causes—such as tem¬
porary absence in other asylums for medical or social reasons.
The record of readmissions is generally purely official and of
slight scientific importance.

It is true that of late attempts have been made to bring
transfers from one asylum to another and readmissions into
scientific categories. No doubt it is important to discriminate
between the various official classes for official purposes, but

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THE MORISON LECTURES,

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these purposes are not relative to medical science. We are
concerned with the conditions on first attack, on recurrence of
attack, and not with the mere accidents of placement. The
number of readmissions into asylums bears but an indefinite
relation to occurring insanity, and is no true indication of the
tendency to relapse. Nor are the first admissions an indica¬
tion of first attacks. Meanwhile it is sufficient to state that
195 persons out of 809 were relapsed cases before their first
admission into the Perth Royal Asylum, and I have no doubt
that careful investigation would establish similar results
elsewhere.

I therefore concentrate attention on 809 persons, and not
on 982 cases.

Subject to these limitations, and proceeding on the foregoing
general principles, I now desire to examine certain statistical
tables which have been prepared as a brief analysis of medical
observations for a period of twenty-five successive years—from
1880 till 1904 inclusive.

Reference to Table I will show that recoveries were recorded
in 31 per cent . of both persons and cases, that deaths were
recorded in 17 per cent. y and so on. But these are not true
vital statistics ; they are merely official statements, good only
for the instant of making them. It is necessary to regard these
persons more closely, and to record the life histories in so far
as possible.

Table VI, to which I shall refer in detail, has been formulated
as an attempt to show final results. It is my advantage to
have been able to keep in touch with many discharged
patients, and I have been repeatedly and greatly obliged by
my colleagues in their sending me information relative to
transferred cases. The two years which have passed since
1904 have brought me further information regarding patients
previously under treatment, and while it is as yet too early to
close the records, it is possible to add to the facts contained in
our official registers.

Any study of insanity must begin with a consideration of
heredity—the earliest conditions affecting the organism. I
therefore reproduce certain tables, and adjust them to
additional information, for the neuropathic heredity is noted
throughout the statistics prepared for these lectures. We
have to determine the effects of heredity, in so far as possible,

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in elucidating questions of prognosis. Is heredity effective in
one direction or another in relation to recovery, relapse,
incurability, and expectation of life ?

Table II shows the incidence of neuropathic heredity in 809
persons observed. It has been found useful to divide it into
three periods, and I lay greater stress on the accuracy of the
last period (from 1895 till 1904 inclusive)—that is, a term of
ten years. Taking the table as a whole, however, the per¬
centage of those with a hereditary history of insanity may be
stated as 45, while the inclusion of the whole neuropathic
heredity increases that number to 72. It is a narrow view of
the heredity of insanity which does not include the occurrence
of the graver neuroses, want of mental balance, eccentricity,
alcoholism and paralysis. These manifestations in one genera¬
tion so frequently issue in pronounced insanity in the succeed-
ing generation that the nature of the incidence is obvious.
This opinion might be supported by very many cases, and I
select a few illustrations :

Observation 1805.—From neuroses to insanity. Paternal grand¬
father neurotic. Father insane; married a neurotic person, whose sister
was also neurotic. The family of these consisted of three persons—
two incurably insane women and a son who died early from alcoholism.

Observation 1635.—From eccentricity to insanity. Father eccen¬
tric. Mother eccentric. The family of these consisted of four persons
—three incurably insane and one dead in infancy.

Observation 2627.—From alcoholism to insanity. Father alco¬
holic. Mother normal. The family of these consisted of six persons—
two insane, two died young, and two reported normal.

Observation 2549.—From paralysis to insanity. Father died of
paralysis. Mother died of cardiac disease. The family of these con¬
sisted of five persons. The eldest son died of paralysis, the second
diec^in infancy, the third reported normal and alive, the fourth incur¬
ably insane owing to degenerative disease of the brain, and the fifth
died young.

It has been objected that paralysis is not necessarily a
disease involving mental aberration, but that must be relative
to the exact situation of the morbid process, and what is
exactly meant by insanity. Nothing is more common in the
practice of the physician than to find a certain mental degrada¬
tion in cases of cerebral paralysis, but, of course, it is a relatively
small proportion who require the care and control of an asylum.

LIII. 17

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I believe that these objections are largely due to the limitations
of the official mind, to which I have already referred. At any
rate, when one finds records of 191 cases of paralysis among
the near relatives of 623 insane persons it is evident that the
facts cannot be explained away as merely accidental.

There is an important class of insane patients who become
insane consequent upon arterio-sclerosis, or other degenerative
changes in the blood-vessels of the brain—cases in which the
cerebral circulation, nutrition, and function are deeply affected,
and issue in a group of symptoms recognisable as a whole.

We have to deal with a condition which has certain heredi¬
tary relations, owing to a defect of organisation, and comparable
with arterio-sclerosis, gout, and other diseases of obscure causa¬
tion. It is not the crude heredity of yesterday, but a failure
in development or metabolism, or a weakening of somatic
defences, apparent in early life, in the period of development,
in the stress of maturity, or in the decay of old age. And the
more marked the parental defect the earlier will be the failure
of the new organism, exactly in conformity with the vital
statistics of gout.

We are so accustomed to think of somatic stigmata and
congenital idiocy as inborn defects that it is easy to misinter¬
pret the true nature of these failures. So far as I can see, the
defect is of the same intrinsic nature, whether the mental dis¬
order be manifested in early idiocy or delayed until senility.
There is no adequate reason to deny the existence of prenatal
toxins, assuming that toxins are effective in the production of
cerebral disturbance and later insanity. By the hereditary
nature of insanity I therefore mean the inborn defect which is
manifested under certain conditions in the existence of the
organism. Not, crudely, that fatuous and furious persons are
so conceived, but that their defect of organisation is such as
renders them liable to fatuous or furious manifestations through¬
out the course of their existence, when subjected to certain
morbid influences.

Dr. John Macpherson lately declared, before the Royal
Commission on the Care and Control of the Feeble-Minded,
that “ feeble-mindedness is a variation which tends to propagate
itself, and, further, that it is useless to attempt to extirpate it
by cutting short the existing obviously defective families.” Dr.
Macpherson has so recently addressed the College on this

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subject that I need not recapitulate what is already well known.
The point for me is, that heredity works out in two directions
—for better or worse. We hear so much of the latter that the
former is neglected, or but partially recognised. The nimble
rectifier of social diseases is always ready with worse remedies.

I look back upon the time of my university education—how
small a part of professional life—as a time when scepticism was
insistent and rebellious. I learnt to write prescriptions in the
grand manner for examination purposes, but with mental
reservations always. Vis medicatrix natures was the still, small
voice which influenced many of us, and which still, with a
wider, a more scientific, and a more capable method, dominates
my medical intentions. Glib talk about the extinction of
families and the eradication of undesirables must be balanced
by the reasoned knowledge of natural processes. On the one
hand, we can discern the ruin and decay of families, in spite of
the constant effort of nature at reconstruction and rehabilitation ;
on the other hand, by the prepotency of new blood and a more
favourable environment there is a reversal of the process, a
rehabilitation just as important and just as certain. Of course
this cannot be demonstrated by the statistics of asylums, and the
official mind—“ subdued to what it works in ”—is obsessed by
the calamities and the degradation of human nature. I daresay
that the physician in daily and intimate contact with general
diseases suffers the same disadvantage, for it seems to me that
there are those who have finally concluded that the world was
made for doctors, and that disease is inclusive in the natural
order of things, constituting the best of all possible worlds.

Let us consider this question of regeneration at its
worst. Chart 4 shows the families of neuropathic parents as
derived from asylum statistics. It illustrates, by the way, the
necessity for immediate reform in our method of recording
insane individuals only. It further illustrates the true incidence
of heredity at the time of observation, and is so designed.
Thirty-eight neuropathic fathers had 240 children : 47 per cent .
were sane, 29 per cent . were insane. Forty-five neuropathic
mothers had 239 children : 42 per cent . were sane and 39
per cent, were insane. I have also recorded those most heavily
burdened, the double heredity shown in the families of twenty-
eight neuropathic fathers and mothers—145 children, of whom
33 percent, were sane and 44 per cent, were insane. Even in this

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THE MORISON LECTURES,

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disastrous class the / efforts of nature towards regeneration are
obvious. The race tends, as Dr. Macpherson showed, to
maintain average characteristics; but, as Professor Karl
Pearson has indicated more recently, there is probably an
intensity of correlation between want of mental balance in
parents and offspring from about 0*25 to 0*30—similar to the
correlation between parents and children in regard to other
and directly physical characters (stature, colour of eyes, etc.).
It is just here that our statistical information generally fails,
for the records of special hospitals must be replaced by the
statistics of the general population taken at random, and I
deeply regret that work of this importance is left to a few
enthusiasts instead of being undertaken by the medical profes¬
sion as a whole, in furtherance of biological and sociological
knowledge. This method of research does not apply merely
to insanity, but to all those constitutional disorders, to all
those departures from the normal which are of the greatest
national importance. Until a collective investigation of the
kind is completed and analysed it is vain to attempt any final
prognostic in heredity. If vital histories of families, with
medical details of their normal and abnormal members, could
be extracted from clinical records and reluctant memories, to the
number of some thousands, the inchoate condition of our opinions
in reference to heredity would be reduced to order and some
degree of precision.

It has been my practice, so far as possible, to construct
graphic charts of each family under observation, and these
have been submitted to Mr. David Heron, whose important
study of the Relation of Fertility in Man to Social Status
gained a wide and appreciative audience last year. Mr. Heron
has kindly formulated Chart V, which shows the incidence of
insanity in regard to individuals—one meniber of each family at
least having been insane. The chart, with the appended table,
shows the absolute and theoretical numbers, if no bias. It
would appear that the incidence bears heaviest upon the eldest
members of the families in fraternity, and that there is a fairly
constant diminution of frequency as the families increase in
size. I am not aware that this calculation has been made
previously—in fact, the methods of applied mathematics and the
working out of problems of probabilities in relation to biology
are as yet in an early stage of development. The important

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253

biometric system advocated and instituted by Professor Karl
Pearson will greatly enlarge our knowledge and correct our
prepossessions, if the desirable data are forthcoming. We
only require a collection of accurate facts in sufficient numbers
to reduce the margin of error.

Lecture II.— Statistical.

I now submit a sheaf of tables and charts which condense
the various observations to which I desire to direct attention,
and pass to Table VI. It will be observed that all cases of
gross pathological nature have been deducted, and that the
remaining cases of obscure pathology only are tabulated.

First, all cases in which alcoholism had a part in the etiology
of insanity are set aside, whether these were cases in which the
toxic effects of alcohol were symptomatic of the underlying
malady or truly causative. The prognosis of alcoholism is
indefinite and generally unfavourable. Fundamentally these
persons are deeply affected by hereditary predisposition to
abnormal conditions. Table XVII is designed to show this.
It will be observed that of no alcoholic certified and voluntary
cases investigated nearly 43 per cent, were hereditarily predis¬
posed to insanity, and nearly 22 per cent, to alcoholism. The
total neuropathic heredity was 70 per cent., and I have no
doubt that this percentage would be increased by further exact
information. There can be no doubt that the alcoholic
patients received into the asylums of the country are generally
and heavily burdened with a morbid heredity, and that their
failure is analogous to that of the ordinary insane—a failure in¬
herent in the organism and often made more manifest by environ¬
ment. I am not discussing drunkenness apart from insanity,
regarding which my opinions have been repeatedly and ener¬
getically expressed—that it is a vice to be reformed rather than
a disease to be cured. The insane drunkards are a class apart;
for instance:

Observation 2459.—Male, aet. 59, a highly-placed official, on the
point of retiring on pension. Mother suffered from recurrent mania
from adolescence. The patient was admitted with the ordinary symptoms
of acute alcoholism. When these wore off a deep melancholia with
strong suicidal impulses was revealed. He informed me that he had
been the victim of recurrent melancholia throughout his adult life, and

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THE MORISON LECTURES,

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had combated that morbid condition by means of whisky of the best
quality in increasing quantities as the attacks became more pronounced.
In the intervals he was practically a total abstainer. In the stress of
winding up his affairs preparatory to his retiring a very severe attack of
melancholia had supervened, and the great amount of whisky he had
consumed had induced or superadded the acute alcoholism which
blurred the clinical picture. Throughout his long service his true con¬
dition had remained absolutely unknown, even to his most intimate
friends. He eventually committed suicide, a common termination in
alcoholism.

Observation 2667.—A professional man, set. 49, admitted in a
condition indicating advanced degeneration of the brain. He belonged
to a neuropathic family, but had been successful and exemplary in all
relations of life until he rather suddenly, about six months before
admission, began to exhibit signs of moral and mental degeneration,
which his family attributed to excessive drunkenness. Post-mortem
a tumour of the dura mater was found pressing on the right frontal
lobe, described by Dr. Ford Robertson as composed of dense fibrous
tissue proliferating rapidly after slow growth for many years.

No doubt these are marked cases, but they indicate clearly
that the underlying condition of insane alcoholics is deep-
seated and definitely pathological. The true dipsomaniac,
usually characterised by periodicity of attack, is an insane
person, usually—I may say always —of neuropathic ancestry*.

A Fellow of this College cannot speak on this subject
without a brief reference to the recent death of Dr. Alexander
Peddie, by which an honoured name is removed from the
Roll. He was one of the first to insist upon the true patho¬
logical significance of dipsomania. His writings arrested
public attention and left an indelible mark.

The next column of Table VI relates to general paralysis—a
disease which is practically incurable and comparatively rapid
in its course. It is generally preceded by syphilis, often by
alcoholism. Dr. Ferrier has discussed this so fully and so
recently that I need not enter on it here, especially as his con¬
clusions command my assent. I would just note in passing
that by observations of lymphocytosis he has been able to
diagnose general paralysis before the pupillary symptoms, etc.,
were established. In Table VII—a statement of correlations—
it will be observed that out of forty cases twenty-three were
undoubtedly syphilitic, and fourteen were alcoholic. There is
in our records presumptive evidence of syphilis in seven other
cases. The exact truth is hard to find :

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I 907 -]

BY A. R. URQUHART, M.IX

2 SS

Observation 2508.—A man, aet. 46, was admitted in the maniacal
stage, with the usual grandiose delusions and motor symptoms. There
was no personal evidence of syphilis, and it was strenuously denied by
his wife and himself. I^ater his wife admitted that he had acquired
post-nuptial syphilis and had been treated for it, but that he would not
continue the medicines prescribed. This patient, in the stage of
dementia, fractured his femur in the middle third by the muscular
exertion of delivering a bowl in the course of a game. The degradation
of body and mind was complete M and I see no difficulty in correlating
the effects of syphilis with the manifestations of general paralysis in
these cases.

Three general paralytics were, in the first instance, cases of
gout of a marked type, and it seems to me that the effects of
gout may be similarly correlated. I do not lay much stress on
sexual excess, and have correlated exhaustion with two cases
only. The prevailing mental complication in causation is
worry. It is so general as to be almost inevitable in my
experience, but I shall refer to mental stress hereafter, merely
remarking here that worry does not stand in our records as a
sole causal factor.

My experience leads me to believe that the hereditary factor
is of importance in general paralysis. It used to be regarded
as not a hereditary disease, an opinion which must be revised,
if my experience is common, for in reference to these forty cases
of general paralysis the heredity of insanity finds expression ten
times, eccentricity four times, neuroses twelve times, and alco¬
holism fourteen times. Rheumatism, gout, and tuberculosis
are also noted. There was a distinct neuropathic heredity in
thirty-two cases.

Observation 2614.—Father died labouring under senile insanity,
mother neurotic. Patient acquired syphilis and became a general
paralytic. Fraternity : two deaths in infancy, one sister asthmatic, one
sister neurotic.

Observation 2421. Atavistic. Paternal grandmother was insane
in senility. The patient was first alcoholic, and then developed general
paralysis. Presumptive evidence of syphilis.

Observation 2379.—Transformation of neuroses. Father normal,
mother neurotic. The patient acquired syphilis and developed general
paralysis. Fraternity: eldest insane and paralysed, second eccentric,
third, fourth, and fifth normal, sixth general paralytic, seventh died sane.

Observation V 76.—Maternal grandfather and grandmother alco¬
holic, only daughter (the mother) neurotic. Father a general paralytic,
his brother's daughter neurotic—an infantile paralytic. Patient general

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[April,

paralytic, alcoholic, and syphilitic. Fraternity: one sister neurotic,
one brother alcoholic—a suicide.

I need not multiply these illustrations, but might note in
passing that the onset of general paralysis in two cases occurred
after severe influenza, and in one case after malarial poisoning.

I lately had occasion to send a specimen of a heavy brain
(60 oz.) to Dr. Ford Robertson for report. The patient was a
congenital imbecile, who had died of influenza at the age of 59.
There was no evidence of neuroglia overgrowth, but the changes
in the cortical cells were recent and acute, apparently connected
with the acute toxaemia from which the patient died.

It would seem that while general paralysis is most frequently
subsequent upon syphilis, alcoholism, the wear and tear of
unrestricted urban life, it may find a suitable germinating soil
in various diseases of an exhausting nature. Both cases of
influenza noted were, however, syphilitic. The toxaemic state
of influenza may, however, have been a final factor, just as it
has operated so frequently in cases of ordinary insanity.

In the earlier stages general paralysis is most difficult to
diagnose, especially if co-existent with chronic alcoholism. If
antitoxines are to be of real service they must be employed at
a very early stage, before degenerative changes have occurred
to any marked extent.

I have, however, been fortunate in having discharged
recovered two cases of syphilitic insanity occurring after
alcoholism and presenting paralytic symptoms.

A full account of these highly exceptional cases was pub¬
lished in the Journal of Mental Science for 1887. Both were
maniacal, but neither exhibited grandiose delusions nor were
the pupils characteristic. One was treated with green iodide
of mercury, the other with iodide of potassium. The former
died of epilepsy sixteen years after discharge, aet. 50. He was
not technically insane, and lived at home with his wife and
family. There was, however, some slight mental dulness after
epileptic seizures. Unfortunately, I lost sight of the other on
his leaving the country, but for some years after his discharge
I had letters from him and his medical attendant assuring me
of his well-being in every respect. Voisin has reported similar
cases to the number of fourteen.

Turning to the cases of epilepsy reported, it will be seen that
they are few in number, and I must add that all do not repre-

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1907.]

sent the ordinary cases of epilepsy which crowd the wards of
the great English county asylums- The number reported in
Table VI is twenty-four—twenty men and four women. Regard¬
ing these more critically, the cases of ordinary uncomplicated
epilepsy only amount to five. Eleven were cases of alcoholic
epilepsy—a^condition implying such a degeneration of nervous
elements as practically precludes the possibility of recovery.
This is not an invariable result, however. The following case
is unique in my experience:

Observation 2444.—A farmer, set. 44. Admitted in a condition of
alcoholic dementia. Physical state very bad, mitral incompetence,
sprawling gait. Had acute rheumatism eight years previously. Had
teen drinking from boyhood. Father and mother both sober. The
former was aged when married. The latter died aged of paralysis.
Fraternity : brother died of cardiac failure after long suffering from
asthma, sister died in child-bed. The patient was the youngest, married,
with no children. He had delirium tremens three years and two years
previously, and had at least three epileptiform seizures shortly before
admission. The mental attack began with mania, and he was brought
to the asylum suffering from alcoholic amnesia and in a very precarious
condition, tongue black and dry, bowels obstinately constipated. It
was one of the few occasions on which I have considered whisky indis-
pensible. In the course of two months he made a complete recovery.
After a lapse of seven years I hear that he is a reformed character, quite
sober, and attending to his duties at the age of fifty-one.

The remaining cases of epilepsy were directly due to organic
disease of the brain or senile degeneration with the exception
of three, which were traumatic.

Observation 2345.—A sailor, set. 27, was admitted in a condition of
mischievous dementia with epilepsy. Father died of cerebral apoplexy,
mother alive and normal. Fraternity : eldest sister subject to juvenile
epilepsy which ceased in adolescence, one brother normal, the patient,
and one younger sister normal. He fell into the hold of his ship and
was unconscious for some weeks, about eight years before admission.
The first seizure occurred two years after the fall on exposure to
extreme heat in Calcutta. He is reported to have been troublesome
and of a low mental standard from boyhood. He died in the status
efilepticus at the age of twenty-nine. Post-mortem there was no evidence
of injury to the skull. Dr. Ford Robertson found a slight degree of
thickening and opacity of the pia arachnoid over the convexity of the
hemispheres. The spinal dura mater was much thickened, especially
in the upper cervical region. On the mesial aspect of the right frontal
lobe there was a slightly depressed area over which the membrane was
thickened and puckered. A large area of softening was found in that
lobe, indicated by the depression above noted. Posteriorly it faded
away in the lenticular nucleus. It seemed to have been the result of
traumatic haemorrhage.

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2 58 THE MORISON LECTURES, [April,

Observation V 73.—An Indian official, aet. 34, admitted in a weak
and facile mental condition. Family history unimportant, except for
angina pectoris in paternal grandfather. Ten years before admission he
fell from his horse and was unconscious for ten hours. He thereafter
slowly changed from a capable, hard-working man to a person of listless
habit. Nine years after the injury he had a fit which incapacitated him
from duty; subsequently several severe fits and daily petit mat —a
momentary clouding of consciousness. The aura was marked, a feeling
of the epigastrium rising to the fauces and choking him, this accom¬
panied by an unpleasant taste, and a further feeling of his head being
involved. He became very childish with marked amnesia. Right
forearm pronated and trembling—a condition which at first could be
inhibited by attention and control. The right side was markedly
affected in convulsions. The right leg became affected. Mr. Cotterill
operated and found a patch of opalescent membrane over the left motor
area and evidence of high tension within the membranes. There was a
distinct improvement in the motor and mental symptoms for a time
after the operation, but in the course of some months he declined and
fell into a state of general mental degradation, and died in an epileptic
seizure at the age of thirty-eight. Dr. Ford Robertson reported on the
cerebral membranes at the time of operation, having found them to
consist of many bundles of dense, fibrous tissue containing a small
number of capillary vessels, the result of a chronic inflammatory pro¬
cess. Post-mortem the membranes were still more affected, and an
infiltrating glioma of the left cerebral hemisphere was discovered. Dr.
Ford Robertson was of opinion that the growth had begun in the
island of Reil, the whole of which was affected, as also were the frontal
and temporo-sphenoidal lobes, the basal ganglia, the whole of the cornu
ammonis, the white matter of the centre of the parietal lobe as high as
the corpus callosum, the cortical surface of the anterior third of the
temporo-sphenoidal lobe and the tissues in the interpeduncular space.
The usual pathological conditions of the nerve cells were noted.

These cases of epilepsy, then, whether obscure in origin, or
alcoholic or traumatic, are definitely of evil omen as regards
prognosis. If the exhibition of bromides do not arrest the
march of the morbid symptoms there is little hope that hospital
treatment can do more than care for a disease which is pro¬
gressive and fatal.

It is interesting to note, however, that senile epilepsy in the
insane has been resolved into two factors of the same nature as
true epilepsy by Dr. John Turner, viz ., an unstable condition
of nerve cells, and a condition of stasis or cerebral anaemia
resulting from arterial disease—endarteritis obliterans. The
thesis of his important paper just published is that the blood
of epileptics is abnormal and characterised by a special tendency
to intra-vascular clotting.

The group of coarse organic diseases of the brain need not

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BY A. R. URQUHAKT, M.D.

259

I 907 .]

detain us. The recovery of a patient so seriously damaged is
a very rare occurrence. I can find but one instance on our
records.

Observation 1901.—A man, set. 65, was admitted with evident
symptoms of organic disease of the brain. Father died of cardiac dis¬
ease. Ten years previously he was irritable and depressed for a time.
Four years previously he had a fit followed by mania with aphasia. For
a considerable time before admission he was exalted and excited in
conduct, alternately with periods of depression and taciturnity.
Tremors of the tongue, thick, indistinct speech ; left-sided ptosis were
marked. After a moderately severe attack of mania he made a good
recovery in three months. He returned to his home and went about
his affairs as usual. No doubt there was some deterioration mentally,
but he was quite able to conduct himself rationally, until he was carried
off by an apoplectic seizure and paralysis of short duration some
months later. This case is also remarkable as a recovery after a period
of Cheyne-Stokes , respiration.

It will be observed that twenty-six cases of traumatic origin
are reported, as usual, mostly in men. I have included cases
of insolation, where there was a probability of that cause having
been effective. It is well known that no insane patient who
has visited the tropics can be admitted to an asylum without
a history of sunstroke. It is a facile explanation. Unfortunately
my experience is that these traumatic cases are of the most
serious import. Dr. Van Gieson investigated many of them in
New York, where it is common to find a person stunned and
senseless from a blow given by a piece of lead wrapped in flannel,
which leaves no external mark whatever. He found it impos¬
sible, post mortem , to distinguish between a brain so injured and
a case of insolation. The pathological changes were invariably
those of early and widespread degeneration of the cortical cells.

I have also deducted the class of idiots and imbeciles, as
persons who by early defect are absolutely incurable, and of no
special interest in this relation.

Table VI therefore properly begins with a consideration of
554 persons suffering from ordinary insanity, as distinguished
from 255 persons of obvious pathological significance. Further,
it will be observed that the incidence of these pathological cases
bears heaviest on the male sex, and illustrates the lower recovery-
rate and the higher death-rate for that sex. The particular
incidence of alcoholism, general paralysis, epilepsy, organic
brain disease, traumata, and even idiocy recorded here is by
far more excessive in affecting men than women. I need not

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260 THE MOR1SON LECTURES, [April,

discuss the underlying reasons for this excess; it is a well-
established fact, and, of course, broadly renders prognosis
graver for men than for women.

The numbers for ordinary insanity, therefore, stand at 235
and 319 out of the totals of 419 and 390 for males and females
respectively.

The second part of Table VI deals with these cases of
ordinary insanity from the point of view of stress. I have been
accustomed to classify all cases as innate or acquired , and also
as affected by mental or physical stress. Naturally a case must
be either innate or acquired, but if there be no evidence
obtainable as to neuropathic heredity the entry is made under
“acquired.” This leaves a large margin of probable error,
familiar to all concerned. The total neuropathic heredity, as I
have said, reaches 72 per cent, of the persons received, and no
doubt more accurate information would enlarge that percentage
materially, and, of course, at the same time diminish the
numbers under “ acquired.”

Previous observers have recorded the heredity of insanity
only. Dr. Hack Tuke calculated the percentage as 20*5 out of
136,478 admissions into English asylums; but that must be
regarded as much too low, for we know that those returns are
absolutely untrustworthy. Dr. H. Grainger Stewart reported
49 per cent, out of 901 cases at Dumfries; but he included
eccentricity, and, so far as I can learn, was the first to recog¬
nise this particular form of want of mental balance as definitely
important. Dr. Savage recorded 34 per cent, in Bethlem Hos¬
pital out of 1072 persons. Dr. W. F. Farquharson recorded
30 per cent, out of 3907 admissions to the Cumberland and
Westmoreland Asylum. The percentage of insanity alone in
my experience is 45, but it must be noted that in the latest
period of observation it rose to 48 per cent.

With regard to mental and physical stress, these are noted
when apparently of definite importance in etiology. Now
severe mental strain, sudden or prolonged, is inevitably put
forward as the cause of insanity in the history of every case in
which it can be alleged. It is analogous to the similar asser¬
tion as to sunstroke in the case of a patient with a tropical
history. Is it really effective in the production of mental
disorder ? I think not.

Observation 2523.—A drunken ne’er-do-well deserted his wife and

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* 907-1 by a. r. urquhart, m.d. 261

two daughters and disappeared in early life. The daughters moved
from old associations and set up a small millinery business by which
they supported their mother and themselves. In old age the business
still continued, although not quite so remunerative. The elder sister,
set 65, began to worry about their future; she could see nothing but
disaster and poverty before them. No doubt there was a substratum of
fact in this, but it is to be noted that the younger sister did not take
that gloomy view; she did not refuse food and prefer death. Indeed,
she still carries on the business, and is a well-nourished and cheerful
person, in spite of having been the victim of a street accident and
greatly shaken. On examination of the patient, however, the usual
somatic conditions were revealed. A long course of ill-considered
dietary and overwork had resulted in a chronic gastritis, with a dry,
cracked tongue and habitual constipation. The pulse was feeble and
rapid, with a slight roughening of the aortic sound and atheromatous
arteries. She was also reported to have had several slight epileptiform
seizures. It is also to be noted that she sustained an abrasion of the#
ankle, which she neglected, and had at length to remain in bed until it
healed. There was no morbid mental symptom until she had been in bed
for some time. The history of the case was towards progressive bodily
and mental degradation, until death at the age of 68. Post mortem
the brain showed the usual degenerative changes, the left ventricle of
the heart was greatly hypertrophied, the arteries were atheromatous, and
the stomach and intestines showed patches of chronic inflammatory
changes.

The mental stress to which these sisters were exposed was
not more severe on the one than on the other. The facile ex¬
planation of her malady was ineffective and misleading.

Or, turning to mental stress of a sudden and unforeseen
nature:

Observation 2148.—Female, aet. 41, admitted in a state of recent
mania, said to have been caused by her brother-in-law coming home
drunk and jumping with a child from a window. Investigation showed
that she had previously suffered from acute rheumatism, and had been
delirious in the course of the attack. She thereafter suffered from
gastric troubles, irregular appetite and constipation. She was sleepless
and the catamenia were deranged. She went to visit her sister in the
hope of a change proving beneficial, when the drunken act of her
brother-in-law apparently determined the further course of her malady,
from which she made an excellent recovery. Her heart was undamaged
by the rheumatic trouble, and under ordinary care and treatment she
soon made progress.

In the light of these experiences I have therefore critically
examined the cases in which mental stress was alleged, and find
that the almost inevitable complement to mental stress is innate
or congenital defect. If a person is entered under “ mental
stress” he is almost inevitably entered under “ innate.” Sixty-

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262 THE MORISON LECTURES, [April,

four instances of this combination are recorded. On the other
hand, the combination of acquired insanity with mental stress
alone is extremely rare. Three cases are recorded, and they
are so recorded before my appointment to Murray’s Asylum.
They may be briefly mentioned: one a case of adolescent
dementia who developed epilepsy in maturity, and died in the
status epilepticus; one a case of adolescent melancholia who
remains resident in a condition of senile dementia; and one,
a case of ordinary melancholia at the age of thirty, who has
long been lost sight of. They rather tend to support my
conclusion.

The study of insane persons, in my opinion, must be mainly
referable to the conditions of physical organisation, and the
♦ conditions of physical pathological processes.

But it will be objected that great sorrow, great affliction,
great mental trouble must necessarily affect the somatic pro¬
cesses, and must be of weight in determining the pathological
event. It is a common observation that worry has a place, and
a very important place, in the genesis of general paralysis. To
that I can only reply that it is not within my experience that a
person of good ancestry, sound in mind and limb, is overwhelmed
to the extent of the mental reduction recognised as insanity.
There may be cases where mental stress alone has so affected
the somatic condition of nutrition and repair in a previously
normal individual that the defences are broken down or
destroyed, and that insanity arises in a secondary manner. I
have not been able to discern such a case among the 809 persons
regarding whom these studies have been made, nor can I find
a case in the records of my consulting practice, in which, of
course, one sees many patients who never require the care and
control of a special hospital. I cannot therefore corroborate
the statement that prolonged mental stress is of evil omen in
prognosis.

I shall not detain you with an examination of the totals or
percentages given in Table VI, which must be submitted with
diffidence owing to the comparative incompleteness of the
information on which it is founded. It is evident that final
results tend to show that the innate or hereditary cases recover
in fair proportion, although they are more subject to relapse
than the acquired. This has been widely recognised, but I do
not know that the heavier death-rate among the acquired cases

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1907.]

BV A. R. URQUHART, M.D.

263

has been shown before. It may be that the more severe causal
factors requisite to issue in insanity in persons not congenitally
predisposed find expression in this way.

I might here repeat that the forms of mental disorders as
named are used quite loosely: melancholia for cases chiefly
characterised by depression, whether excited or not; mania for
cases chiefly characterised by excitement or exaltation, whether
depressed or not; delusional insanity for those cases dominated
by delusions, generally systematised and fixed; dementia for
those cases of mental enfeeblement generally issuing in terminal
states, including folie circulaire, which always in the end tends
to enfeeblement more or less pronounced. Recent means that
the malady on reception of the patient was of less duration
than one year. The recovery rates of melancholia are 3379
and 13*51, having regard to recovered and relapsed cases in
innate cases, and 28*13 and 7*81 in acquired cases. On the
other hand, the recovery rates of mania are 31*16 and 24*64
for innate cases, and 39*62 and I3’2i for acquired cases. The
recoveries from delusional insanity and dementia require closer
scrutiny.

Observation 2180.—A farmer, set. 27, admitted after an irritable
period characterised by delusions of persecution, which had lasted for
six months. Father alcoholic, two aunts insane. His delusions were
well marked and apparently fixed ; he was under the influence of unseen
agency by means of a “norapath” for collecting sounds. These
delusions persisted for nearly twelve months, when he was discharged
recovered. It was a question whether he did not effectively conceal
his delusions, but they did not at least interfere with his work or con¬
duct in life for many years thereafter.

It is open to doubt whether the female dements entered as
recovered should have been included in this category, for
certainly both were alcoholic.

Observation 2281.—A married woman, set. 28, with three healthy
children. About two years before admission developed psoriasis and
persistent vomiting, with want of appetite and gravely impaired nutri¬
tion. Six months later she took alcohol to excess, and so continued
until peripheral neuritis and dementia supervened. She walked with a
feeble, shuffling gait, her memory was a blank, she did not remember her
children. Mentalisation was extremely slow, and her reflexes were
generally dull. Under thyroid treatment her memory returned, the
psoriasis disappeared, and she made marked and rapid improvement.

A foul, purulent discharge from the vagina was successfully treated.
She was sent home perfectly recovered in 1895 and so continues.
There was no indication of syphilis. I believe that the alcoholism was

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264 THE MORISON LECTURES, [April,

subsequent to, and consequent on, the earlier symptoms described.
Still, there had been excessive drinking, and, as I have previously said,
the prognosis in such a case is most doubtful.

We may now glance at the age period of Table VI in
relation to final results. It will be noticed that I have
grouped these periods as adolescent (up to 25 years of age),
mature (up to 40 years), climacteric (up to 60 years), the senile
cases having been already separated. With regard to the
group of melancholias the adolescents are in a marked
minority, while the period of maturity exceeds that of the
climacteric, the absolute numbers being 40, 97, and 75.
The position is reversed for cases of mania by the numbers
83, 78, and 69. The percentage of recoveries from melancholia
tends to diminish as the age periods increase—a condition of
affairs directly the opposite in reference to mania. The
tendency in regard to all the death-rates is towards an
increase with age, the adolescent naturally showing the
lowest figures.

I infer that the slight mental reduction of melancholia in
youth is eminently curable, for if we add the recoveries and
relapses the total is 62 per cent .; but the deeper reduction of
mania, even omitting the development of dementia, is less
likely to end favourably by 11 per cent. This table, however,
relating to the more recent cases of adolescent insanity, cannot
be considered complete, the period having ended with 1904,
and the results having been only carried down two years later.

The following abstract of Table VI is of some interest:

Total Nos. Pathological. Ordinary.

Melancholia 115 150 265 29*57 12 66 20 00 70 43 87 33 80 00

Mania 149 154 303 5101 23 38 36 96 48 99 76*62 63*04

Enfeebled . . 144 83 227 . 43*75 15*66 33*48 56*25 84*34 66*52

Table VII is designed to show certain associated conditions
found on first admissions in various correlations. In our
search for a definite cause for insanity—an indispensable

factor which can be found in every case—there is a certain
impatience in the consideration of multiple causation. I do
not consider that this is a reasonable attitude, nor is it likely
to be appropriate in the prophylaxis of insanity. The con¬
tributory causes are certainly of sufficient importance to
demand careful investigation in each individual case, and
I have, therefore, constructed this table as a resume of their

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BY A. R. URQUHART, M.D.

265

1907 .]

incidence in association. As the table stood originally it
occupied great space, having been carried to final results in
each column. I submit a condensed copy which is sufficient
for the present purpose. It refers to all forms of insanity in
809 cases. The total neuropathic heredity (581 cases) is thus
seen to be effective in combination with other causes; for
instance, it is pre-eminent in epilepsy, general paralysis,
alcoholism, gout etc., tubercle, syphilis, traumata, and even
in senile cases of insanity. Again, the association of general
paralysis with syphilis and alcoholism is readily determined;
the frequent association of tubercle with neuropathic heredity
is evident; and the inevitable relation between alcohol and
syphilis.

If these combinations are studied in reference to results of
treatment the influence of hereditary defect is more apparent
in depressing the final recovery rate and raising the death rate.
While the neuropaths who suffer less important and less vital
disorders maintain their favourable position, the combination,
for instance, of neuropathic defect and alcoholism, or tubercle,
or syphilis, renders the prospect of recovery much less favourable.
Taking the less formidable combination of non-toxic exhaustion,
by which I mean over-exertion with hereditary defect, the
numbers are—from 27 persons 4 recovered, 18 did not recover,
and 5 died, or 14,66 and 18 per cent . respectively; or, in reference
to syphilis, 7 per cent . recovered, 60 per cent . did not recover, and
32 per cent . died.

It was formerly thought that the association of tubercle with
insanity was particularly fatal in results. I have therefore
worked out the percentages of neuropathic tuberculosis as
follows: In 25 persons—recovered 32 per cent ., unrecovered
32 per cent., and died 36 per cent . Although these are small
numbers and therefore liable to a wide margin of error, I believe
that they will be found approximately correct for modern
practice. In a period of overcrowding and defective hygienic
conditions 13 per cent . of all the deaths in the Perth Royal
Asylum were due to tuberculosis, nor did that represent the
whole incidence of the disease, for post-mortem examinations
reveal a much larger proportion in present asylum practice.
In the period under review the percentage of these deaths was
little more than half— viz. 7 per cent. Modern methods of treat¬
ment may be illustrated in results as follows :

LIII. 18

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266 THE MORISON LECTURES, [April,

Observation 2488.—A male patient, aet. 28, admitted in a very
exhausted condition, with delusions that he is in heaven, etc., restless
and excited. Father died of cardiac disease, mother died of tubercular
peritonitis. Maternal uncle insane. Brother alcoholic. Phthisis in
several members of the family. The left lung was evidently seriously
damaged, and his heart was affected by mitral stenosis. A more
unpromising case could not have beqn received. Within two months,
however, he was discharged recovered, and he has been engaged in his
daily avocation for the last six years. I occasionally hear from him, in
good health and spirits.

Table VIII is designed to illustrate the incidence of occupa¬
tion and environment , with reference to heredity and results of
treatment . The occupations are arranged in the census groups
and represent the whole number of persons under care. The
stress of life in towns is often unfavourably compared with the
idyllic conditions of the country. First of all, it is difficult to
decide how to place many of these patients. It seemed reason¬
able to divide urban and rural dwellers in accordance with the
size of the towns—a population of some 5000 being reckoned
rural. The usual place of residence for several years previous to
admission was regarded as fixing the classification. On that
principle, 456 might be considered as of urban extraction and
353 rural. In the former 73 per cent . were of neuropathic
heredity and 27 per cent, were acquired cases. In the rural class
70 per cent . were neuropathic and 30 per cent . were acquired.
That represents no great difference and no marked evil effect of
town life as regards heredity. The towns, of course, are steadily
recruited from the country, but if neuropathic disorders are
degenerate that untoward influence is nearly as effective in the
one as the other. Of course I am not dealing with the
industrial class, but with a comparatively’stable class, which has
apparently attained its maximum ratio to the general popu¬
lation, and, at least for some years, has shown no tendency to
increase.

When we turn to the nature of the mental disorder, whether
ordinary or pathological, we find that these stand in the pro¬
portion of 70 to 30 per cent . in urban cases, and 81 to 19 per
cent . in rural cases. The untoward side of urban environment
is thus revealed. The effective soil for the germination of
insanity was nearly equal, while the evolution of actual insanity
was aggravated by the environment, resulting in a difference of
3 per cent, in the death rate.

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Chart IX is designed to show the seasonal incidence of
insanity. The usual statistical tables of the months of admis¬
sion to asylums bear no close relation to the onset of the
malady. They are merely official statements, and should be so
regarded. The period of importance is not the time of certifi¬
cation and legal interference, but the time of inception.

The onset of insanity has been comparatively neglected; it is
obscure, often overlooked, and generally regarded as of little
significance. On the contrary, the whole tendency of modern
research is towards the elucidation of the prodromal and incep-
tional periods. If insanity should be proved an affair of
toxines, as the studies of competent observers appear to indi¬
cate, it will be in the early stages that medical treatment will
be most efficacious; even under present conditions that is con¬
ceded. I need not labour the point.

If we regard the facts of arterio-sclerosis, which in my belief
frequently issue in insanity, we can discern a similar train of
causation, a similar importance of early treatment, and a
similar degeneration proceeding from innate defect aided, it may
be, by toxines, lead, alcohol, or syphilis. Similar agencies are
at work, and if the vessels of the brain be affected there is, of
course, a relative anaemia resulting in vertigo, confusion, etc.,
which process may proceed to thrombosis, localised necroses,
and softenings.

The pathology of arterio-sclerosis is therefore of great im¬
portance in insanity, not only as a cerebral degeneration, but
as affecting the brain by an invasion of other vital organs ; and
its early recognition is essential if the disease is to be stayed
and controlled, whether it issues in an anaemic atrophy of the
kidney or an anaemic atrophy of the brain.

On the general principles of medicine, therefore, I have
always endeavoured to ascertain and record the earliest sym¬
ptoms of somatic disturbance heralding insanity, and I may
say at once, and finally, that in every case these somatic dis¬
turbances can be clearly recognised and recorded if one is
dealing with persons of ordinary intelligence who have been in
close relations with the patient. They are well known : general
malaise, gastric and intestinal disturbance, sleeplessness, irrita¬
bility, inability to go about the ordinary affairs of life, and so
on. The fear of impending madness is quite common, especi¬
ally in general paralysis, and it is soon masked by other mental

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268 THE MORISON LECTURES, [April,

manifestations : but the feeling of bien ctre is never a prodrome—
it is a symptom of declared insanity.

I regard the inception of the attack as the period when these
vague prodromata culminate in indubitable insanity—that is to
say, when it evolves as insanity from the medical point of view,
altogether apart from the question of certification for legal
purposes.

It has been found possible to determine this date in 913 cases
with sufficient precision. Many years ago Sir Arthur Mitchell
constructed a most interesting chart relative to deaths regis¬
tered under various diseases, showing the seasonal incidence of
deaths. Unfortunately, I can only refer to it from memory,
but it was impressed upon me as showing the maximum inci¬
dence for respiratory diseases in spring, for nervous diseases in
summer, and for abdominal diseases in autumn. That was
in consonance with the undoubted high prevalence of suicide
in July and the low rate for November. The chart which I
now submit is more in consonance with still older observations.
Dr. Edward Smith (Health and Disease , 1861) says that “ brain
diseases prevail in the cold season/’ and he found that writers
of the seventeenth century placed diseases of the head and
nerves under the sign Aries—that is, April—when, according to
ancient writers, diseases began in the head, descending to the
throat in May, to the stomach in July, and so on.

If we consider the total incidence in three-monthly periods,
beginning with December, the inset in the chart shows a culmi¬
nating rise till May, when the fall is continuous until November.
My impression as to asylum excitement has been that it does
not so much depend upon the season as a change in the type
of weather—the more rapid and complete the alteration the
more marked the effect. But although we have kept charted
records of the barometer and thermometer for many years and
have attempted to correlate them with the varying conditions
of patients, no order has been evolved from the complicated
series of facts so dealt with.

To return to Chart IX, it is evident that the points marked
are at maximal elevations for April, June, and December,
showing a singular abrupt fall in May and a more prolonged
fall towards the autumnal months. These 913 cases have, of
course, been spread over a period of twenty-five years, and
there does not seem to be reason to regard the results as

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BY A. R. URQUHART, M.D.

269

1907.]

untrustworthy. The fall in May and the rise in June is inex¬
plicable, especially when it is noted that the charts of recoveries
and deaths to be found below show the same regression.

Sir Arthur Mitchell has kindly constructed a chart of inci¬
dence on onset for me (No. IXb) which shows a more equable
course, for the influence of the preceding and succeeding
months of any one month are taken into account. The average
is carried out instead of the absolute numbers. The result is
a period of greater and lesser intensity in winter and summer
respectively, and I believe that this gives a better idea of the
total incidence as regards seasons.

I also submit curves for the onset of the male and female
cases separately, and for melancholia and mania occurring in
males and females separately. From these it would appear
that the weather exercises a greater effect upon women than
men, and certainly meteorological conditions seem to find them
more sensitive in asylum life.

Table X is designed to show the duration of attack on admis¬
sion in relation to ordinary insanity, together with the facts of
heredity and results of treatment, correlated with the age-
periods. It shows that the cases who are received early and
promptly treated are in better expectation of recovery, not¬
withstanding the hereditary burden under which they may
labour, and it thus emphasises what has been already brought
out by Table VI. I need not linger over it, as these references
have long been emphatically expressed. The results of treat¬
ment, whether recovery or death, are mostly crowded into the
earlier months of asylum life.

Chart XI is designed to show the age on first attack , arranged
in quinquennial periods. It will be apparent that the curve
rises rapidly from ages less than twenty to the maximum on
the completion of adolescence. From that point it falls, with
two short increases, to the eventual minimum. These regres¬
sions mark the climacteric periods of women and men when
the curves for the sexes are separately studied.

Chart XIa shows the recoveries from first attack in relation to
age on recovery. These have been calculated as nearly as
possible for 253 first recoveries, and constitute a curve similar
to that of the ages on first attack. This should be read in
comparison with the curve for ages on first relapse, although it
deals with smaller numbers.

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270

THE MORISON LECTURES,

[April,

It is certainly disquieting to find that out of 809 persons
admitted no fewer than 195 had already suffered previous
attacks, as set forth on Table XI 11 A. It is good reason for a
thorough revision of our methods, for a closer study of the
early symptoms, and for a revisal of treatment.

The cyclic order of life, the slight diurnal changes in health,
are, of course, frequently magnified in disease, and there is a
distinct tendency to enter upon, and to continue in a vicious
circle of mental disorder. Table XIIIa shows how common
these relapses are. I have stated that nearly a quarter of the
whole number received were already relapsed persons on first
admission, and may add that 76 of the 173 readmissions were
returned relapsed. I am also informed that 18 relapsed after
final discharge. Appended to the Table is a statement of the
number of attacks referable to 250 persons. Further, the
recoveries reported have been regarded as either temporary or
permanent, with the result that 38 per cent. of the former yields
but 17*18 per cent . of the latter.

This attempt to arrive at the true recovery rate is worked
out in another way, within the limits of asylum statistics, in
Table XII. The net recovered persons during forty years are
stated at 29 per cent .—which is manifestly too high. Dr.
Robert Jones ( British Medical Journal , 1905) stated that 30 per
cent, recover of the total admissions, and that 28 per cent, of the
recoveries relapse—rather more than 1 in 4. Dr. Clouston,
referring to this, calculated that, excluding the obviously
pathological group of cases the majority recover, and of that
majority one-third relapse—in proportion similar to cases of
rheumatism, gout, and bronchitis; and he further added that
given earlier treatment, comparable with that afforded to
rheumatic patients, more would recover. But it is this loose use
of the word “ recovery ” which confuses the issues. A hospital
recovery from rheumatism or an asylum recovery from insanity
is justifiably recorded for the time being; but these diseases of
obscure causation have a marked tendency to relapse or recur,
and must remain records of failures until our methods of treat¬
ment are efficient to prevent these relapses and recurrences.
A generation ago Dr. Pliny Earle effectively exposed the
absurdities of the statistical methods formerly prevalent in
American asylums—methods which resulted in statements of
recoveries having occurred at the rate of 100 per cent. He

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190;.] BY A. R. URQUHART, M.D. 271

traced the gradual decline of these optimistic extravagances,
and endeavoured to guide the specialty into a discrimination
between cases and persons . The hunger for “ recoveries *' still
exists to confound us in statistics. They must be obtained in
another way. It is incredible that the methods of a previous
generation were capable of inducing better results than the
methods of to-day; but I have already, elsewhere, shown that
the patients coming under treatment were then more acute in
their malady, less aged in their years, and less deeply affected
by gross pathological changes.

I have carefully reviewed and considered the recoveries of
persons and cases, with the result submitted, and am certain
that 17 per cent . of permanent recoveries represent the limits of
truth in the desirable direction; yet it must be borne in mind
that those relapsed cases on temporary recovery have often long
periods of freedom from disorder, and are often for years useful
citizens in their respective spheres of life.

The Table of recoveries after first admission (XIII), correlated
with neuropathic heredity, age periods, and duration since
first attack, need not detain us. It establishes the fact that
recovery takes place in the greatest number of instances within
a period of six months. Of course the recoveries noted after a
long period of years do not denote first recoveries. The inci¬
dence of neuropathic heredity is thus seen from the side of
recovery.

I had also prepared a table showing the increase of body
weight in recoveries, but it may be summarised in a few
words. The mean gain on recovery was 10*51 lb. in men, and
13*43 lb. in women. On the other hand, the mean gain among
men removed unrecovered was only 1*00 lb., and among women
there was an actual mean loss of 3*79 lb. The important
bearing of this observation has been frequently discussed, and
I need not revert to it here.

A table of patients removed unrecovered has been omitted,
the results being obscured by financial, social, and official
incidents.

It will be convenient now to refer to the ages of first relapses,
which are also shown on Chart XIa. There is a steady and
regular increase in the numbers year by year up to the age
of 40, when the line falls until it marks the occurrence of
the climacteric. The deaths show nothing peculiar to the

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272 THE MORISON LECTURES, [April,

insane on these charts, and they must be studied from another
point of view.

One of the questions of prognosis has reference to expecta¬
tion of life . This is of importance in the matter of life insur¬
ance, in the matter of financial arrangements made in the
interest of private patients, in the matter of asylum accommo¬
dation for State-supported patients. Does insanity shorten
the life of the individual, and if so, to what extent ? Obviously
the occurrence of general paralysis decides the question for
that class within a year or two, although one could recite
exceptional cases of a chronic type. The somatic con¬
ditions must be taken into account in individual cases, and
broad generalisations must be applied with discrimination. It
used to be stated that, granting that the person survived the
acute attack, his life in regular and ordered routine would be
actually prolonged, and every asylum of old standing records
patriarchal ages on death. Dr. Robert Jones (British Medical
Journal , 1905), investigated the death rate for asylums com¬
pared with the whole population, and concluded that death
occurs amongst the insane at least six times as frequently as
among the sane at corresponding ages. He also found that
the average age of men received by the London County Asylum
was 42 years, and the average age at death 507 years, instead
of the normal expectation of 66 years. The results are not
quite so gloomy in my experience. I find that the average age
on admission for men is 36 years, and the age at death 54*65
years, as against 63*96 years for healthy males, while the
average age on admission for women is 38 years, and the age
at death 60*93, as against 66*83 for healthy females; but the
percentage of deaths on the average numbers resident in
Murray’s Asylum for the past 40 years is only 6*03 per cent.,
compared with 7*1 per cent, in the London County Asylums.

This question may be approached in another way, and
Mr. Mayhew Allan has kindly constructed tables—comparing
the percentage of deaths among the insane at various age
periods with the Hm. Tables of the Society of Actuaries.
Ages 15 to 25 show a better result for insane than for sane;
ages 25 to 60 reverse this finding, while the results at ages
above 60 return to the adolescent characteristic. The table
must be presented with considerable doubt as to margin of
error, a separation of the sexes having resulted in still further

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I 907 -] BY A. R. URQUHART, M.D. 273

doubt, yet it tends to show the heavier mortality for males, as
has been previously stated.

Tables XIV and XV deal with the deaths in admissions and
readmissions. The former shows the general causes of death
correlated with neuropathic heredity and forms of mental dis¬
order on admission. On examining the aggregate numbers it
will be seen that deaths occur most frequently consequent
upon mania and dementia. Deaths from melancholia and
mania do not arise from exhaustion, except in rare instances.
The deaths are, like the admissions, the results of somatic
diseases, the diseases of the cerebro-spinal system naturally
predominating. Therefore, from whatever point of view
insanity is regarded, we return to the basal fact that it is
somatic. The slight degradation of melancholia finds ex¬
pression in twenty-nine cases, whereas mania is represented
by seventy-three cases. The enfeebled class, of course, repre¬
sents the accumulated wreckage, and includes many different
conditions, from idiocy to senility.

The number of deaths after first admission is 140 : males 86,
females 54, the percentages being 17*30, 20*52, 13 84 for these
respectively. This, again, establishes the fact that insanity in
men is much more fatal than in women, and is distinctly trace¬
able to conditions previously referred to—alcoholism, paralyses,
and organic diseases which preponderate in the male sex. Of
course this Table does not show the complete mortality from
general paralysis, nor, indeed, any of the somatic diseases, because
many patients were removed unrecovered. It is merely a record
of fatal results in reference to certain accidentally selected cases.
Table XV mainly illustrates the heavy mortality in the earlier
months of insanity, and I do not analyse the details.

To resume, 809 persons were admitted, 252 recovered, 315
were removed unrecovered, and 140 died, leaving 102 resident.
The percentages are: recovered 31*14, unrecovered 38*93, died
I 7*30, remaining 12*60—slightly differing from the returns of
Table I for admissions and re-admissions. The expectation
for this class of patients therefore would be : of every 10 patients
received 3 will recover, 4 will leave unrecovered, 2 will die
during residence, and 1 will remain indefinitely resident. But
it is to be noted that of the 3 discharged recovered it is pro¬
bable that not more than 2 will remain permanently sane.
This practically agrees with Dr. Thurnam’s finding in a

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274

THE MORISON LECTURES,

[April,

similar institution half a century ago: “Not more than two
remain well during the rest of their lives.” It is a gloomy
prognosis, verified too long and too surely. I hope and trust
that the future will mend it.

Lecture III. Somatic Correlations and Resume.

Having reviewed the clinical experience of twenty-five years
from a statistical point of view, I shall now proceed to con¬
sider certain correlations between somatic and mental phe¬
nomena.

There is no doubt just at present some disparagement of
psychology in these studies, and a sceptical attitude towards
the assumed occurrence of a mental disorder without an
operative physical cause, yet I cannot range myself w r ith the
opponents of psychology. For instance, by his researches
into the phenomena of fatigue Kraepelin has explained what
was formerly obscure, and improved the methods of education
throughout Germany. Mental fatigue and bodily fatigue exer¬
cise the same effects upon the brain, and it is a mistake to
suppose that by altering the kind of fatigue reparative pro¬
cesses will be encouraged thereby. Italian observers have
demonstrated the toxic nature of fatigue in the lower animals,
and we can precisely understand the process.

I have reported from time to time cases of communicated
insanity —folic a deux , and have inquired into cases reported
in the newspapers as they occurred. The circumstances are
somewhat difficult to unravel because of the prepossessions of
those who relate them, and it would appear that these inci¬
dents are more common in France and Ireland than with us.
Is it possible to infect , so to speak, a person with insanity by
immaterial communications ?

Observation 2607.—Two sisters arrived at the asylum one after¬
noon, the younger being in possession of the usual legal papers for the
detention of the elder. They both presented the same pronounced
delusions of persecution, both had experienced the same mysterious
influences, and both had seen the same visions. They declared that
commands were issued to them simultaneously, and they had to obey
simultaneously. It became evident that this account of their troubles
would not stand rigid scrutiny. The elder sister, who had been
successful in business, dominated the younger, and was the active
partner, the suggestor of every morbid idea. She had performed the

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BY A. R. URQUHART, M.D.

275

part of a Joanna Southcote, and her sister, her only disciple, explained
the failure of intention as the direct result of Satanic interference. It
also became evident that the elder sister's insanity had been of con¬
siderable duration before the younger sister joined her in lodgings;
and, indeed, she remains an ordinary case of chronic delusional
insanity. The younger sister, after the separation, improved somewhat
at home, but was eventually sent to another asylum, where she partially
recovered and was accordingly discharged. As usual, any hereditary
disease was denied, and, as usual, the hereditary defect was ascertained.
I do not believe that any case of this kind could be traced to a family other
than neuropathic *. In this particular instance the occurrence of two
cases of insanity in the family was only what might have been predicted.
It was not by any means simultaneous in inception, or development, or
symptomatic phenomena; and I believe that the younger sister would
have become insane had the elder remained in her foreign home. She
was neuropathic, she lived immersed in morbid influences, and in such
a manner as to encourage disaster.

A successful showman said the other day that the public
like to be gulled, and I have no doubt that his appreciation of
that psychological fact assured his success. Far-fetched and
mysterious explanations of vital phenomena are assuredly
popular, and there is a constant ineffective endeavour on the
part of insane friends of insane patients to explain away
the occurrence of insanity by the principles of Heinroth, by
the dispensations of Providence, by the occult influence of
hypnotism.

Observation 2522.—A clerk, aet. 27, had been leading an eccen¬
tric, irregular life, and was admitted with the information that he had
been insane for a month in consequence of his having been hypnotised
by a friend. It was evident that his malady had been of much longer
duration, and of insidious development. He laboured under fixed
delusions of persecution, was most indolent and untidy. He had no
initiative or consideration for others, and his future was of no interest
to him. He was removed in that condition and so remains. The
family are neuropathic, and it could not be impressed upon them
that the hypnotic experiment was a mere incident in a degenerative
disease.

These cases need not be multiplied; indeed, it is with some
diffidence that I have referred to them at all. Vulgar errors
are of an incorrigible nature, however, and they are so con¬
stantly intruded on medical attention that they insist on some
recognition. Esoteric Buddhists, or Christian Scientists, or
some such perverts are always with us—not always under care.

The age and health of the parents at the time of conception
of offspring are of importance in the evolution of the race. I

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276

THE MORISON LECTURES,

[April,

have recorded several instances of paternal drunkenness in this
connection, but the mere accident of one act of drunkenness is
relatively unimportant compared with the habitual condition
of the persons noted. Nor have I been able to discover any
definite relation between the use of midwifery forceps and the
individuals who have come under my care.

What is of real importance in the study of neuropathic
children is the immediate ancestry, the environment and the
education which condition them. Dr. Clouston has so lately
studied the psychoses of development that I need not enter
into this important branch of our subject. Dr. Dewey, of
Chicago, has also investigated the early life conditions in 200
sane and 200 insane persons. This comparative method elicits
a series of facts which tend to confirm the observations which
I have submitted. Briefly, whatever tended to eugenics found
expression in the sane in a higher degree than in the insane.
For instance, excessive use of alcohol, of tobacco, of tea, of
coffee appears more frequently in the insane families; tuber¬
culosis, insanity, malarial environment follow the same rule.
Neglect and poverty, lack of home discipline, defective schooling
were all more apparent among the insane. In short, a neuro¬
pathic heredity was continued in a neuropathic environment,
and issued in a neuropathic generation.

The evolution of character, ability, temperament, and
success has not been studied with that care which the subject
demands. It is not sufficient to write around the great names.
We know that the race tends to average abilities, with some
slight advantage to the families of exceptionally able, well-
balanced , intellectual parents. It is the kind of mistake to
which I have already referred that exclusively considers the
exceptional, the bizarre, and the extremes. For the deter¬
mination of the probabilities of inheritance of any character,
physical or mental, within normal limits, or the possibilities of
disease, a study of the general population is absolutely neces¬
sary. The successes and the failures must be considered in
detail. Professor Karl Pearson has found that the intensity of
correlation between “ want of mental balance ” in parents and
insanity in children is from 0*25 to 0*30, probably the same
as exists in regard to other characters— e.g., stature, colour of
eyes, and so on—thus showing, as might be expected, that
somatic conditions are paramount in the first instance ; how-

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BY A. R. URQUHART, M.D.

2/7

1907 .]

ever, environment may possibly influence the organism in its
growth and development. I plead that Professor Karl Pearson
will have the support of the College in his endeavour to collect
sufficient data for the further elucidation of this question, in
the firm belief that the results will lead to a better under¬
standing of the national requirements towards the attainment
of health and efficiency.

A study of the influence of marriage, widowhood, and divorce
as affecting the development of insanity is so complicated by
individual circumstances that any generalisation is almost
impossible. I have had little experience relative to divorced
persons, and the social conditions of widowhood vary so
greatly that there is no possibility of generalising upon them.
Unsuitable and unhappy marriages are unfortunately only
too common, and I have so seldom known a proposed
marriage broken off on the grounds of insanity that there
seems to be no immediate hope of relief in that direction. On
the contrary, one neuropath seems to have an elective affinity
for another neuropath. Probably in matrimony the average
practical man looks for the average practical woman; for
the fainting fits and genteel spasms of eighteenth century
young ladyhood are now quite out of fashion, and athletics
reign supreme.

No doubt the daily round, the common task, are irksome to
the nervous and decadent.

Observation V 86 —A married woman with an adolescent family
was admitted in a taciturn, apathetic condition. Her home life had for
long been burdensome, although the causes are not obvious to others.
From time to time she breaks out in violent paroxysms of rage, and
expresses the most unjustifiable suspicions of her husband and other
members of the family. From time to time she disappears, and once
got so far as to engage herself as a domestic servant. She suffers
from planomania—an inveterate recurrent impulse to wander. This
has been studied under the descriptive title of vagabondage and no
doubt constitutes the foundation of the myth of the Wandering Jew.
The disorder is common enough, whether one regards it as an ancestral
regression or a defect of yesterday. All the cases known to me have
been deeply neuropathic; and I can only regard the fact of marriage
in this instance as purely accidental, and irrelevant to the real issues.

I have already referred to meteorological considerations and
my difficulty in placing before you any coherent account of my
observations. I might add here that we had a good opportunity
of studying the influence of the moon, which, when full, formerly

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27B

THE MORISON LECTURES,

[April,

so excited the Tom-all-alones of a former age, and which, in
nomenclature, will remain with us while Acts of Parliament
and official documents so carefully conserve the tradition. In
my seafaring days sailors were full of superstitions more or less
unaccountable. One particularly in evidence was the baleful
influence of the moon—the superlative danger of sleeping on
deck in moonshine unless under the shadow of the sails. I
suppose that those old tales are already forgotten, like the
sailors’ chanties, for nothing suits the mariner now but the
latest ditty of the music-hall.

Certainly noise and excitement were at their maximum in
Murray’s Asylum on bright moonlight nights for many years.
Th^t was matter of common knowledge, which we reduced to
written records. The rooms for disturbed patients were lighted
from the south-east and shutters had not been fitted to the
windows. When that omission was remedied the change was
at once apparent, and the influence of the moon was finally
abolished.

As sleeplessness is the most invariable prodromal symptom
of insanity, so it is of the greatest importance in the course of
the malady, whether from the view of treatment or prognosis.
The high pressure of the blood interfering with repose and
nutrition is the chief disturbing factor. The whole endeavour
of treatment must be bent towards the restoration of sleep, not
so much by the crude effects of narcotics as by the wider
application of medical skill. It is not my purpose to touch
upon treatment or nursing, nor is it necessary to insist on the
importance of this point. The management of the insane at
night is quite as important as their management by day, and
their conduct at night is just as indicative of their future as
their conduct by day. The return of sleep is a sign of recovery
or failure to recover—a good sign if improvement is concurrent
in other directions, a bad sign relatively if there is no, or but
partial concurrence. For insomnia is not a symptom of
chronic insanity. Dr. Whitcombe forcibly directed my atten¬
tion to this fact many years ago. An alarm of fire occurred in
a large dormitory at night-time in the Birmingham Asylum.
The fire brigade entered and retired, but not a single patient
moved from her bed; most slept through the incident. Except¬
ing a few cases of chronic mania, a few of circular insanity in
the excited phase, and especially of that class in which hallu-

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279

cinations are prominent, or the coenaesthesia is greatly per¬
verted, the old standing cases sleep soundly and are aroused
with difficulty. This restoration of sleep bears a close resem¬
blance to the increase of body-weight; if the nutritive processes
become active and there is a concurrence of other favourable
signs the outlook is hopeful; but degeneration may go hand in
hand with an unhealthy pallor, and an undesirable, flabby
corpulency accompanying permanent enfeeblement of mind.

It is this morbid somnolence which permits of the frequent
and necessary attention of nurses to the chronic insane. One
must clearly discern the values of all the symptoms existing
before coming to a conclusion that the cessation of insomnia is
of good omen.

When the nightly duration of sleep is charted it is usual to
find a cyclic variation, in conformity with observations in other
directions. The sleep may be sufficient on alternate nights, or
the cycle may extend to seven or more nights. Usually it is
variable and dependent upon the somatic changes.

Observation 2627. —Melancholia, female, aet. 40. At first for about
a week varied on alternate nights between no sleep and eight or nine
hours of sleep. Thereafter slept well for four or five nights, with one
bad night intervening, while, at the end of six weeks, sleep was re¬
established concurrently with marked mental improvement, which
ended in an excellent recovery.

Observation 2623.—Adolescent mania, female, set. 21. At first, for
about three weeks, a tendency to alternate nights of three hours and
seven hours; later, smaller irregular variations between six and eight
hours. In the second and third months of residence there was a
tendency to stupor, marked by taciturnity. Thereafter it was
unnecessary to record her sleep and she was discharged recovered in
three months. This patient was phthisical before admission, and
gained nearly three stones in weight in the course of treatment.

Observation 2575.—Acute delirious mania, female, aet. 35. The
posthumous daughter of a paralytic father, admitted on the eighth day
of her malady. First night no sleep, second night one hour, third
night two hours, fourth night one hour, fifth, sixth, and seventh nights
no sleep, eighth and ninth nights somnolence followed by death. No
skilled observer could have mistaken the somnolence of the two nights
preceding death as an interval of reparative processes.

Observation 2559.—Recent melancholia consequen tupon sepsis,
pyelitis, cystitis, and renal calculus. Admitted in a very prostrate
condition. A surgical consultation resulted in the opinion that the
malady was cancerous. Sleep good and bad almost certainly on
alternate nights until death after a residence of four months.

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280 the morison LECTURES, [April,

Observation 2412.—Circular insanity, observations during maniacal
phase, aet. 77, January, 1905. For a week little or no sleep, then about
a week of six hours nightly sleep, thereafter about a week of sleepless¬
ness, and so on. In October, November, and December of the same
year he had on an average three hours of sleep at night and none by
day. But in these cases of circular insanity it is a constant surprise to
observe how tireless they are, how little sleep they get, how little
apparent damage is done to the brain, and, above all, how very seldom
they die during the phase of excitement. A sudden onset, a period of
mischievous reasoning mania, sleeplessness, without apparent mental
deterioration in the sphere of memory, inevitably betrays a neuropathic
heredity, and an incurable alternating insanity which may persist into a
comparatively long life.

Observation 2636.—Recent excited melancholia, female, aet. 48.
After admission for many weeks slept alternately not at all or little.
When sleep did at length return it was liable to occasional failure for
many weeks, and when it was at last re-established there was no
appreciable improvement in the mental condition. She has fallen into
an incurable condition of chronic melancholia. I say incurable
because she shows marked somatic stigmata. She belongs to an
intensely neuropathic family and her bodily condition is depraved.
With a height of 4 ft. 10 in. her weight has not appreciably varied from
6 st. 3 lb. Were there no somatic stigmata, were her ancestry a
healthier stock, had her malady been limited to one attack, the case
might not have been so hopeless, for delayed recovery occurs from time
to time, especially in the class of female melancholiacs. It is not the
querulent mental condition but the somatic conditions which are
fundamental.

Observation 2604.—Melancholia recent and delusional, female,
aet. 38. Persistent sleeplessness on admission after three months of
depression. With certain remissions sleep was re-established, but an
incorrigible premature menopause resisted all treatment. During a
residence of two years she increased in body weight, but the delusions
were fixed and unvarying, and the somatic processes were defective;
she suffered from oedema pedum and a similar condition in the face.
Notwithstanding her unsatisfactory condition her body weight increased
by four stone during the period of her residence. She was removed
unrecovered, menstruated soon afterwards for the first time for several
years, and found means to commit suicide some four months later.

When the somatic failure is general it is evident to the most
casual observer. The chronic degraded patients of one asylum
closely resemble those of their class in any other asylum. The
physiognomy of insane persons used to find occasion for remark
in the formal legal certificates almost as a matter of course,
and perhaps it is a sign of more accurate scientific knowledge
that these observations are less frequent in the practice of

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1907.]

to-day. I do not know that it is a gain. Dr. Lionel Weatherly
told me that when he went home from college to his father’s
practice he had occasion to see a patient suffering from pneu¬
monia. He returned with his diagnosis, and, to the best of his
ability, described the symptoms as revealed by the stethoscope.
His prelection was very ill-received, and he had to go back in
order to bring his father a full, true, particular account of the
patient entirely apart from the precise stethoscopic condition
of the lungs.

We cannot neglect the facial appearance of the patient in
discussing the question of prognosis. It is characteristic of
degradation, if degradation has declared itself. Apart from
the emotional expression of the prevailing mental tone there
is an immobile, listless, preoccupied appearance which augurs
badly for the future. The nervous system is out of gear, and
the enfeebled muscles indicate that failure. The complexion is
pallid and the skin shares in the general inefficiency. The
eyes are relaxed and their mobility is restricted. Pigmentation
of the skin is of evil omen, and if it is systematically picked by
the patient one can hardly look for recovery. I could cite one
or two cases to the opposite effect, but they are very rare and
present other counterbalancing symptoms.

The morbid condition of the skin in insanity has not been
sufficiently investigated as yet. The development of nervous
system and skin from the point of view of embryology may in
some measure elucidate these complications. In any case, the
extremes of harsh dryness in certain forms of melancholia and
copious perspirations in certain forms of mania are commonly
recognised. Also the greasy, offensive appearance in degraded
cases. Perhaps the most important cutaneous symptom from
the point of view of prognosis is the pigmentation which so
frequently occurs, and which must be considered as indicative
of a progressive and intractable disorder when it is unmistakable
and long continued.

The appendages of the skin are also affected. The state of
the hair is a valuable index to the general condition. This was
most marked in a case of alternating insanity, in which the
strong black hair stood absolutely on end during the excited
period. Sir Arthur Mitchell expressed a doubt if this were
possible without the manual interference of the patient, who
was therefore closely and continuously watched for a consider-

liii. 19

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THE MORISON LECTURES,

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able period. It proved to be a true somatic condition. The
patient so affected long suffered from phthisis, and as her bodily
strength diminished the stark condition of her hair became
much less marked. There are other records of affections of
the nails, and notes of desquamation which I need not discuss
at length.

A persistent high temperature is a warning of evil import, as
regards recovery, and even as regards life. The high tempera¬
tures of insanity, apart from complications, are, of course,
usually very moderate compared with other diseases. I have
already alluded to this in speaking of observations made pos¬
sible by the clinical thermometer.

The general nutrition, perhaps, is the most certain index of
the progress of a case, as has been well brought out by the
study of body-weight in recoveries and removals. In asylum
life the periodical and exact weighing of patients is a routine
practice generally adopted, and generally trusted to indicate
the variations in somatic conditions which are so important in
the adoption of remedial measures suitable for each particular
case; also as indicative of the earliest warnings of complica¬
tions such as tuberculosis. A restoration of lost body-weight,
like a restoration of diminished secretions, is almost invariably
one of the first signs of returning health.

The muscular system presents very many problems of
interest, apart from the pareses and paralyses of pathological
insanity. The fumbling fingers of a general paralytic fail in
muscular energy, in co-ordination, and in the guiding direction
of the higher cortical centres. In lesser degree the finer adjust¬
ments of intention and action are discernible in ordinary insanity,
and as the degradation deepens so the inability becomes declared.
The somatic failure is then positive. Instruments of precision
are applied with difficulty in the elucidation of these conditions.
The common failure in attention renders it impossible to record
reaction time, or the appreciation of weight, without making
large allowance for error. Again, the motor reflexes, even in
cases of advanced dementia, are sometimes, and exceptionally,
very brisk. But as a general rule it may be stated that the
deeper the mental degradation the more obvious are the reflex
defects, whether motor or mental. All cases displaying rhythmic,
monotonous movements are to be regarded as most seriously
damaged. In some cases these movements, apart from idiocy,

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I907-] BY A. R. URQUHART, M.D. 283

have a gross pathological basis. I recall an extreme case of
cerebral atrophy, especially of the frontal lobes.

The morbid condition of bones in the insane has long been
recognised, and I believe that the anaemic failure of the chronic
insane is part and parcel of the osseous defect. I shall not
venture to discuss questions of craniology, in reference to which
palatal deformities are of importance in determining a neuro¬
pathic heredity in many cases where information is given
reluctantly. A few words may be permitted in reference to
oral sepsis and a common symptom of general paralysis—a
persistent grinding of the teeth.

Dr. Rayner’s work in the out-patient department of St.
Thomas’s Hospital has been amongst the insane, and espe¬
cially amongst incipient cases ; and his conclusion is that one
of his most important duties has been to hand over these
persons to the care of the dental surgeon. The improvement
in mental condition after his attentions are completed has been
so remarkable that Van der Kolk might have added another
sympathetic insanity to his list. I need not load this aspect of
the subject with clinical details. The importance of oral sepsis
as a cause of widespread mischief is now generally accepted.
I have noticed, too, that recurrent insanity, or exacerbations of
insanity, are often ushered in by attacks of toothache or facial
neuralgia, and think it of sufficient interest to mention this fact,
which may be regarded as a danger signal.

The gait of insane patients is characteristic; the bent, stiff
neck, the downcast eyes, the untidy dress, the careless slouching
walk are all in various degrees indicative of somatic and mental
degradation. Extraordinary attitudes impress one unfavourably.
Often these are assumed by adolescents who may recover, but
my experience is that they are symptomatic of relapse sooner
or later.

Alterations in handwriting, and tricks of voice or speech
indicate the interaction of mind and body in many important
directions. Vain and purposeless repetitions of phrases in the
letters of a person not appreciably insane are often evidence ot
chronic alcoholism, and specially, I believe, of cocainism. In
the case of a person tending towards chronic insanity such
repetitions are a mark of incurability. The corresponding
phrase of speech is not less ominous; still, there is a lower
grade— tcholalia , in which there is a repetition of words heard

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284

THE MORISON LECTURES,

[April,

by the patient and immediately reproduced ; and lower still
in the scale is verbigeration , in which new words are invented.

Observation 1884.—Student of medicine, aet. 27. Family neuro¬
pathic. Convulsive fits in infancy. A sensitive, studious, and solitary
young man, developed grandiose delusions, wrote verses and sent them
to Matthew Arnold and Ruskin. They were quite ineffective in thought
and construction. He then became convinced that he was poisoned,
and began to invent words, most of which showed a vein of persecutory
ideas— e. g .:

“ Bothered with toothache,

Tooth with a bore ;

Doctor should jankler take
Or no cure.

“ Ding about talking,

No thrapple-up;

Take goak of walking,

Joksutty and sup.”

This perversion of intellect is, of course, quite different from
the confusion of mania where rhymes are commonly strung
together in an incoherent succession, yet connected by some
associations of sound or sense. It is, so far as I am aware, the
outcome of a brain incurably perverted, and calls to mind the
thesis of that interesting old book —Wigan on the Duality of
Mind .

Long periods of absolute taciturnity may result in recovery,
confusion may very readily disappear, but the occurrence of
verbigeration is a symptom of degeneration not less ominous
than persistent amnesia.

Stuporose states often mark the swing of the pendulum from
high excitement to temporary exhaustion, and it is often very
difficult to distinguish between curable and terminal dementia.

Observation 2188.—Lady, aet. 25, admitted in a condition of acute
mania. Family neuropathic. A discharge from right middle-ear
disease had ceased on the inception of the mental disorder. Erythro-
melalgia had been observed, and the usual somatic concomitants were
recorded. The malady was prolonged and threatening to end in
chronic insanity. A stuporose condition varied with subacute transient
excitement—a complex which I regard as ominous. Under a course of
thyroid treatment she made a good recovery, and throughout the years
which have passed it continues necessary for her welfare to take one
or two thyroid tablets weekly. A prominent feature in this case was
the occurrence of drenching perspirations which Millingen long ago
regarded as indicative of failure. I must refer to Dr. L. C. Bruce’s
clinical studies for the modern explanation of this complication, and its
place in the evidence for toxic invasion.

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285

To resume, then, these various conditions of the organism
betray, each in its own relations, the generalised nature of
insanity, the generalised defect and disorder in which the
mental symptoms originate, and upon which they depend.
Within the compass of these brief lectures it is impossible to
discuss all the somatic conditions. I rather endeavour to indicate
the trend of experience, and prefer to reserve the consideration
of highly specialised subjects of importance, such as the work
of Flechsig relative to the association fibres of the brain
demands.

I now, therefore, submit Table XVI, which represents an
attempt to correlate somatic disorders with the mental
phenomena of insanity. It is generally recognised that pro¬
gnosis will vary with the incidence of these disorders and
diseases. If bodily health can be re-established there is hope
of mental improvement and recovery. For instance, if there is
no possibility of restoring a damaged cardio-vascular system
the outlook is gloomy. Prognosis, therefore, must await the
determination of these events. However, a case may be
desperate yet recoverable:

Observation 2353.—Female, set. 46. Admitted in a condition of
excited melancholia. The mitral valve was seriously damaged, the
heart was dilated and hypertrophied. The state of the pulse was most
alarming. She had been seen repeatedly by Dr. George Balfour, who
had found that her heart was always susceptible of improvement by
large doses of digitalis. He saw her in the Perth Royal Asylum when
greatly exhausted by continuous excitement, and was satisfied that the
treatment formerly successful would be successful again. In three
months she was discharged improved, and completed her convalescence
at home.

The following interesting case of myxoedema might be cited
as definitely toxic:

Observation 2553.—Female, aet. 31. Admitted in a condition of
acute mania. Family neuropathic. She had long been neurotic and
myxcedematous. Under thyroid treatment she generally improved. She
went abroad to escape the cold of winter in this country, and unfortu¬
nately took a large quantity of thyroid tabloids with her and consumed
them recklessly. It was impossible to determine the exact amount, but
she had suffered so greatly and had so much benefit by the treatment
that she went to great extremes. After admission and a complete
cessation of the drug during the acute symptoms it was resumed in
small doses, and convalescence appeared to be established. Dr. L. C.
Bruce kindly examined her blood in this phase, and found leucocytes

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286

THE MORISON LECTURES,

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13,424 per c.mm. as compared with 14,027 on a previous occasion.
Polymorphonuclears 56 per cent., lymphocytes 28 per cent., eosino-
philes 4 per cent. Blood plaques increased. He thereupon gave a
good prognosis, which was fully justified within a short time.

Referring to Table XVI it will be observed that it deals
with sensory disorders, appetites, instincts, disorders of
emotion and delusions. In its original state these were
extended to affections of memory, reason, etc., but the entries
were so numerous under perversions of intellect and conduct
that they practically included every case, and no further
deductions could be drawn from them. Insanity is in essence
from the psychological side an affection of intellect made
manifest in conduct, and I therefore present the table with
these deducted.

Of course those with somatic stigmata generally tend to
marked mental degeneration.

It is necessary to read for haemopoietic disorders, ancemia .
The important variations of the blood, discoverable by modern
methods can, of course, find no place in old records. In the
cardio-vascular group it is interesting to note the depression
and fears which are exaggerations of the usual features of
these maladies. Gastro-intestinal cases are similarly affected.
The great excess of the female sex under the heading of
generative disorders is in accordance with general experience.

I have not been able to corroborate certain American observa¬
tions which record extraordinary voluminous morbid details in
the sphere of gynaecology. There can be no doubt that the urine
and vaginal discharges of the insane are highly toxic, but the
vast array of surgical necessities alluded to is not within my
experience, either by the bedside or in the post-mortem room.

The common concomitant of generative disorder is the
irregularity or suppression of the catamenia. It is usually
said that menstrual periods are accompanied by exacerbations
of insanity. That is by no means the rule according to my
observations. No doubt the return of catamenia is a favourable
indication, and we have had several such cases after the exhibi¬
tion of ergoapiol where other drugs had failed. I might also
record a case of recovery in which the catamenia continued
suppressed, and were restored by the introduction of a stem
pessary at home. Quite exceptionally I have had good results
from the use of ovarian extract after ovariotomy, but can

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I907-] BY A. R. URQUHART, M.D. 287

present no case under asylum treatment in which that prepara¬
tion altered the mental condition.

It is our routine practice to record daily on calendars the
excitement or depression noticeable in individual patients.
These calendars also show the days of menstruation. I have
condensed these observations for years together, and on
examination of the results find that it is quite exceptional
to correlate the catamenia with the exacerbations of insanity ;
occasionally this is discovered in mania, but never in melan¬
cholia, so far as my observations go.

What is of much more importance are the toxic conditions
of these tracts, whether puerperal or not.

Observation 2697. —Male, aet. 57. Family neuropathic. Admitted
in a state of alcoholic dementia, with delusions of identity and hallu¬
cinations of hearing. He had lost all sense of time and space.
Apparent total amnesia. Urine purulent and highly ammoniacal. His
physical condition was greatly deteriorated. Under a course of helmitol
the urine cleared and his mental state improved. He made an excellent
recovery and returned home. I am informed that he has not resumed
his habit of alcoholism ; but the pathological state of the urine became
again evident. He was naturally anxious as to this disconcerting
experience, and helmitol was again administered ; the urine cleared up
and he continues in better health than he has known for years.

Dr. MacHardy (.British Medical Journal , 1905) has recorded
two cases of general paralysis improved, if not recovered, by
the use of urotropine; unfortunately we have had no such
result in these extreme circumstances.

One point in regard to these generative disorders and their
correlation with the sense of smell is remarkable. It is gene¬
rally stated that the connection is obvious and common. I have
not found it so ; in spite of a special examination of all the cases
I have not discovered any record in corroboration of that state¬
ment, and can only conclude that it is not so obvious as has
been asseverated, or that we have overlooked a series of facts.

Another general statement relates to the probability of
recovery after the patient has had a crop of boils. That is
quite opposed to my experience. The microbic infection of
boils does not seem to me to have acted as an alterative , far
less has it exercised a beneficial effect physically or mentally.
The question of alteratives is of special importance in medicine,
general and therapeutical. It offers an interesting opportunity
of discussing unconscious memory in relation to insanity, in the

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THE MORISON LECTURES,

[April,

light of the suggestive and philosophical work of Dr. Charles
Creighton. I leave it with reluctance, and do not purpose enter¬
ing on any psychological analysis of the cases reviewed. My
aim has rather been to direct attention to somatic disorders
and to correlate these with insanity under the two broad
divisions—ordinary and pathological. Yet it is necessary to
say something in general terms. For instance, the primary
fact of consciousness has a relation to prognosis ; if it is lost
for any considerable space of time it is a measure of mental
degradation indicating incorrigible defect. Mere confusion is
not at all a hopeless condition, but delirium is of the gravest
import. I have not found that perversions of identity are so
incurable as was formerly supposed; but as a general rule it
may be stated that perversions relative to self are much less
intractable than those relative to others. Did time permit
these opinions could be supported by clinical illustrations ; but
I must pass to the sphere of sensation. The general ccenasthenia
is of importance in this connection. It is a common measure
of convalescence to observe carefully the mental attitude relative
to fatigue. A loss of the sense of fatigue, an abolition of sensation
in regard to fatigue, denotes an uninterrupted course of mental
disorder ; on the contrary, when the patient begins to complain
of fatigue and pain and discomfort the complaint is welcomed
as the first sign of improvement.

The sensations colour the delusions, and in that respect the
study of Table XVI is interesting. The genesis of delusions
from the painful sensations of gastro-intestinal disease is readily
understood : it is easy to pass from the feelings of gastritis to
the feelings of poisoning. In fact, I would venture on the
generalisation that perverted sensations determine the tone of
the delusions, and the general mental condition. It is unthink¬
able that the depressing nature of abdominal disease, altogether
apart from insanity, should issue in grandiose ideas or pleasur¬
able excitement.

It would seem that hallucinations can be an affair of auto¬
suggestion in some cases.

Observation 2514.—Female, set. 38. Family neuropathic. Admitted
in a state of chronic alcoholism with mania. She professed to have the
power of calling up pictures in the fashion of a cinematograph. Waving
her hands in front of the wall of her room she asked for a subject,
and, failing a suggestion, preceeded to describe moving pictures with
great emotional display. This is plainly fantastic rather than imagina-

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live. She soon recovered, and stated that she had quite forgotten these
incidents.

And, further, it is uncertain how far such delusions will be
carried:

Observation 2164. —Female, aet 34. Family neuropathic. Admitted
in a condition of delusional insanity with fibroid phthisis. She com¬
plained of persecution and bodily torments; said that her thoughts fell
from her nose and tinkled on the floor, and that I could hear them by
attentively listening. I called the nurse to sweep up the litter of
thoughts so falling and so tinkling. She was most indignant, on the
ground that no one could sweep up thoughts.

As I have already indicated the former case, having been
alcoholic, is of no importance in prognosis, but the latter case,
owing to the somatic condition and the deep perversions, could
only prove incurable.

The emotional states, of course, vary in every conceivable
direction; perversion and degradation are only too often
recorded. It is always a favourable sign when a patient returns
to natural ties, when natural affections resume their sway.

The measure of degradation may be ascertained by observa¬
tion of the power of attention and memory; yet these may be
acute and the condition of the patient may be hopeless as
regards recovery. It is commonly supposed that an unim¬
paired memory is an indication of sanity, yet the idiot savant
may have a memory of extraordinary tenacity. The perversion
of intellect may be complete, and both attention and memory
perfectly unimpaired. I have, at present, two patients who are
old-standing cases of delusional insanity—persecuted perse¬
cutors. They generally live in one of our detached houses.
During the temporary absence of one the other gravely asked
me if I would hasten his return, for her enemies were very hard
upon her, and if he came back it would distract their unwel¬
come attentions from her. If the degradation is not wide it
may still cut very deep.

In point of time we have already seen that recent cases are
most favourable in expectation of recovery, and that cyclic
variations are common. Also that a sudden onset and a
sudden recovery almost inevitably mean neuropathic inheritance,
and recurrence sooner or later. A settled periodicity is bad,
yet if there are no remissions tending to recovery the outlook
is not less gloomy. The best sign in this respect is intervals of

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290 THE M0RIS0N LECTURES, [April,

remission, daily becoming of longer duration, and it is specially
gratifying when self-knowledge returns, interest in surroundings
is displayed, neatness of dress is studied—in fact, when there is
an indication of an appreciation of the amenities of existence,
when the prayer of the Kilbarchan weaver is answered—in
moderation.

And so we inevitably come back to the initial stage of this
discussion—the importance of somatic conditions in relation to
the mental states. Prognosis in insanity must proceed upon a
wide and careful review of the whole circumstances affecting
the individual, who is in a degenerative condition physically,
and therefore mentally. All that goes to make up that degene¬
rative condition must be separately investigated and summed up.
The elements of prognosis are analytical and synthetical, and
it is determined by the nature of the degree of the involvement
of the organism in the widest sense. If all the functions are
involved, if the degenerative process is universal and intractable,
the future of the individual is desperate indeed ; if the defect is
partial and amenable to treatment, naturally the case is more
hopeful as these limitations of involvement decrease.

In that sense how hopeless is the case of pernicious anaemia,
in which the mental manifestations are the direct result of an
impoverished brain! For a time it may be possible to draw
upon the reserve of red blood-corpuscles, but the stock is not
inexhaustible.

It is in consonance with these observations that the toxic
theory of insanity demands our most serious attention and
excites our liveliest hopes.

Prognosis can never be an affair of aphorisms; these obiter
dicta require to be fitted into the general scheme of things;
they are altogether too facile and too partial for our purposes.

I shall not stand suspect of neglecting the therapeutical and
general treatment of insanity in having discoursed at length
upon data and deductions. The therapeutical position is being
slowly won by the steady advance of our science and art.

We have, perhaps, carried architectural planning, training of
nurses, farming and gardening as far as it is desirable, for there
is a general consensus of opinion that this country holds an
honourable place among the nations in these matters. When
Mr. Holloway was moved to erect a hospital for the insane of
the poorer middle-class, in the course of his inquiries he asked

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1907.] by a. r. urquhart, m.d. 291

Dr. Yellowlees if asylum entertainments were undertaken in
the interests of the patients, or merely in order to find notice
in the local newspapers. That was a shrewd question by an
expert in the gentle art of advertising. It was answered to his
satisfaction by a practical demonstration, followed by no public
references.

I hold it desirable that a physician should know the baths
and wells of Europe, and that he similarly should know the
hospitals of the country before he distributes his patients
amongst them. There has been some foolish talk about the
Hanwell Wall , and the segregation of the insane—as if the insane
became insane in asylums. I know no hospital for the insane
where our colleagues are unwelcome in their most intimate
medical concerns; and the burden of these lectures is the
burden that is laid upon our honourable profession, not to be
borne by asylum physicians alone but shared by every worker,
in every contributory detail. The problem does not, unfor¬
tunately, concern the mass of chronic and incurable insanity,
it is relative to the inception of insanity—the early treatment of
insanity as it is presented to the family doctor and none other.
These metropolitan provincialisms want clarifying.

For anyone desirous of following out the individualised,
mental and moral treatment of the insane, I know of no book
so interesting as that of the late Dr. John S. Butler, of the Con¬
necticut Retreat. It is a little book, a very little book, on a great
subject, and it will keep his memory fragrant and green as a
wise physician. It is rosemary for remembrance. And yet,
Dr. Butler, occupied with this aspect of his work, insists again
and again on the importance of the early somatic conditions
of insanity, and the necessity of early and appropriate medical
treatment.

Finally, on the general question of prognosis of insanity we
have been counselled to give a guarded opinion, because it is
the unexpected that happens. An eminent physician once said
that he was paid for an opinion, not for a prophecy. But an
opinion is truncated and ineffective if it be only relative to the
moment of delivery. The questions demanded of us are urgent
and necessary: Is the family business to be wound up? Are
the pressing difficulties permanent or temporary ? Is the home
life to be altered for a time or for ever ? Are careful plans for
a career to be abandoned or postponed ? I am impatient with

Digitized by C^ooQLe

292

THE MORISON LECTURES,

[April,

a science that executes a strategic retreat before such a battery
of questions. In the last resort the kindly words of Horace
recur to us:

“ Tu ne quaesieris, scire nefas, quern mihi, quem tibi
finem di dederint, Leuconoe, nec Babylonios
temptaris numeros.”

Yet it is a poor account of scientific medicine if it is to be
recorded of us that our premonitions are of no more value than
a Chaldean horoscope.

It is an excellent practice, in which throughout the years
I have followed Sir James Crichton-Browne, to sum up the
probabilities in the Case-book on the reception of every
patient. At least, it is a stimulating corrective for self-satisfied
science; at best, an incentive to the careful study of every
circumstance affecting each patient. For it is only by that
study, indefatigable and personal, that advance is possible to
us or to our profession.

More steadfastly than ever our profession labours for the
prevention of disease. That resolves in questions of eugenics,
education in the widest sense, and a determined, informed study
of all morbid phenomena.

(*) The Morison Lectures, delivered before the Royal College of Physicians
Edinburgh, January, 1907.

Digitized by C^ooQle

Table I .—A Genei'al Statement of Admissions and Removals , regarding Admissions, Readmissions, and Totals;
with Percentages during the Period under Review , 1880-1904 inclusive .

1907.]

BY A. R. URQUHART, M.D.

293

Digitized by LiOooLe

Percentage of Readruissions on Total Numbers admitted—Males, 15*35 ; Females, 19*91; Total, 17*61.

Table II .—A Statement of Insane and Neuropathic Heredity recorded in reference to 809 Persons-

1884-1904 inclusive .

294

THE MORISON LECTURES,

[April,

Digitized by v^ooQle

1907]

BY A. R. URQUHART, M.D.

295

Digitized by LiOOQle

Noth.— For F. F. read Father’s Father, F. B. Father’s Brother, etc.

298

THE MORISON LECTURES,

[April,

Table Va.— Families containing at least one Insane Member.

Frequency of size
of Family.

II.

No. of Persons born
1st, 2nd, etc.

III.

No. of Persons bom
1st, 2nd, etc.,
actually Insane.

IV.

No. of Persons
bom, 1st, 2nd,
etc., and Insane,
if no bias.

No. in
Family.

Fre¬

quency.

Order.

Fre¬

quency.

Order.

Fre¬

quency.

Order.

Fre¬

quency.

1st

815

1st

108

1st

77*3

2nd

305

2nd

74-8

3rd

291

3rd

71*4

4th

249

4th

61 1

5th

219

5th

537

6th

171

6th

41*9

7th

134

7th

7tli

32*9

8th

22*8

9th

13-5

10th

8*6

11th

5*4

12th

3*4

13th

1-2

315

1908

468

468*0 j

Family = Fraternity.

Digitized by v^ooQle

* 907 ]

BY A. R. URQUHART, M.D.

299

Digitized by LiOOQle

310 pr>4

Table VI.— Continuer 7 .

300

the morison lectures,

[April,

Digitized by LiOOQle

BY A. R. URQUHART, M.D.

301

I 907 -]

Digitized by LiOOQle

Kirand Total . 23fi:m>f»51 47 01138 33 41 71 102,121 223' 33 CO 119 233 319 554

Asylum Statistics—Certified Patients .

302

THE MORISOK LECTURES,

[April,

Digitized by LiOOQle

Autotoxic—Gout, etc.

with Heredity and Str*** % and Result* of Treatment. Certified ratiente.

1907.]

BY A. R. URQUHART, M.D.

303

Digitized by LiOOQle

Table VIII .—Continued

304

THE MORISON LECTURES,

[April

1907]

BY A. R. URQUHART, M.D.

3°5

Table IX .—Chart of Total Numbers , showing the Monthly Incidence
of the Attacks , Recoveries , and Deaths . Certified Cases.

Digitized by v^ooQle

i 9 o;.]

BY A. R. URQUHART, M.D.

307

Chart IXb.

fek. MarcM April Mag June July Aug. Sept• Oct. Moo. Dec. Jan.

767 Cues, showing the curve of monthly incidence at inception of attack, con¬
structed from percentages, and showing the incidence in the month immediately
preceding and the month immediately following any month.

Digitized

Table X.— Showing the Duration of Attack on admission in relation to ordinary Insanity and the facts of Heredity, and the
Remits of Treatment correlated with the Age Periods. First admissions. Certified Patients.

308

THE MORISON LECTURES,

[April,

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Duration op Attack.

Males— 1

liCss than three months . . .
Three to six months . . . . 1
Six to twelve months . . . . 1
More than twelve months . . >

Totals . . .

Females—

I^ess than three months . . ,
Three to six months . . . . 1
Six to twelve months . . . . ■
More than twelve months . .

Totals . .

Totals— ,

J/OM than three months . . . 1
Three to six months . . . . |
Six to twelve months . ... \
Moro than twelve months . .

" i

Digitized by v^ooQle

3 io

THE MORISON LECTURES,

[April,

Table XLl —Chart showing Ages on First Recovery , First Relapse, and
Death — Males , Females , and Totals.*

Digitized by v^ooQle

I907-]

BY A. R. URQUHART, M.D.

3*i

Table XIb. —Showing Age on Death of Patients under observation,
compared with the Tables of the Institute of Actuaries.

Age Group.

Insane.

Hm. Table.

Age Group.

Avenge
Age at
Death.

Percentage of
Number of
Deaths to
Total Number.

Average
Age at
Death.

Percentage of
Number of
Deaths to
Total Number.

15-25

25-40

40-60

60-75

Over 75

...

Over 75

312

THE MORISON LECTURES,

[April,

Table XIc. —A Statement of Age on First Attack , First Recovery ,
First Relapse , calculated from information obtained. Age on Death
from Asylum Statistics.

Age on First Attack.

First Recovery.

First Relapse.

Age on Death.

1 .

-20

...

107

...

134

108

...

+ 75

...

382

782

117

136

253

160

Unknown

Idiots .

Idiots

...

419

390

809

164

Digitized by LiOOQle

1907.]

BY A. R. URQUHART, M.D.

3*3

Table XIL —Showing the Admissions and Recoveries of Persons during
Forty Years ,, so far as Asylum Statistics go.

Persons admitted

Of whom discharged recovered

Of whom readmitted relapsed .
Leaving recovered and not
relapsed ....

Relapsed persons recovered

Net recovered persons

504

156

117

143

475

166

118

143

979

322

235

286

Being 32*89 per cent, of
the persons admitted
(M. 30*95, F. 34 *94).

Being 29*21 per cent, of
the persons admitted
(M. 28*37, F. 30*10).

Showing Admissions and Recoveries of Cases during Forty Years,

Asylum Statistics.

Admitted ....

599

585

1184

Recovered ....

180

204

384

Being 32*43 per cent, of
the cases admitted
(M. 30*05, F. 34*87).

LIII.

Digitized by v^ooQle

314

THE MORISON LECTURES.

[April,

Table XIII .—Recoveries after First Admission , correlated with Neuro-

Persons recovered and not

Digitized by v^ooQle

1907.]

BY A. R. URQUHART, M.D, 31

pathic Heredity, Age Periods , and Duration since First Attack . Also

relapsed. Certified Patients .

[April,

3*6 THE MORISON LECTURES,

Table XIIIa. — Relapsed Cases.

M. F. T. If. F. T.

First Admissions 419 890 809—of whom these had one or more previous attacks 92 103 195

Readmissions . . 76 97 178—of whom these were admitted relapsed . 31 46 78

Total . 496 487 982 123 148 271

Add reported relapsed after final discharge 11 7 18

134 166 289

Relapsed Persons.

(289 (7mm m above referable to 260 Penont.)

F. T.

( 81

74 166 had 2

attacks, being 19*16 % of 809.

[ 16

22 88 „ 8

»» »* 4*69

18 16 „ 4

.. .. 1*86

8 3 „ 6

„ 0*36

Of 260 persons < 3

2 6 „ 6

»* .. 061

„

11 23 had many „ „ 2*96

6 11 unknown number, ,, 1*86

131 260

Sum 80*98

Recovered here

Recovered after

Total

after First

Removal.

Removal and

Admission.

Readmission.

Of Males . .

. 419

120

146

,, Females .

. 390

182

161

Total .

. 809

262

807

Not Relapsed.

Of Males . .

. 146

„ Females .

. 161

Total .

. 807

110

189

Percentages.

Of Males . .

. 419

Total Recoveries 84*84%

Permanent Recoveries 15*76%

„ Females .

. 390

.. 41*28%

tt •»

18*71%

Total .

. . 809

.. 87*94%

1718%

Digitized by LiOOQle

1907.]

BY A, R. URQUHART, M.D.

317

Table XIV .—Causes of Death , correlated with Neuropathic Heredity
and Forms of Mental Disorder on admission . Certified Patients
admitted and readmitted . Asylum Statistics .

Forms op Ordinary Insanity.

Cause of Death. Melancholia. Mania. Delusional. Dementia. Aggregate.

M. F. T. M. F. T. M. F. T. M. F. T. M. F. T.

Ccrebro-Spinal . NP. 3 .. 3 11 10 21 3 .. 3 15 2 17 32 12 44

O. 2 2 4 7 6 13 3 1 48 1 9 20 10 30

Aggregate .

7 18 16 34 6 1 7 23 3 20 62 22 74

Circulatory

Aggregate .

8 4 2 4 01.. 1218 0 814

2 2 2 4 6 2 ..

1 5 0 11

3 3 1 4 11 14 25 |

Respiratory .

NP. 3 .. 3 3 4

Aggregate

4 5 9 1 1 2

Alimentary

3 3 1 .. 1

11114

Aggregate

T. .. 3 3 1 .. 1

1114 6

NP. .. 1 1 2 1 3 I .. I 2 2 •• 1 1

Aggregate

T. .. 1 1 2 1 3

1112 5

Aggregate

NP. 2 3 5 3 5 8 2 2 4 2 6 11 10 21

O. 1 12 13 4.. 1 12 2 4 47 11

T. 3 4 7 4 8 12 2 1 3 6 4 10 15 17 32

NP. ' .. 1 1

1 .. 1 1 3 1 4

Aggregate

T. .. 1 1 2 .. 2

13 14

NP. 9 11 20 24 24 48 6 2 8 22 7 29 01 44 105

Grand Aggregate

( NP. 9
i O. 4

4 6 9 11 14 25 6 3 9 13 3 16 34 25 59

13 10 29 35 38 73 12 5 17 35 10 45 95 69 164

318

THE MORISON LECTURES,

[April,

Digitized by LiOOQle

Grand Total*

BY A. R. URQUHART. M.D.

3*9

I907.]

Tabu XVII .—Showing the Incidence of Heredity in Patients addicted
to the intemperate use of Alcohol and Drugs Certified Class .

Heredity of—

Percentage calculated on 110.

M. P. T.

Inanity....

45*88 32*00 42*73

Neuroses

5*88 4*00 5*45

Alcoholism

18*83 3200 21*82

None ascertained .

29*41 32*00 30*00

110

100*00

By Periods—

Percentage calculated on 110.

Fin* to 1884.

11*77 12*00 11*82

Swoad to 1894

25*88 20*00 24*54

Third to 1904

62*35 68*00 63*64

110

100*00

Digitized by boogie

Mi «f Ufc MT®'

Grand Total*-\L3'J0,r.ai2

322

PSYCHOLOGY OF THE CRUSADES,

[April,

O71 the Psychology of the Crusades . II. By William

W. Ireland.

In the “children’s Crusade” we witness the enormous
credulity of the Dark Ages in its simplest form, although the
delusions which the children indulged in must have been
encouraged by their parents. The orders of the King of
France to stop their pilgrimage had evidently been disregarded.
Was it that a whole people had become mad ? Some writers
have argued that nobody is quite sane ; in that case we should
need another word for those who cannot do without restraint.

No doubt amongst the crowd of pilgrims there were persons,
frenzied, hysterical, paranoiacs, not without their influence in
inciting the others; but the bulk of the Crusaders were
different from ordinary lunatics. The inmates of an asylum
could not be united for any one purpose ; if they show any
general desire, it is to be set at liberty, which they could effect
if they would only combine.

Granting their premises to be true, the pilgrims cannot be
said to have acted illogically. If, as they believed, the Church
could grant them a sure entry into heaven by taking the cross,
it was bare wisdom to accept such a permit as a lucky chance ;
whatever befel they would escape impending damnation and
gain eternal happiness. In the present day there are many
persons who profess beliefs in which they have not sufficient
faith to lead to action. Indeed, it is amazing how many incon¬
sistent beliefs some people nowadays quietly entertain without
troublesome comparisons.

We have such graphic accounts of the first Crusade that the
characters of its leaders stand out with unusual clearness.
Of Robert, the unfortunate Duke of Normandy, the eldest son
of William the Conqueror, we know enough. Godfrey of
Bouillon was renowned for his prowess: he is reported to have
cut a Saracen in two so that the one portion of the body was
carried away by his horse. He is described as tall and thin,
agreeable in conversation, with an inexhaustible sweetness of
character. We are pleased to learn that on the taking of
Jerusalem he did not join in the massacre, but went humbly
to say his prayers at the Church of the Holy Sepulchre.
Bohcmund, the Norman, from Sicily, is described as taller by

Digitized by C^ooQle

»907-]

BY WILLIAM W. IRELAND.

323

the head than the other chiefs. He was much feared by the
Greek emperor and regarded both by the Christians and
Mohammedans as the ablest in council; brave but prudent, he
never forgot his own aggrandisement. It is worthy of note that
both Bohemund and Baldwin the brother of Godfrey were made
prisoners by the Saracens, who might have put them to death,
as the Mexicans did the Emperor Maximilian, in revenge for
the massacre of the Mussulmans at Jerusalem. However,
neither of these chiefs was actually present at the storming of
that city and their captors were satisfied with a heavy ransom.
Tancred, a relative of Bohemund who followed him from Sicily,
left the reputation of a gallant knight-errant ever seeking
brave adventures, punctilious of honour and quarrelsome, but,
like the rest of the Normans, ambitious and eager for gain.
Tancred appears as the most attractive character in Tasso’s
great epic “ Jerusalem Delivered.”

The Abbot Guibert (*) has some very edifying accounts of
the rigid chastity of the Crusaders in the leaguer of Antioch.
Evidently unacquainted with the habits of soldiers, he feels safe
in presuming that those who were every day exposed to lose
their lives could not abandon themselves to sensual passions.
No prostitutes were suffered in the camp. If a woman who
had no husband was found to be pregnant, she was forthwith
severely punished along with her seducer. A monk from a
celebrated convent was surprised with a woman. Convicted
by the ordeal of red-hot iron, he was, by the orders of the
Bishop of Puy and the Princes, walked through the whole
camp along with his concubine. They were then stripped
naked and whipped, to the great edification of all who
witnessed the sight.

Yet there are other passages which hardly bear out this
exemplary state of things. The dissolution of home ties and
the mingling of pilgrims of both sexes in a disorderly march
gave both temptation and opportunity. Moreover, one might
fairly infer that the promise of complete forgiveness of sins
without any repentance following upon a pilgrimage to
Jerusalem or to Rome was not conducive to morality.
Another writer of the Crusades gives us a lurid picture of
the corruptions of the morals in those days amongst both the
laity and the clergy.

Men beset with one idea have effected wonderful things in

Digitized by

324

PSYCHOLOGY OF THE CRUSADES,

[April,

the world’s history, and no fanatic has done more mischief
than Peter the Hermit. Anna Comnena ( 2 ) tells us that her
father, the Emperor Alexis, who had sent a party to rescue
him from the Turks, in a friendly way reminded Peter how
he had neglected his advice. The Hermit, who had left so
many thousands to perish, boldly replied that he was not to
blame for the evil which had come upon them because they
had neglected the commands of God and his own counsel.
They were, he said, “ brigands and robbers not worthy to
be admitted to the adoration of the holy sepulchre.” No
doubt many scoundrels had followed his leading, but there
must have been not a few humble, trusting, pious souls who
in their simple faith wished to give back to God love for love,
sacrifice for sacrifice, and thought to exchange the cares and
miseries of the world for the eternal joys of Paradise. The
Greek princess describes the huge piles of bones which she
saw about Nicaea, lately the framework of living men and
women, who might have peacefully finished their lives in
their own villages had they not been led to destruction by
those whom they so blindly trusted.( 3 )

Peter, who had not lost his sanctity in the eyes of the
common people, accompanied the army of the princes and
counts, acting as a guide to a crowd of beggars who had
followed the camp.

A man from Normandy managed to keep this disorderly
crowd under some rule: he called himself King of the Tafurs,
or tramps ; he would not allow his followers to keep in their
possession any money whatever. These men made themselves
useful in carrying burdens, in foraging and scouting, though
it was dangerous to enter their encampment. Anna Comnena
tells us that the first host of Crusaders led by Peter on entering
Asia Minor, amongst other enormities, dismembered sucking
children, transfixed them with wooden spits, and roasted them.
The Abbot Guibert admits that in some times of great distress
they were reduced to eating pieces of the flesh of the Saracens.
Raoul de Caen, himself a Crusader, confesses that some men in
the pangs of hunger came to eat human flesh, and that they
had thrown young Gentiles into the pot, and had put infants
upon the spit, roasted, and eaten them. Raimond d’Agiles
tells us that at Marpah some of the besiegers greedily devoured
the bodies of the Saracens which had already lain for a fort-

Digitized by C^ooQle

BY WILLIAM W. IRELAND.

325

1907 .]

night in the ditches of the town. In the old French ballads
quoted by von Sybel these horrible feasts are loudly pro¬
claimed. As they lay in leaguer before Antioch :

“ In evil case the army stood, their stores of food were spent,

Peter the Holy Hermit, he sat before his tent.

Then came to him the King Tafur, and with him fifty score
Of men at arms, not one of them but hunger gnawed him sore.

‘Thou holy Hermit, counsel us, and help us at our need,

Help, for God’s grace, these starving men with wherewithal to feed/
But Peter answered, ‘ Out, ye drones; a helpless pack that cry,

While all unburied round about the slaughtered Paynim lie;

A dainty dish is Paynim flesh, with salt and roasting due/

‘Now by my fay/ quoth King Tafur, ‘the Hermit sayeth true/

Then fared he forth the Hermit’s tent, and sent his menye out
More than ten thousand, where in heaps the Paynim lay about.”

We may spare the reader the disgusting description that
follows.

Some of the Christian princes passing that way, the Emir
cried from the walls:

“ ‘To do dead bodies such foul wrong is insolence and sin/

But Bohemund made answer: ‘ Fair lord, what here ye see
Is none of our commanding, nor wight thereof have we.

’Tis King Tafur’s devising, his and his devil’s crew,

An ill rout are they, God wot/ ”

We have the testimony of Guibert that the hardships of the
siege were too much for the hermit, who fled with some others,
but was persuaded by Tancred to return: even this scandal did
not destroy his influence. ( 6 ) After the crusading host had
entered Antioch they were surrounded by a Moslem army and
reduced to great distress. Peter the Hermit was sent with four
others as an envoy to deliver a challenge to the Emir Kerbogha
the Commander of the Persian Army. The interview is graphi¬
cally described by Raoul de Caen. Peter, a man short of
stature, of a tawny complexion and a lean face, in a shabby
gown, with naked feet, and mounted upon a pony poorly
harnessed, approached the Saracens’ camp. They thought he
had come as a suppliant, but, standing erect, the hermit ordered
the Persian general to withdraw the army or, if he refused, to
appoint an equal number of champions, three or six, to decide
to whom the city should belong. The Persian emir, thinking
he had the invaders in his power, returned a haughty and

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PSYCHOLOGY OF THE CRUSADES,

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menacing answer. The courage of the host was again revived
by one of those visions which were frequent amongst these
credulous devotees. A Provencal peasant named Pierre
Barthelemi came to the Bishop of Puy, who was with the
besieged army in Antioch, announcing that the apostle St.
Andrew had appeared to him several times, revealing to him
that the head of the lance which had pierced the side of the
Saviour at the crucifixion lay buried in the Church of St. Peter,
at that time used as a mosque. The saint actually took him
to the spot and told him that by obtaining this weapon the
victory of the Christian host would be secure. Twelve men
dug all day at the place pointed out; nothing was found till
the evening, when Pierre himself descended into the hole and
promptly struck upon the lance-head. This find was received
with great enthusiasm, and the lance was borne in front of the
troops in a vigorous sally in which the Mohammedan army was
scattered. The Provencals attributed the victory to the favour
of St. Andrew and the holy lance. Count Bohemund, who was
more a politician than a devotee, pointed out the incoherency
of the story, which was supported by Raimond, Count of St.
Giles and the Provencals. In denouncing the imposture
Bohemund was seconded by the Dukes of Normandy and
Flanders. Great quarrels ensued, when Pierre was called
upon by the Council to submit his pretensions to the ordeal of
fire. He was to make his way nine paces through two rows
of flaming bushes. It was assumed that if his story were true
he should come through the fire safe and sound ; after three
days* fasting and praying, Pierre, clad in a tunic and drawers,
passed through the flames. Raoul de Caen says that though
he got through he fell down all burned, and died the next day,
on which the people saw that he was an impostor, who had got
what he deserved. Guibert tells us that Pierre went twice through
the fire, obviously an embellishment of the story. Foulcher
de Chartres tells us that the man died after twelve days, when
people recognised that he was an impostor. The Provencals
would not give him up so easily. Raimond d’Aigles, who was
present both at the finding of the lance-head and the man’s
death-bed, says that on his emerging from the flames the
people crowded upon him and trampled him so that his back
and his ribs were broken, which was the real cause of his death.
Pierre himself, when asked to explain some burns noted upon

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his legs, averred that Christ had appeared to him while in the
middle of the flaming way and took him by the hand, saying :
“Since you have doubted about the discovery of the lance
when St Andrew revealed it to you, you will not get through
without injury ; but you will not see hell.” Raimond assures us
that in his last hour Pierre swore that he had told nothing but
the truth. The Count of St. Giles retained his faith in the
genuineness of the relic, and kept the lance-head with him till
it was accidentally lost.

This story vividly displays the stupid credulity of the
Middle Ages. They could only test an imposture by making
use of a delusion. In those days, when portents and miracles
were rife, it was thought a fair deduction that God would sus¬
pend the ordinary laws of combustion to save an innocent
person, and that the usual action of fire on the skin was a
proof of guilt. The steadfast believers in Pierre’s stories might
have wondered why the Divine protection was withdrawn after
he had passed through the flames, so that he was fatally injured
by the crowd immediately after.

During the first twenty years of the kingdom of Jerusalem
the Franks held only a few fortified towns ; the country was
ravaged by the Moslems. They were even abetted, and shel¬
tered by the Syrian Christians, who did not disguise their
hatred of the new-comers, whose rule only made their con¬
dition worse. Baldwin, who succeeded Godfrey, had made
himself master of the towns by the coast ; but even the road
between Jerusalem and the seaport of Jaffa was so insecure that
it could not be traversed without an escort. In 1119 Hugo
de Paynes formed a brotherhood which took the name of the
Poor Knights of Christ from the Temple of Solomon. Taking
as their rule Estis monachi virtuibus , milites actibus , they
soon earned great praise for the austerity of their lives and
their bravery against the Saracens. They gained largely from
the pilgrims whom they protected, and the order received rich
endowments in all Christian lands. They are said to have
possessed more than nine thousand residences in Christendom.
Their ranks were reinforced by banished or excommunicated
knights who took the vows of pilgrimage as an atonement for
heinous sins. Brought to the front, their turbulent spirits were
expended in warfare against the infidel. The sovereign who
had banished these offenders might be content to get rid of

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them, but the Church did not wish transgressors to escape her
anathemas without penances, so she was displeased with those
military monks of the temple who lightly absolved their wild
companions in arms or buried them with holy rites when they
fell in combat. The force of events made the Templars lose
the bigotry of the early Crusaders in Palestine ; in Syria they
came into contact with the Mohammedans and soon learned the
falsehood of the calumnies against them. Christians and
Mussulmans had disputes about their varying faiths, and though
they seldom made converts, they infused doubts into one
another’s minds.

Many of the Templars belonged to the country of the
Albigeois, against whom the Pope had directed a bloody cru¬
sade followed by a cruel inquisition, and the suspicion of heresy
long clung to the order. It was said that in their secret rites
the initiated were made to deny Christ and spit upon the
cross, and that they believed in two gods, one inferior to
the other ; they were accused of filthy immoralities, and it was
undeniable that they led luxurious and licentious lives in their
endowed seats. They were even accused of having treacher¬
ously connived with the Turks to cause the siege of Damascus
to miscarry. ( G ) It is a question in history which will never
be solved whether there was any truth in these accusations
of impiety which wrecked them in the popular mind, and
which were taken advantage of by Philip the Fair to suppress
the order, with the consent of the Pope. Some historians have
explained that the denial of Christ was at first simply a trial
of obedience of the neophyte, or that it was a rehearsal of the
denial of St. Peter, or that it was a ceremony gone through to
fulfil a promise of a grand master of the Order, made in captivity
to a Sultan. In any case, they admit that the ceremony had
lost its significance ; what had been done as a play was in the
end treated as a serious matter, and this goes far to imply easy
indifference to the Christian spirit, if not a pronounced scepti¬
cism. ( 7 )

Western Europe had entered into the Crusades in the entire
belief that they were doing the will of God ; thus they counted
on the Divine assistance. The ecclesiastics attributed the first
disasters to the sins of the pilgrims, although we learn that
these misfortunes had induced some of the captives to turn to
the faith of Islam, The taking of Jerusalem was, naturally,

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held to be the fulfilment of the Divine protection ; but when
Jerusalem was lost, and the tide of war kept steadily against
the Christians, the Templars, their mission gone, idle and
discontented in their rich endowments, began to entertain mis¬
givings whether God was really on their side. Such doubts
were boldly expressed in the verses of a Provencal poet( 8 )
After the news came that Bibars, the Sultan of Egypt, had
taken the town of Caesarea and the Castle of Arsouf in 1265,
the poet thus exclaims : “ Ah, Lord God, what has become of
so many knights, so many servants, so many citizens, who were
within the walls of Arsouf? These accursed Turks have
sworn not to leave in these places a single man who believes
in Jesus Christ. They say that they will make a mosque of
the Church of St. Mary. Well, if God, whom all that should
displease, consents, and finds it good, we must also be satisfied.
He is very foolish who seeks to quarrel with the Turks when
Jesus Christ permits everything to them. What wonder that
they have conquered Franks and Tartars, Armenians and
Persians, and that they beat us Templars every day. God,
who formerly watched, now sleeps while Mohammed puts out
his whole strength and helps his servant Malek-Daher [Bibars].”

The historian of the Hospitallers ( 9 ) believes that the order
existed in Jerusalem as a charitable brotherhood to relieve
pilgrims even before the taking of that city. In the next
generation the hospital took a military character. Although it
soon became richly endowed, the Hospitallers never attracted
the same suspicion and odium as the Knight Templars, and on
the fall of the latter order the Hospitallers came into possession
of much of their rich endowments.

The kingdom of Jerusalem took no root in Eastern soil.
The defenders of the Holy Sepulchre were reinforced by
penitents and devotees who came in Genoese or Venetian
galleys, eager for fighting, difficult to hold in, breakers of truces,
bold raiders, the terror of the Mecca pilgrims. The Syrian
Christians, who had hailed the coming of the first Crusaders,
soon found that they had gained nothing from changing the
yoke of the Mussulman for the feudal rule of the Franks and
the supremacy of the Western Church. The children of the
first Crusaders who stayed in Palestine grew up a weaker race
in that hot climate. While the Mohammedans were engaged in
a death struggle with the Frankish invaders, the Emperor

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Alexius was busy regaining some of his lost territory in
Anatolia. The Turks were driven from the islands of Rhodes
and Chios, and the Greek dominion was extended along the
coast from the Hellespont to the Syrian Gates. In the pro¬
secution of the Emperor’s claim of sovereignty the Byzantine
troops came to blows in Cilicia with Bohemund and Tancred,
the Norman rulers of Antioch.

As the Franks were losing ground in Palestine the Pope,
Eugenius III, charged the celebrated St. Bernard to preach a
new crusade. Beyond the purity of his life, his eloquence and
learning, there must have been some great reserve power of
character which made the Abbot of Clairvaux the oracle and
champion of the Catholic Church, the arbiter between rival
popes and worldly potentates. His Life has been written by
three of his contemporaries, one of whom was his secretary,
who attributed to him numerous miracles. A great assembly
was held at Vezelai like that held fifty years before at Clermont.
A scaffolding was erected in the plain from which Bernard
addressed the multitude ; King Louis VII, with many of his
nobles, took the cross from the hands of the Abbot. The
report of some miraculous cure increased the enthusiasm of the
multitude and of the people, and confirmed their faith in the
predictions of the saint, who promised signal victory and con¬
quest for the arms of the French king. Bernard was able to
write to the Pope : “ The Crusaders are multiplied beyond count¬
ing ; in the cities and castles for seven women you may scarcely
find one man ; everywhere you will find widows whose husbands
are alive.” A man of much superior capacity to Peter the
Hermit, St. Bernard had sense enough to refuse the request
that he should take command of the Crusades. France was
again aflame, and the movement passed to Germany. As
before, it began with a massacre of the Jews in the Rhine
country. St. Bernard went on to Germany, and although he
did not understand the language of the country, he succeeded
in inducing the Emperor, Conrad III, to take the cross. At
the same time the holy man stirred up the Saxons to make a
religious war against the heathen Wends.

It is said that the Pope, who wanted Conrad’s assistance for
other purposes, was aghast at the success of his missionary.
The King of France left the Abbot Segur, who tried to dis¬
suade him from the Crusades, in the charge of affairs at home.

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Louis himself took the march with an army said to amount to
260,000, Conrad with 100,000 infantry and 60,000 horse.
These figures are probably not founded upon accurate numera¬
tion, though it is averred that the Greeks counted 900,000
Crusaders who crossed the Hellespont. Had the Christian
princes acted in unison, there was no power in the East
which could have resisted them, but the Greek Emperor,
Manuel, was terrified b y % the march of these hordes so near
his capital, and had to guard his western territory against
the Norman King of Sicily. Advancing through a desolated
country, the unwieldy hosts of the Germans were thinned by
hunger and exhaustion and finally cut off by the Turks. Conrad,
escaping to Constantinople, met the French King advancing,
but Louis refused to profit by the other’s experience. The
Greeks were accused of giving false intelligence and even of a
secret alliance with the Turks. After some bloody defeats the
King of France was glad to escape from the Cilician shores
with the rest of his knights, leaving the plebeian crowd to the
mercy of the Seljuks.

These miserable failures aroused loud murmurs against St.
Bernard. His biographer ( 10 ) consoles himself with the thought
that if the Eastern Church was not delivered by the expedition
it at least served to fill the celestial Church with pious souls.
The saint defended himself after a lofty fashion : “ If it is abso¬
lutely necessary that people should do one of two things, murmur
against God or myself, I prefer that the murmurs of men should
fall upon myself rather than upon the Lord.” His biographer
tells us that at the time when the first report of the rout of the
crusading army was spreading through France a man brought
his son who was blind, imploring St. Bernard to restore his
sight. The holy man, putting his hand upon the child, prayed
to the Lord that if it was really His word which Bernard had
uttered, or if the Holy Ghost had really inspired him when
he preached the Crusade, God should deign to prove this by
opening the eyes of the blind. On which the child cried out,
14 What ought I to do now ? for I see.”

The Crusaders regarded the Greeks as false and treacherous
allies, while the Greeks were alarmed at the cupidity and
ambition of the Franks. This chronic hatred ended in an
army of the Franks with a Venetian fleet taking Constanti¬
nople and establishing a new kingdom there. The Greek empire,

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PSYCHOLOGY OF THE CRUSADES,

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deprived of its capital, was broken into three pieces, and fifty-six
years elapsed before the plunderers were expelled. Thus the
fourth Crusade, ostensibly for the recovery of the Holy City,
ended in the pillage and weakening of the Byzantine empire.

The Pope Honorius III had exacted a vow from the
Emperor Frederick II before his coronation that he should
undertake a crusade for the delivery of Jerusalem. When
Frederick succeeded to the Kingdom of Naples and Sicily the
papal curia, sometimes swayed by religious and sometimes by
political motives, saw with dismay the patrimony of the Church
shut in on both sides by the domains of the successor of the
German Emperors, with whom they had perpetual contentions.
Frederick had, by espousing for his second wife Isabella, the
heiress of the Kingdom of Jerusalem, acquired a title to that
lost possession. Certainly in delaying to fulfil his vow the
Emperor might plead that the popes gave him work enough to
do in stirring up his Italian subjects against him. The old
enthusiasm had passed away; men were no longer ready to
take the cross, and the Emperor had a serious illness, which
increased his reluctance. At last the impatient Pope Gregory
IX launched upon him an excommunication with an interdict
against any place where he might reside. The next year
Frederick sailed with a large fleet for the Holy Land followed
by the curses of the Pope, who denounced him as a pirate and
a friend of Mohammed because he had not solicited to be
freed from the ban of excommunication.

The Emperor had none of the religious zeal of the early chiefs
of the Crusades. He was known to indulge in philosophical
questions most unpleasing to the Church, now, not without
cause, jealous of heresies, and scepticism. The Court of
Frederick had become a centre of Arabian culture and
religious indifference. ( H )

The Emperor knew Arabic, and had lffkrried dialectics from
a Mussulman of Sicily. At his Court might be seen astrologers
from Bagdad in long robes and Jews employed by the Emperor
to translate works of science from the Arabic. He corresponded
with sages in different parts of the Mohammedan world.

On landing his army in Palestine Frederick received tidings
that the papal troops had entered his Neapolitan territory, and
messengers came from the Pope forbidding all with him to obey
his orders. This made him willing to make a treaty with the

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Saracens, for which the occasion was favourable. There was
strife between Alkamil the Sultan of Egypt and the Emir of
Damascus. Envoys were sent, presents exchanged—falcons and
horses and costly clothes from the Emperor, and an elephant,
camels, Arab mares, monkeys, and precious stones from the
Sultan. After much negotiation a treaty was signed by both
sovereigns by which Alkamil agreed to evacuate Jerusalem and
the towns and villages around and leave to the Christians a
narrow stretch of country along the coast from Jaffa to Beirut.
The mosque of Omar was to be respected, the Mussulmans not
to be molested in the exercise of their religion, and the Syrian
dominions of the Sultan were to be protected even against the
Christian principality of Antioch. On March 17th, 1229,
Frederick entered Jerusalem, and next day he was crowned in
the Church of the Holy Sepulchre. On the 19th there came
the Archbishop of Caesarea, the Pope’s legate, who laid the
Holy City under an interdict, to the great indignation of the
pilgrims.

The Emperor scandalised his orthodox followers by open
mockery of sacred subjects. He visited the mosque of Omar,
and the Mussulman guardian who accompanied him was able
to repeat pleasantries disagreeable to the zealots of either
religion. What little time Frederick spent in Jerusalem was
employed in friendly discussions with Arabian savants on
mathematics and philosophy. In thus winning back the Holy
City forty-two years after it was taken by Saladin, the German
Emperor had, without drawing the sword, accomplished what
Frederick Barbarossa, Richard Coeur de Lion, and Philip
Augustus had with dire loss and bloodshed striven for in vain,
and by establishing friendly relations with the Mohammedans of
the Levant and the Barbary coast he restored to Europe the
rich trade of the East. Yet neither of the votaries of these
warring religions were satisfied. The Christians said Frederick
had gained too little, the Mussulmans that Alkamil had granted
too much. Jerusalem remained a frail and insecure possession
in Christian hands for fifteen years, until in 1244 theCarismian
Turks displaced from the shores of the Caspian by the Mongols
swept over Asia Minor. The military orders were destroyed
in one battle, Jerusalem was taken, the grown-up inhabitants
slain, and the young men and children led into captivity.

In 1249 King Louis IX, generally called St. Louis, succeeded,

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not without persuasion, in leading the chivalry of France and
some noblemen from England into an invasion of Egypt.
This expedition, called the seventh Crusade, though it might
be called the tenth, ended in the King with all his nobles being
made prisoners. They had to pay a heavy ransom to be free.

The impulse to new Crusades was evidently losing its force.
There were signs that better days were coming, yet the feudal
lords still made the lives of the people miserable with their
oppressions, and the clergy made the future terrible with their
threats of an inferno in describing which Dante displayed his
vivid and cruel imagination. The misery, insecurity, and
oppression of the times were manifested in brain excitement
and motor restlessness ; but people showed a receptivity to
other forms of excitement than the blind rush to Jerusalem.

During the captivity of King Louis an unfrocked Cistercian
gave out that he had received a commission from the Virgin
to preach a Crusade to the poor and humble. His followers
were called Pastoureaux, or shepherds. The ferment spread,
so that in a short time he gathered together a multitude
said to amount to about one hundred thousand, moving along
in company with a banner bearing a cross and a lamb. “ He
assumed a priestly character, preaching, absolving, annulling
marriages. At Amiens, Bourges, and Paris itself he was
received as a Divine prophet.^ 12 ) The Queen Blanche, who
was regent, at first tolerated the religious movement. The
new prophet declaimed loudly against the idleness and greed
of the clergy, and his followers began to lay violent hands on
the priests and to plunder the monasteries, on which the
governing classes turned against them, slew many, and dis¬
persed the rest. A similar insurrection broke out seventy
years after, which was distinguished by a massacre of the Jews.

Other examples of these epidemics of religious lunacy in
the Middle Ages are furnished by the Flagellants in Italy,
Germany, and Poland, the Bianchi in Italy, and the dancing
mania which broke out at Erfurt in 1237, at Utrecht in 1278,
and at Aix-la-Chapelle in 1374. These nervous maladies,
propagated on the wings of thought, convulsing the mind by
exciting the senses, have been described by Hecker in his
learned work on The Mental Epidemics of the Middle Ages .

For the thirteenth century Christendom had its own wars to
engage its attention : the popes were more anxious to prose-

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cute their feuds with the house of Hohenstaufen than to
succour the Eastern Christians now separated from the Latin
Church ; the Venetians and Genoese were at war for the
trade of the East.

On the other hand, the zeal of the Mohammedans was in no
way abated. Bibars, the Sultan of Egypt, vigorous, untiring
and unrelenting, took it for his life work to expel the Christians
from Syria. He stormed the castles of the Templars and
Hospitallers, who disdained to help one another. In 1267 he
took Antioch, which had been for a hundred and seventy years
in Christian hands. The men were cruelly put to the sword, and
the women and children sold as slaves.

The report of these disasters stirred Louis to a new Crusade,
directed against Tunis, in which the King died of the plague,
leaving a warning to his people against further foolhardy
enterprises and gaining from the Church the honours of saint¬
hood.

In 1271 a new Crusade was started by Prince Edward of
England, afterwards Edward I. With 300 English knights and
500 Crusaders from Friesland added to the Templars and Hos¬
pitallers, he formed an army of 6,000 men. Marching upon
Nazareth, he caused all the Mussulman inhabitants to be
slaughtered. The Sultan Bibars advanced to meet him,
when the English prince retreated within the walls of Acre.
After having made a narrow escape from the dagger of an
assassin, on a truce being concluded, he left for England in
1272.

As the times became more enlightened the clergy found an
increasing difficulty in stirring on men fated to destruction to
new Crusades. People began to question whether these disas¬
trous expeditions were really a duty enjoined by the Christian
religion. We can only wonder at the slowness of their doubts,
the obstinate perseverance of Europe, “ that no instruction
should have been drawn from constant and adverse expe¬
rience, that the same confidence should have repeatedly grown
from the same failures, that six succeeding generations should
have rushed headlong down the precipice that was open before
them, and that men of every condition should have staked
their public and private fortunes on the desperate adventure of
possessing or recovering a tombstone two thousand miles from
their country ” (Gibbon).

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The taking of Acre by the Mohammedans in 1290 closed
the struggle for supremacy in Asia between Christianity and
Islam, which had lasted for well nigh two hundred years and
cost the lives of millions of men.

During the Crusades hostilities were carried on with shock¬
ing inhumanity. War between the different States of modern
Europe and America has been refined into a series of combats
between regular soldiers, wearing a distinctive uniform, who
direct missiles against one another at such a distance that the
enemy can scarcely be descried. Even while the work of
destruction is going on surgeons are employed to traverse the
field and attend the wounded, often caring for both parties
alike. Prisoners are subject to no further hardship than being
detained till peace is declared ; but when European troops
meet adversaries of different civilisation and colour hostility
assumes a harsher spirit. We know what savage reprisals
were made by our troops during the Indian Mutiny. Unques¬
tionably the provocation was great ; but the continuation of
unsparing massacres and wholesale executions after the first
grief caused by the treachery of the Sepoys make us see that
the fury of the Crusaders may still be traced in their descend¬
ants. The Crusaders had been taught by many senseless
stories to regard the Mussulmans as something more hateful
than wild beasts ; their foreign dress, their dark complexion,
their strange language, and their rival religion heightened the
abhorrence with which the pilgrims had been taught to regard
them.

Let us take two instances of the savage hatred of the
combatants. After the capture of Antioch Raimond d’Aigles
records an incident, which, as he observes, “was for us very
agreeable and truly delicious.” Some Turks seeking to escape
amongst the hills to the north had their retreat cut off and
were turned again to flight with such impetuosity that they
dashed over the precipices. “ It was,” Raimond goes on, “ a
true joy for us to see them thus fall ; but we had to regret
the loss of 3co horses which perished at the same time.”
Geoffrey de Vinsauf, in his Itinerary of Richard /, tells us
that the King resolved that the hostages, whose ransom
Saladin was slow in paying, should all be hanged, except a
few nobles who might ransom themselves or be exchanged for
Christian captives. “ King Richard, anxious to destroy the

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1907.]

Turks root and branch, and to punish their wanton arrogance,
as well as to abolish the law of Mohammed, and to vindicate
the Christian religion, on the Friday after the assumption of the
blessed Virgin Mary, ordered 2700 of the Turkish hostages to
be led forth from the city and hanged. His soldiers marched
forward with delight to fulfil his commands.”

It now and then happened during the Middle Ages that the
prelates of the Church tried to reconcile hostile princes and to
abate the fury of war amongst the Christians, but in this
struggle it was the clergy who kept up the crusading spirit and
increased the animosity of the combatants. The Bishop of
Puy, the Pope’s legate at the siege of Antioch, advised that they
should cut off the heads of the Saracens and sticking them upon
lances, expose them to the defenders of the ramparts.

The abbot Guibert Nogent gives a story which throws a
curious light upon the military surgery of the times. Baldwin,
the brother of Godfrey and the second King of Jerusalem, had
received a severe wound in trying to save one of his soldiers.
The surgeon who attended, seeing that the wound in the
abdomen was a deep one, was afraid to endeavour to close the
outer edges by plasters, fearing an internal abscess. To relieve
his uncertainty he asked the Prince that one of the Saracen
prisoners should be delivered up to him upon whom he might
inflict a similar wound, for, the Abbot remarks, to propose such
an experiment upon a Christian would be a crime. The
surgeon desired to kill the prisoner after having given him the
wound, in order that by opening his body he might at ease
compare it with the injury which the King had received.
Baldwin, however, declared that he would never consent to
cause the death of any man, even of the most odious race,
merely to seek through so many uncertainties to save another
life. The persevering vivisector then requested the French
Prince to have a bear given to him whom he could hang up by
the forepaws and then give the beast a similar wound in the
abdomen which he might compare with that of his royal
patient. The experiment was made and the surgeon came to
the conclusion that it would be dangerous to try to close up
the lips of the wounds at once. No doubt he received the thanks
of the King for his scientific treatment.

This took place six hundred years ago, yet only the other
day it was announced that as the results obtained by experi-

Lin. 23

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merits in animals are so uncertain as to be virtually worthless,
it has been proposed to the Ohio legislature that it should be
made legal to practise vivisections on criminals condemned to
death!

It has been wisely observed by Emilio Castelar that “ those
who look upon life from one side, upon time from one age, the
doctrines of one religion only, humanity from one people, will
never understand the human mind.” So let us try to realise
the feelings and thoughts of the Mohammedans when the
sudden inundation from the West burst upon their territory.
The bravery with which they defended their country gained for
the Turks the unwilling admiration of the Crusaders. “What
brave men ! how skilful in war ! if they were only Christians!”
It was fortunate for the Crusaders when the first army of the
Franks entered Phrygia that the power of the Seljuks was greatly
broken. Asia Minor was divided amongst emirs warring against
one another, and the Sultan of Egypt even coveted the alliance
of the Christians against the Turks. The Armenians were
awaiting the coming of the Crusaders as their deliverers.
After the taking of Antioch and the defeat of Kerbogha the
towns on the march through Palestine submissively gave pro¬
visions to the invaders, but the massacre of the inhabitants of
the Holy City caused a burst of indignation through the whole
of the Mohammedan world. As an Arab chronicler wrote, “the
tidings of that terrible catastrophe reached Bagdad in the
month of the Ramadan, consecrated to fasting and austere
penitence. The couriers who brought the dreadful news
implored the assistance .of the Caliph and his Emir in the
most touching terms. The inhabitants of the capital insisted
on a speedy succour, shed tears without ceasing, and ran about
the streets uttering cries of lamentation.” The Sultan of Egypt
promptly marched upon Jerusalem, but was defeated by
Godfrey and his army destroyed. Had he waited a few months,
till the bulk of the Crusaders had left for Europe, he might
have been more successful. At any rate, his overthrow struck
terror amongst the Mussulman population from Cairo to
Samarkand.

Bohemund ruled at Antioch, and Baldwin, the brother of
Godfrey, the King of Jerusalem, gained the principality of
Edessa across the northern Euphrates ; but when the petty
States of Syria and Anatolia were united under the vigorous

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I907.] BY WILLIAM W. IRELAND. 339

rule of Zenki, Neureddin, and Saladin the fortune of war
favoured the Crescent. In the history of the Crusades there
is no more striking figure than Saladin ; his valour, his gene¬
ralship, his magnanimity, his generosity to the vanquished,
made him famous over the East and the West. Dante puts
him in the limbo of his Inferno in the same circle as the sages
of antiquity.

There was more religious toleration in the domains of Islam
than in western Europe. About seventy years before the first
Crusade Mahmud of Ghazni, who sought to extend the faith
into India, went no further than plundering the Hindu temples
and breaking the idols. There is no record that he put any
Hindu to death save in battle or in storming a fort. It was
even said that he questioned the Divine message of the Arabian
prophet, and that he professed doubts of a future state. A vein
of scepticism had accompanied the military conquests of Islam,
and descended even to the fourth century of the Hegira. There
were a number of sects in Asia Minor and in Persia, some of
which altered, others rejected, the Mussulman faith. Certainly
Omar Khayydm, the astronomer poet of Persia, who lived at the
time of the first Crusade (dying in 1123) would have been
burned by the Inquisition had he dared in Europe to commit
to writing those materialistic verses which in an English dress
are now so much admired.

Some writers of history have allowed much influence to the
intercourse of the Crusaders with the higher culture and civili¬
sation of the Mussulmans ; but the bitterness of the prolonged
struggle for the possession of the Holy Land was a powerful
cause of alienation. The course of trade for the products of
the East, however restricted, would have much better helped
the exchange of thought. It was through Spain, not from
Palestine, that Arabian philosophy entered Europe. For two
centuries the Arabs had cultivated the science of the Greeks ;
it seemed as if Islam were capable of allowing sufficient
liberty for a rational philosophy. It was by translations from
the Arabic that the philosophy of Aristotle taught in the
schools of Cordova passed to the universities of Europe. But
with Averroes Arabian science came to an end (a.d. i 198).

Rather a commentator than an original thinker, his name
was denounced by the Church as the leader of the free thought.
Although the triumph of the Catholic faith in Europe seemed

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34°

PSYCHOLOGY OF THE CRUSADES.

[April,

to be absolute, there were still some philosophers who cautiously
confided their rationalism or their unbelief to one another.

There is no surer way to stiffen men in their belief than to
get them to fight about their cause. The fierce manners of
the Crusaders and the massacres of Antioch and Jerusalem were
told in every mosque, and were the burden of grief and ire
amongst the Mecca pilgrims. Volunteers came from all parts
of the domain of Islam to combat the Christian invaders.
The Catholic priests represented the Mussulmans as idolaters;
but the rigid monotheism of the Mussulman was offended by
the doctrine of the Trinity, the worship of the Virgin Mary, the
miraculous part assigned to the saints, and the idolatrous
reverence paid to the holy cross and the images and statues in
the churches. And so the followers of the prophet clung
closer to his revelation. It was in the twelfth century, the age
of the Crusades, that, as Renan tells us, “ Islamism triumphed
over the undisciplined elements which raged in her bosom, and
this by the advent of the Ascharite theology more severe in its
conduct and by the violent extermination of philosophy.
Since that age never has a doubt been produced nor a pro¬
testation raised in the Mussulman world. ,,

From what I have seen, heard, and read of the Mohammedans
of our day I believe that free thinkers are rarer amongst the
Mussulmans than amongst the followers of any other religion.

P) Guibert dc Nogent, Histoire des Croisades, Liv. iv, p. 148. Jacques de
Vitry, Liv. II, chap. iv.—( 2 ) Alexiados, Lib. x, Venetiis, 1729.—< 5 ) Kugler,
Geschichte der Kreuoziige, Berlin, 1891, p. 19, treats Peter’s dream as a legend,
which gives a supernatural origin to the first Crusade. He quotes Anna Comnena
to show that the hermit did not succeed in reaching the Church of* the Holy
Sepulchre. In the passage appealed to the Princess leaves it to be understood
that Peter, after enduring many hardships from the Turks, had failed to attain his
object, and fearing to go the same road alone, desired to take with him a powerful
force which would insure his safety. For this somewhat insufficient motive Peter
incited the Franks to make an armed pilgrimage to Jerusalem. But under the
conditions there was nothing supernatural in Peter’s dream. The story is related
by several writers much more likely to be well informed than Anna Comnena,
whose narrative is not free from errors. It is given by Albert d’Aix, a con¬
temporary, and by Jacques de Vitry, nor is it contradicted by any 'Western
writers who left histories of the Crusade.—( 5 ) Peter was at the taking of Jerusalem.
He returned to France in 1102 and founded the Abbey of Neufmontier, near
Huy, in Flanders, where he died at an advanced age.—( 6 ) See Entivickelung
und Untergang des Tempelherrenordens , von Dr. (ph.) Hans Prutz, Berlin, 1888 ;
The History of France , by M. Michelet, translated by G. H. Smith, pp. 312—
330; Kugler’s Geschichte der Kreuzzuge , Berlin, 1891, kap. xi.—(') Histoire de
la Poesie Proven^ale, par M. Fauriel, Paris, 1846, tome 11, p. 138.—(®) Te S
Hospitallers, en terre sainte et a Chypre , 1110-1310, par. H. Delaville le Roulx,
Paris, 1904, chap. ii.—( 9 )— Vie de St. Bernard , Livre Troisi&me, par. Geoffroi,
Moine de Glairvaux, chap. iv.—( 10 ) Renan Averroes et Averroisme , Paris, 1866 ;

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RECIDIVISM.

341

1907.]

chap, ii, sec. xiv.—( ll ) Hallam’s State of Europe during the Middle Ages y vol. iii,
chap, ix, London, 1834 .—( u ) Michaud’s History of the Crusades , translated by
W. Robson, London, 1852, vol. iii, p. 57; Die Kreueziige und die Kultur ihrer
Zeitvon Otto Henne am Rhyn, Dritte Auflage, Leipzig, 1903, p. 510.

Recidivism, regardedfrom the Environmental and Psycho-
pathological Standpoints. By J. F. Sutherland, M.D.,
F.R.S.E., Deputy Commissioner in Lunacy for Scotland.

PART I.

PAGE

1. Introduction.341

2. Statistics of crimes and offences, and of Recidivism in Scotland and

England for 1903 (with cartes graphiques) ..... 344

3. Age, sex-ratio, frequency of conviction for different crimes and offences

at certain age periods.355

4 Education.357

5. Occupation ..358

6. Interchange of crimes, and of crimes and offences, infrequent. . 360

[7. Prevalence and significance of insanity, from the psycho-pathological
standpoint, among the authors of the different crimes, and the
dominant mental factors governing those crimes—to wit, malice,
avarice, and lust.

8. Geographical distribution and loci of Recidivism .....

9. International statistics.

10. Criminal anthropology.

11. Criminal anthropometry (with cartes graphiques and polygon of observa¬

tions and theory), normal distribution.

12. Criminal Physiognomy ..........

13. Degeneracy.

14. The causation of Recidivism—

(a) Inherent (internal) : Bad heredity and degeneration, both of the

genetic and toxine-induced kind, plus an unfavourable ante¬
natal environment—mental warp and weak-mindedness .

(b) External: Post-natal environment—the most potent factor of all

—embraces slum dwellings, with a noxious moral and material
atmosphere, alcoholic excess, poverty, lack of employment, and
low wages, parental neglect, illiteracy, and truancy .

15. Jurisprudence and penology .........

16. Prophylaxis and treatment.]

Introduction .

RECIDIVISM is the French coined term most appropriate to
express the persistent, reiterated lapses of the same individual,
in that small section of habituals found in every country, both

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342

RECIDIVISM

[April,

among criminals engaged in serious crimes against the person
and property, and among petty offenders, whose delinquencies
or misdemeanours are drunkenness, public disorder, prostitution,
and vagrancy. The former are aggressive, noxious, anti-social,
and, to a slight extent, industrious and productive; the latter,
as a rule,'are passive, idle, debauched, parasitic, and unproductive.
The two types are quite distinct, and there is little or no inter¬
mingling ; that is to say, the recidivist engaging in the major
crimes in the criminal calendar does not forsake the ranks of
that class to become a recruit in the ranks of the minor and
petty offender class, and vice-versd.

Whatever the causes of its existence and vitality, within or
without the individual, recidivists of both types live, move, and
have their being, in spite of, and in antagonism to, the laws
made by society, for the protection of the person and property
of the individual, and of the commonwealth as a whole.

The laws of progressive countries are, fortunately, not like
those of the Medes and Persians—unchangeable—and therefore
liable to be broken suddenly. And thus it comes about that
persons who, in one age and generation, were denounced,
subjected to every humiliation, and confined as felons, in another
were hailed as heroes, martyrs, and altruists, and that those who
to-day, in exalted stations under the aegis of the law, are carrying
on, in the name of haute finance , etc., with the aid of wealth,
gigantic frauds against the weak and trusting members of
society, may to-morrow find themselves carrying on their
schemes under laws calculated to check this refined and subtle
development of that human, or rather, inhuman, acquisitiveness
and avarice, which, like a demon, spreads its dusky wings over
mankind, and enveloped in the legal mesh, just as surely as the
vulgar thief is now.

Recidivism cannot but have for psychologists and alienists a
special interest. The propositions put forward by the Italian
school of Criminal Anthropology, with Lombroso at its head,
quickened that interest for some years, as well as criticism, often
unmeasured, until that inevitable reaction set in, which, as a
rule, happens when extreme claims, based on slender data, are
put forward, and cannot, upon further investigation, be main¬
tained. What applied to, and might be true of, a few, was
claimed as covering the many. Absolute certainty in methods
of'observation and of results was claimed, when these, in the

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1907.] BY J. F. SUTHERLAND, M.D. 343

most favourable light, could only be considered of relative and
uncertain value.

For some reason or other the problem of recidivism has all
but eluded the grasp of legislators, jurists, sociologists, peno¬
logists, and psychologists, only indifferent success, up till now,
attending their separate and combined efforts, and what little
success could be shown followed experiment after experiment,
made in a haphazard way, without any real guiding principle.
The beneficial changes, slowly and constantly evolving in
wisely-governed communities, which have arrested the growth
of recidivism, or prevented that growth beyond the growth
which could only be justified by the increment of population—
the latter not much to boast of—have taken place by an adjust¬
ment of the laws referable to land and property more in
harmony with the views of the many. The government of the
people by the people, and not by the few, has brought about a
better state of society, better laws, better conditions of living
and labour, a fairer distribution of the wealth accruing from
labour, the extension of liberty, the spread of education, and
equal opportunities for all to rise in the social scale ; and, last
of all, a better understanding of penological principles. Under
favourable conditions, such as these, it will be possible to dis¬
cover the large number of reformable recidivists at present in a
rebellious mood. A residuum will always remain requiring to
be suitably dealt with, and treated as pathological entities of
various types and degrees. It is coming to be recognised in
Great Britain, the United States, and on the Continent—and this
is the view of the writer—that in the study of habitual criminals
much may be done for them, and through them, for society, on
the following lines : first in importance, by a study of the post¬
natal environment in its numerous and far-reaching aspects
from childhood to adolescence ; second , by a study of heredity*
including ante-natal environment,which might reveal degeneracy,
mental and physical defects of such a nature as to make the
proper exercise of the will in conduct and duty a very doubtful
one; and third, by means of criminal anthropometry, in order
to view him in contrast with the entire population, and with the
classes from which the different type of recidivists chiefly come.

The central and local administrative authorities throughout
the country have, at different times and in various directions,
at great cost, attempted to combat and solve this problem,

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RECIDIVISM,

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hitherto baffling and insoluble, by experiments of a juridical,
penological, and social nature, but the criminal, irrepressible
Frankenstein rearing its hydra-head, and stalking through the
land with limbs of brass, as well as the weak-minded and
obsessed petty delinquent recidivist, remain with us. But the
psycho-pathological and environmental lines of inquiry,
especially the former, have yet to be tried in earnest by
competent investigators.

It is becoming abundantly clear that the line of investigation
in the future which promises to all nations good results is that
which recognises the two principal causes of criminality, the
sociological one external to the recidivist—namely, environment,
and the economic conditions bringing it about and perpetuating
it, the other internal and hereditary—to be estimated by the
psychological and the psycho-pathological method. With some
knowledge of recidivists gained in a wide field of observation,
and likewise of the penal system of this and other countries
which prevailed for a time and passed away, this is the con¬
fident belief of the writer. Racial differences are not of much
moment, except in regard to the drink habit so prevalent
among the Celtic, Teutonic, and Slavonic peoples in Northern
France, the United States, Northern Germany, Russia, Denmark,
Sweden, Belgium, the Netherlands, and Great Britain and
Ireland, and the habit of carrying lethal weapons practised by
the Celtiberian peoples of Spain, Portugal, the Balkan States,
Italy, and along the littoral of the Mediterranean.

Statistics of Crime arid Petty Offences in Scotland and England

for 1903.

It has been the custom of not a few who speak and write
with some authority on criminal matters to decry the presenta¬
tion of vast masses of figures as not only puzzling, but of little
value. The puzzling nature of them to many is admitted,
but not the lack of value. National, as well as international,
statistics have a relative, if not an absolute, value, even when
the methods of compilation and classification of crimes are
neither uniform, nor the best, nor, indeed, what one would
expect them to be. Before a nation attempts to grapple by
newer methods—or, indeed, by any method—with the problem
of crimes and minor offences in their various noxious and per-

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*907-]

BY J. F. SUTHERLAND, M.D.

345

sistent forms—it very properly demands that a rough estimate
should be made of habitual criminals and delinquents who have
failed to benefit by past methods. If any investigation of
masses of figures revealed, on analysis, only a few recidivists—
whether felons of the hostes humatti generis type, or delinquents
of the drunkard, vagrant, tramp class—then it may safely be
assumed that society, sociologists, and penologists would not
trouble much about une quantity n£gligeable y but would be
inclined to allow them to fulfil speedily their destiny in their
own way, thereby giving testimony to a full belief in the
doctrine of the survival of the fittest. Some would revert to
Sparta’s methods. But the humanitarian, the political, judicial,
and penal reformer, and the psychological observer have to be
reckoned with in every civilised land, and the question which
cannot thus be disposed of is not allowed to rest or slumber.
Like the problem of poverty and the unemployed, while the
aggregate is small, not much is heard of either, but let it grow
in dimensions and obtrude itself on a nation’s notice, then
legislators make an effort to ascertain the causes and to remove
them.

Two statistical tables (I and II), with graphic representations
('circles concentriques) of each class of crimes and minor offences
(misdemeanours) in Scotland and England for 1903, are sub¬
mitted.

Scotland .—The total apprehensions in Column 1, namely,
166,180, or 1 to 27 of the population, have at first sight an
alarmist look, and would suggest that things—social and ethical
—are not well either in Scotland or England, in which the
liberty of the subject secured under many Magna Chartas is the
palladium of the people. But this immense total, it should be
borne in mind, only furnishes 36,710 individual prisoners. It
will be observed that the totals in the five different columns
steadily diminish until the noxious, aggressive, and anti-social
recidivists in Class 1 number approximately 1700, or 1 to 2690
of the population, and the parasitic and passive recidivist in
Class 2 (#), 3000, or I to 1 500, every one of whom, unlike the
worst type of recidivist who escapes justice three out of four
times, are accounted for by the police.

Both kinds number 4700, or 1 to 1000 of the population.
0*38 per 1000 of the population waging an aggressive war
against society does not look bad, although the annual cost of

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RECIDIVISM,

[April,

the 1700 for maintenance, supervision, and the machinery of
the law, in addition to the loss to the nation when they are at
liberty, falls little short of a million sterling annually !

Among the 4700 recidivists there are, from calculations I
made in 1895, 2500 who are weakminded and mentally
unstable. That would mean *5 per 1000 of population—a ratio
somewhat similar to that given for England some years later
by Mr. C. S. Loch, C.B.

The recidivists in Scotland, it is true, do not increase beyond
Scotland, 1903.

Population , 4,580,000. Apprehensions and Prosecutions for Crimes ,
25,680; for Offences , 140,500. Total\ 166,180.

Sex-ratio.

Crimes
known to
police.

V g J

eL c

CL O

< *5

Convictions. “

0 .

M »

O.C

J= £

Number of
Individuals +■
imprisoned.

Number of
recidivists ^
free and un* *
confined.

Class I. — Crimes .
a. Homicides,* grave as¬
saults, cruelty to children

11 to I

4.590

4,762

3,975

1,976

b. Rape, unnatural sexual
crimes, libidinous prac¬
tices .

362

310

233

c. Malicious injury to
property +

14 to 1

4,221

4,627

3,627

d. Crimes against property
•with violence, robbery,
housebreaking, burglary

16 to 1

4.736

1 .568

1,282

1,219

E. Crimes against property
•without violence, theft,
reset, fraud, forgery, etc.

3 to 1

21,152

13.834

10,928

6,498

f. Other crimes.

2 to 1

—

473

—

Total of Class I .

5 to t

—

25.574

20,329

10,921

8,340

(b) 1,700

Class II. — Petty Offences.
a. Breach of peace and
drunkenness .

3 t0 1

95,681

70,096

36,108

2,000

b. Prostitution .

—

2,886

2,714

2,006

—

c. Vagrancy, begging

7*5 to 1

—

4.037

3,757

2,561

—

1,000

d. Other petty offences

6 to 1

—

38,002

38,200

8,220

—

Total of Class II

3 to 1

—

140,606

92,166

48,956

29,370

(a) 3,000

Grand total of I and II

3'5 to 1

—

166,180

112,700

60,076

37,710

4,700

* Homicides apprehended, 62.
f Arson (fire-raising), 38 ; known to police, 54.

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1907.] by J. F. SUTHERLAND, M.D. 347

Fig. 1 .

1. From circumference to centre = apprehensions.

2. „ „ „ = convictions.

3. „ „ „ = imprisonments.

4. „ ,, 1, = number of individuals imprisoned

5. Habitual criminal recidivists.

6. Habitual petty offender recidivists.

the figure justified by growth of population, and that is not
much to boast of; neither do they diminish. The gaps made
in their ranks by the ravages of debauchery, disease, and pre¬
mature death, and by the wearing down of prolonged, penal
sequestration are soon filled up, and will continue to be filled up
so long as that pernicious moral environment possible in the slums
of cities and towns is allowed to continue. It will be noted that
all those coming under the cognisance of the police are divided
.into two classes : the authors of crimes, and the authors of
petty offences (misdemeanours), the apprehensions of the former

348

RECIDIVISM,

[April,

numbering 25,570, being 15 per cent . of all crimes and offences,
and 1 to 180 of the population, of the latter 140,600, being
85 per cent. y and 1 to 39 of the population. Of the 25,570
apprehended in Class 1, 20,330 are convicted after trial on
indictment, and 10,920, representing 8340 individuals, or 1 to
550 of the population, go to gaol ; and among those and their
comrades at large are to be found 1700 noxious and hitherto
incorrigible recidivists. In the case of larceny (thefts), reset,
fraud, and forgery, the sex ratio is 3 to 1, not a few women
and girls in the latter class being degenerate and weak-minded,
pilfering, both when sober and partially under the influence of
alcohol, when they become reckless and unconcerned. The
sense of shame and remorse is a minus quantity. No less than
25 per cent . of the authors of crimes in this category escape
apprehension, “ slimness ” and cunning being exercised by the
smart ones.

In regard to crimes of blood and violence, murder, culpable
homicide, assaults on wives, cruelty to children, etc., the authors
betray a coarse, callous, and cruel nature, but not, except in
rare instances, calculation or deliberation in their execution.
Speaking for Scotland, the mental attributes of hatred, malice,
and revenge in evidence in this class of crime suggested by the
foregoing sentence requires modification, for it is within the
mark to say that 70 per cent . of such crimes are committed by
persons more or less in a state of alcoholic intoxication, and
therefore more or less irresponsible, or by persons degraded by
chronic alcoholism.

Jurists working upon precedents and judicial dicta genera¬
tions, if not centuries old, declare that intoxication, which, in
the view of the writer is temporary insanity pure and simple, is
no excuse for the gravest of all crimes—homicide. There can
be no freedom of will in such a state. Others, again, having
better conceptions of what the intoxicated state means in
relation to crime and responsibility, advocate that at least he
should be punished and sequestrated, if not for the resultant
crime, for imbibing too freely of a toxic agent, which he knew,
or ought to know, in himself, and by its action upon others,
would deprive him of inhibition, and of clear judgment as to
conduct. There is something, indeed, much, to be said for
this view in any rational system of jurisprudence. But even
here the question is begged so far as chronic drunkards are

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19 ° 7 -] BY J. F. SUTHERLAND, M.D. 349

concerned, and it has yet to be determined by alienists in what
cases the alcoholic habit is a vice, and in what cases an
evidence of a neurasthenic or defective organisation, or the
outcome of a pathological state, both of mind and body,
induced by long indulgence to excess. In many of the latter
class no doubt there was a stage in the life of the drinker
when responsibility might be assumed, but it is by no means
an easy task for the alienist or physician to fix the stage
when responsibility ceased and irresponsibility began. For
some murders committed in passion or frenzy to avenge a
wrong—real or imaginary—it is possible to plead justification
and extenuation; but for the foul, cold-blooded, deliberate homi¬
cides of notorious criminals and prisoners, who, for lust or gain,
have put out of existence wives, helpless children, and others,
no shadow of an excuse can be offered, in view of the fact that
without resorting to such extremes the former passion could be
gratified to the full sexual pitch, and the latter realised with
the risk of loss of liberty to himself rather than the loss of life
to another. And the term “ instinctive criminal ” should not be
set up as a shield to protect such inhuman monsters from the
justice, not the lex talionis, of laws, both divine and human. For
such elimination or perpetual sequestration is called for in the
interests of society. Such criminals—moral monsters if you
like—are not one in a million, and fortunately, being so rare,
it is indefensible to erect them into a class and write as if they
were in evidence on all sides, and a standing menace to life
and property.

The number of recidivists in this class of law-breakers is
few. It could not be otherwise, seeing their acts of violence are
the outcome of passion, hatred, and malice gratified with, or
without, the aid of an intoxicant, and in their graver forms are
seldom repeated, punition having a salutary effect.

With regard to the perpetrators of crimes against chastity,
viz., rape, incest, unnatural crimes, etc., it has to be said that in
no class of crime is the psycho-pathological element so apparent.
Krafft-Ebing has for all time shown how many of these abnor¬
mal acts are due to sexual perversion and obsessions. The
abnormality and unnaturalness of them all is self-evident to
every unprejudiced physiological being. The numbers known to
the police in the nature of things are few, and nearly all committed
by males. But, for obvious reasons, all such crimes do not

350

RECIDIVISM.

[April,

come to light, and females take part in them, it is true, to a
less extent, the sexual function being a less impelling one in
them. Not only do these crimes, one and all,, suggest to the
normal individual a psycho-pathological and pathological side,
but the repetition of them in spite of severe punishment
confirms this view. The recidivists known to the police are
few—fewer than they really are.

Of crimes entitled “ Malicious Injury to Property,” arson is
the most serious, and suggests obsession when deliberately
done. Malice is at the root of it, and the male sex are mainly
engaged in it. Recidivism is rare.

Coming to Class II—“ Petty Offences ” (misdemeanours)—
no less than 140,600 apprehensions, being 8 5 per cent . of all
crimes and offences, were made by an unnecessarily vigilant
police, who seem to pounce automatically upon any staggering
object on city streets.

The zeal and activity hitherto displayed by the guardians
of public order is in this matter being somewhat curbed by the
timely action of the Secretary of State. The ratio of such
apprehensions is 1 to 33 of the population. Of this enormous
total drunkenness and breach of the peace (95,680), prostitution
(2,886), account for 98,567, or to 1 to 46 of the population.
The great majority of the authors of these offences are in no
sense criminal or recidivist, being males who get drunk on pay
and fite days, work hard during the week, and maintain a home.

The phase of prostitution, which has for its votaries the
demi-monde , is synonymous with drunkenness, dress, and indo-
ence, these having, perhaps, as much, or more, to do with it
than lust. The ranks of prostitution are not recruited, except to
a very small extent, by the progeny; rather from those who up
to adolescence have lived respectable lives upon small earnings.
There is to be found among drunkards and prostitutes 2000
habituals, four fifths of whom are women—not many, consider¬
ing the total apprehensions and the number of individuals
(30,000) which they represent. But the 2000 are parasitic,
lazy, debauched recidivists, for a proper estimate of whose
moral and mental qualities, and of their future destiny, the
psycho-pathological tape is required. They are, without a
moral crutch, unable to guide and support themselves, and, like
jetsam and flotsam, drift through society, not realising that
they are social pests.

Digitized by v^.ooQle

1907.] by J. F. SUTHERLAND, M.D. 35 I

The great majority of petty offenders are (casuals) engaged
in honest, often profitable, labour, the rewards of which are on
occasions put to the worst use—to the detriment of themselves,
their homes, dependents, and society. And such, getting into
the hands of the authorities three or four times a year, cannot by
any stretch of the imagination be reckoned “ habitual drunkards ”
or recidivists, requiring prolonged seclusion in some other place
than an 800 cubic feet cell, in which twenty-three out of every
twenty-four hours are, as a rule, spent.

In this class, also, are to be found the vagrant and beggar,
and they are responsible for 4037 apprehensions—a total far
short of the breaches of the vagrancy laws. A timid, super¬
stitious, and hospitable public will lodge them in outhouses,
and support them rather than report them to the police, and
have them put behind bars and bolts, or in labour colonies, or
workhouses. The brief term in gaol does no good to the nomad
or “knight of the road.” Very different treatment is required.
The ablution on reception is not considered a boon. On dis¬
charge they are again enveloped in filthy rags, and thus the
cycle goes on. This class being migratory, and not long
amenable to one jurisdiction, contributes few recidivists—fewer
than they really are. They are in the proportion of eight
males to one female. The hardships are too great for the latter
sex, except for the hardiest. In a legal sense the attachment
of sex may be said not to exist, and, in any sense, the progeny
is few, what there is being in infancy decimated by hardships,
exposure, and disease. They manifest a conservative element,
when, with the approach of winter, the majority seek for months
the shelter of the workhouse, and with the advent of spring
resume the lines of march. Others seek out the “dosser”
houses and night shelters of each town on the line of march.

For a proper understanding of many of the tribe of the
wandering foot and weary breast, also, the psycho-pathological
tape is required, and a different destiny than the gaol which
society has erected for them and for other delinquents and
disiquilibris with mental warp, as a fortress of despair, not a
house of hope. With truer conceptions of psychology, ethics,
and social pathology there is no reason why in coming
years the incorrigible, lazy tramp suffering from the cacoethes
ambulandi , or what German writers designate “ vagabund-
wahnsinn,” whose mode of life is a puzzle to ordinary observers,

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352

RECIDIVISM,

[April,

and to the officials of workhouses and night shelters, suggest to
the normal man one of great discomfort, misery, and misdirected
energy, because twenty miles of the road daily is not accom¬
plished without loss of energy—perhaps having regard to the
relative diets little less than is expanded by the honest labourer
in his eight hours* day—should not find his place in the ranks
of the large army of mental degenerates, and thereby of lunacy.
But a life of ennui , footsoreness, and an outhouse with or with¬
out a pallet of straw, or the side of a brick kiln, no more disturbs
him than the embedded grime on his skin, and the pediculi
and acari which thrive undisturbed on his body. The applica¬
tion of the aesthesiometer reveals that the sensory nerve endings
are not responsive to the usual stimuli.

In England there were 36,800 apprehensions of tramps,
making up a corps cTar?nce of ragged regiments roaming at
large over the whole country, with a full knowledge of the
roads and the shelters, and billeting themselves nolens volens
on a hospitable or terrified public, who are thus largely re¬
sponsible for the existence and continuance of this parasitic
army, constantly on the move in singles or in couples.

There is no need, it is assumed, to make anything but a
casual reference to that large mass of offences (38,000) against
education acts, road acts, bye-laws and regulations of police
acts, game laws, sanitary laws, etc. They are of little signifi¬
cance in a criminal or delinquent sense. They are bound to
exist in all self-governing and progressive communities striving
to attain to a more ideal and perfect state, when the humblest,
poorest, and least intelligent in the community will be educated
up to a full observance of such statutes.

England \—Having dealt at some considerable length with
the delinquent statistics of Scotland, there is no call to write
much about those of England. Whatever differences there are
in the whole, and in sections, is not due to any racial difference,
or to any difference in the laws governing serious crime—these
being the same in both countries, and enforced with swift,
unerring, and impartial certainty—but rather to a difference in
the laws appertaining to petty offenders, and the method, or
lack of method, of their application.

The grand total of apprehensions—745,000, or 1 to 44 of
population—like the Scottish one, dissolves through convictions
(1 to 104), imprisonments (1 to 146), and number of individuals

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»9o;.]

BY J. F. SUTHERLAND, M.D.

3S3

(i to 200) engaged both in crimes and offences, to 167,900
individuals, of whom 33,000 recidivists, 13,000 of the noxious,
anti-social recidivists of the burglarious, fraudulent, and larcenous
type being in Class I (or 1 to 2500 of population), and 20,000
in Class II (or 1 to 1630 of the drunken, prostitute, and vagrant
order), who are parasitic and passive, and only in small measure
anti-social, if, under the present rigime> they are to be allowed
to live at all, and be at large when unoffending.

Both types of recidivist combined are in the proportion of
1 to 1000 of the population.

England, 1903.

Population , 32,716,710. Apprehensions and Prosecutions for
Crimes , 99,750; for Petty Offences , 635,225. Total , 734 * 975 -

4 -

•

•j- J 2 -o
g << g

0 • § .

Sex rate

Crimes
known t
police.

Apprehe

•ions.

*►

Imprlsoi

ments.

.§2 §
in

Z.E .§

Number
recidirii
free and
confined

Class I.— Crimes .

a. Homicides/ grave as-

saults, cruelty to children
& Rape, unnatural sexual

4'5 to '

18,254

18,050

—

crimes .

—

1,401

1. 39 1

—

c. Malicious injury to pro-

8 to i

potyt .

0. Crimes against property

16,176

16,073

—

with violence, robbery,
housebreaking, burglary.

30 to 1

9,920

3.734

t Crimes against property

without violence, theft,
reset, fraud, forgery

4 5 to 1

69.14s

57.636

—

t. Other crimes.

i*5 to x

3.054

3.099

—

Total of Class I .

—

99.983

—

(b) 13,000

Class II .—Petty offences. \
a. Breach of peace and

drunkenness .

3 to x

—

282,320

—

■. Prostitution .

—

".530

—

c. Vagrancy, begging, etc.
D. Other trivial offences .

9 to I

10 to I

33 .68 o

308,695

—

Total of Class II.

5 to 1

—

636,225

—

(a) 20,000

Grand total of 1 and 11

S to 1

—

736,208

314.060

223,910

167,900

33 .°o°

* Homicides, 388; made known to police, 436.
t Arson (fire-raising), 213; made known to police, 272.

LIII. 24

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[April,

3S4

RECIDIVISM,

Fig. 2.

I. From circumference to centre =

2 - ii a a =

3 * »» »» »» =

4 * •# »» »» =

5. Habitual criminal (recidivists).

6. Habitual petty offenders.

apprehensions.

convictions.

imprisonments.

number of individuals imprisoned.

Of the 745,400, there were apprehended, for homicides,
assaults, wounding, sexual crimes, crimes against property, with
or without violence, 99,980, or 13*4 per cent . of the whole, and
1 to 327 of the population. Crimes against property totalled
61,370, being 61 per cent of all serious crime, and equivalent
to 1 to 533 of the population. Sexual crimes amount to
1*4 per cent of grave crime.

The petty offences (not the offenders) in Class II number
635,225, or 85 per cent . of all crimes and offences, and are in
the proportion of 1 to 5 1 of the population. Of those in this

Digitized by C^ooQle

1907.] by J. F. SUTHERLAND, M.D. 355

class calling for notice it has to be observed that drunkenness,
disorder, prostitution, vagrancy, and begging account for
327,530, the apprehensions for the first there being 293,850,
or 1 to ill of population, and the fourth 33,680, or 1 to
1000 (circa).

The other petty offences, numbering 308,695, or nearly
50 per cent, of all minor offences, are no evidence, either in
their numbers or in their nature, of delinquent tendencies, but
rather the measure of imperfection of a large section of society
not educated to, or not in a position to adapt themselves to, a
variety of recent laws, passed with the object of attaining to
a more perfect social and civil state.

To a proper understanding both of criminals and offenders,
and especially the habitu/s among them, certain civil and social
conditions require to be stated, and among these obviously are
sex, age, and usual place of abode, housing, training in child¬
hood and youth, education, occupation, civil condition, single
or married, widower or widow, living in family or separated, and
the probable cause, habits, and frequency of conviction. All
these are embraced in the great environmental factor external
to the criminal, to be discussed later, alongside of other factors
in criminality inherent in the criminal himself, and evidenced by
a physical and mental make-up of such a kind as to suggest that
judgment as to a true sense of right and wrong is so warped,
that freedom of will to choose between right and wrong does
not, in many instances, in reality exist. The presence of con¬
genital mental defect or mental warp, it may be of small
degree, is often sufficient to make the acquisition of the most
elementary knowledge all but impossible, and, if that be so,
what is to be expected in regard to the moral sense ?

(1) Sex and Age.

In official statistics this alone of all the points is stated with
that fulness which makes the figures valuable, and refers to
crimes and offences en masse , and also in detail at certain well-
defined and critical age periods in life. In this way the prone¬
ness of sex to different crimes and offences at certain age
periods is made known, and it is significant, from the sex point
of view, that in regard to crimes of blood and violence, sexual
crimes, crimes against property with violence, and the offence

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356

RECIDIVISM,

[April,

of vagrancy, females play a small part. On the other hand, for
crimes against property without violence, and for the minor
offences of drunkenness, breach of the peace, and prostitution,
they are strongly in evidence. In Scotland and England, for
these important age periods, the relative percentage of crimes
and offences was in 1903 as follows :

Percentage of Criminals and Petty Offenders of Both Sexes at
certain Age Periods .

Scotland.

England.

Under 16.

16-ai

years.

50 years
and over.

Under 16.

16-11

years.

50 years
and over.

Crimes.

Homicides, assaults

0*2

10*6

10*8

Rape, unnatural crimes,
etc. .

2*5

Crimes against property,
with violence

Crimes against property,
without violence.

x 9

7*4

Petty offences.
Drunkenness, breach of
peace ....

1*2

124

Prostitution, etc. .

—

Vagrancy

2*4

9*5

22*2

—

Instructive also are the following figures for England, as to
the relative proportion of the sexes at all age periods:

England.

Under

1 a.

Under

16.

16-31

years.

u-30

years.

30-40

years.

40-50

years.

50-60

years.

Above

60.

All

ages.

Indictablecrimes
against property
without vio¬

lence, theft, re¬
set, fraud, etc. .

100*17

100*8

100*11

100*14

100*20

100*12

Larcenies and

petty theftstried
incourtsof sum¬
mary jurisdic¬
tion .

1006

100*14

100*19

100*20

100*31

100*25

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I 907 -] BY J. F. SUTHERLAND, M.D. 357

In Scotland the sex ratio at three well-defined age periods
is as follows :

Under 16 years.

16-ai years.

Above 50 years.

Crimes against property without vio¬
lence .

Petty offences of drunkenness, breach
of peace, and prostitution

100*17

100*10

100*22

IOO36

100*50

100*55

Sex ratio in relation to frequency of conviction or recidivism
is a matter of some moment, and in Scotland is as follows :

Offences and crimes.

3 times.

4-10

times.

11—JO

times.

ai-50

times.

Si-100

times.

zoi and
upwards.

(a) Drunkenness, breach

of peace, and prostitu¬
tion ....
(6) Crimes against pro-

100*50

100*70

100*7

100*90

IOO180

100*330

j perty, with violence
(c) Crimes against pro¬

—

100*6

100*2

100*27

—

perty, without violence

“

100*26

100*40

100*50

100*130

“

It is strikingly borne out by this last set of figures that as
frequency of conviction advances, the female sex advance with
it, until ultimately it exceeds the male sex in a remarkable
manner.

It is significant that in England, of those convicted of indict¬
able crimes, 18*5 per cent . were under sixteen years of age ; at
one time it was higher, but a judicious use of reformatory and
industrial schools, and of the lash (birch) in lieu of the prison,
has reduced the number. It is still, it will be admitted, a high
figure, and one calling for searching inquiry in order to deter¬
mine how far it is due to their organisation and how far to the
lack of opportunity for doing good, and to the lack of educa¬
tion, training, and a trade. These juvenile felons and delin¬
quents have not attained adolescence, and the inhibitory power
of the brain has not been properly developed.

Education .

In England, of 188,678 persons imprisoned, 19 per cent .
could neither read nor write (a fact at the first glance not credit-

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358

RECIDIVISM,

[April,

able to a country with the freest institutions, and in the
enjoyment of free and compulsory elementary education) ; 78
per cent . could “ read and write imperfectly,” 24 per cent
“could read and write well,” and “ 008 had a superior educa¬
tion” These startling figures would seem to justify Victor
Hugo s estimate of the part illiteracy plays in crime. But any
deduction from those figures must be qualified by the statement
that a great many, from mental incapacity and weak-minded¬
ness from birth and in early life, were incapable of receiving
that elementary instruction which would raise them in the
social scale above the lower labouring classes. Not a few who
do possess sufficient mental capacity are in this position from
parental neglect and bad upbringing. These percentages, it
should be explained, are given for all sorts and conditions of
prisoners en masse. It would be much more helpful to those
on the outlook for preventive measures if the state of education
was given for prisoners in each of the different classes of
criminals and offenders, and likewise an estimate of their moral
and mental capacity. It is well known, however, that crimes
against the person show a lower level of intelligence than
crimes against property. But the psychological and psycho-
pathological tape, although of profound value, has hitherto not
been applied. The scale of intelligence and capacity might
profitably be arranged somewhat as follows :

(1) Mentally defective—the simplest facts understood, but
an incapacity to perceive or reason about the relationship
between facts.

(2) Slow, dull capacity for perceiving relationships between
facts in limited fields with long and continuous effort.

(3) Slow, very slow in thought generally, but with time
understanding is reached.

(4) Slow, intelligent, sure of knowledge when once acquired.

(5) Intelligent, capable of understanding with much effort.

(6) Very able.

This line of inquiry, conducted by competent psychologists,
would settle wiiy illiteracy, and a state not far removed from
it, is so prevalent among criminals and offenders in England
and Scotland.

Occupation .

To be of value, this, like education, should be given for

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1907 .]

BY J. F. SUTHERLAND, M.D.

3S9

criminals and offenders in each class, and not en masse as is
done at present The state of education reached and ascer¬
tained practically decides what the vocation in life will be. In
England, of 188,680 prisoners, 38 per cent\ were styled
11 labourers,” 25 per cent. “ trades and handicrafts,” 37 percent.
“prostitutes,” and r8 per cent, “domestic servants.” And of
the occupations of 268 convicts in Scotland in 1905, 110, or
48 per cent., had former sentences of penal servitude, that for
“ labourers ” amounting to 56 per cent., “ handicrafts and
trades,” 30 per cent. ; “ professional,” 2 per cent. ; and mis¬
cellaneous, 11 per cent. Of the 268, 19 per cent, were guilty
of homicides and grave assaults, 40 per cent, of housebreaking,
burglary, and garotte robberies, 30 per cent, of theft, reset, and
fraud, and 9 percent, of rape and unnatural sexual crimes.

From a return prepared for me, with the authority of the
Prison Commissioners, in 1905,of 370 male convicts and long
term prisoners in Scotland, 199 of whom were convicted of
housebreaking and burglary with violence, no less than 67 per
cent . of the 199 were in the social scale “ labourers” by occupa¬
tion, or something very much akin to it, and 3 1 per cent, had
learned handicrafts. The latter figure—a large one for this
class—is not surprising, although disappointing, as among them
there are to be found skilled workmen capable of earning more
than a competency, or living wage, by honest industry. Of
no convicted of theft, reset, fraud, etc., 47 per cent, were
“ labourers,” and 41 per cent, “skilled workmen,” and 6 per cent.
professional men. Of 55 convicted of homicides and assaults,
54 per cent, were “labourers,” and 27 per cent, “tradesmen,”
and of 14 convicted of sexual crimes, 80 per cent, belonged
to the labouring classes, and 21 per cent, had acquired the
ordinary trades. In all the four classes of crime 60 per cent.
were of the labouring classes, and 33 per cent, had learned
trades. Some trades yield a larger proportion than others,
but unless one knew the number of each in the general
population no good purpose would be served by further
analysis. It is clear that the great majority committing the
four kinds of crimes come from the labouring and least
educated class, and that many of them are illiterate. It
should not be forgotten that the “ labouring ” class form the
largest section of the population. Between occupation and
education, as between illiteracy and crimes and offences, there

36 o

RECIDIVISM.

[April,

is, however, a close intimacy. The obvious moral, in spite of
Lombroso’s contention to the contrary, is that ignorance is a
danger to the State.

No information whatever is vouchsafed in judicial statistics,
or blue books, as to the nature of the home (if any), the early
training of criminals and offenders and their civil condition as
to marriage, etc., as to habits, temperament, mental capacity,
etc.—information absolutely essential to a right understanding
and proper treatment of criminality and delinquency of the
recidivist order. It is evident that our criminal statistics, to
be of use and helpful to reformers, require re-casting.

Interchange of Crimes , and of Crimes and Offences , and of
Criminals and Offenders .

The writer has been at some pains to find out how far this
takes place, and the answer must be only to a slight and
negligeable extent. The types of felons engaging in the
different crimes in Class I (Tables I and II) differ from each
other in regard to the dominant mental characteristics—revenge,
malice, lust, acquisitiveness, and avarice—governing each to such
an extent that there is little or no interchange save between
those who attack property with and without violence, in which
it is considerable.

The large number of petty offenders (misdemeanants) in
Class II commingle freely during the year and through life
their offences of drunkenness, breach of peace, and prostitution,
and, to a much less extent, vagrancy and begging. But few
of them pass into the category of major criminals, and these
few are the drunkards and riotous, whose frequent deeds of
violence, disorder, and cruelty more often than not, by the
merest accident, resulting in slight bodily injury to their
victims, end in their being charged with homicide and indict¬
able assaults. It could not be otherwise.

An intoxicated person, in a state of frenzy, is a constant and
potential danger in a community. Reckless and unmeasured
violence are the characteristics of the individual thus tem¬
porarily insane. Indeed, there is not, within the whole range
of lunacy, a more complete picture of insanity than that
presented by an intoxicated person, every sense being disordered.

Prostitutes frequently vary their mode of living and

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I 907 -] TREATMENT OF THE EPILEPTIC INSANE. 361

offending with drunkenness, and less often with theft, their
victims, as a rule, intoxicated or apparently so, being persons
of the opposite sex. A minority of vagrants and tramps are
apprehended for drunkenness, breach of peace, assaults, fire-
raising, and malicious injury to property, but the great majority
are comparatively harmless, homeless, aimless, wandering
tramps and beggars.

( To be continued.)

Notes on the Management and Treatment of the
Epileptic Insane , with a Special Reference to the
NaClfree (or “ Hypo - chlorisation ”) Diet . By

G. Foster Barham, B.A., M.B., B.C.Cantab., Assistant
Medical Officer, London County Asylum, Claybury.

In the light of our present knowledge as to the causes of
epilepsy, it almost might be said that, pending further dis¬
coveries, the last word has been spoken on the subject of its
treatment; it is hoped, nevertheless, that some useful purpose
may be served by recording a few observations on certain
methods of treatment and their practical application under the
conditions existing in a large asylum for the care of the insane.

In the treatment of epilepsy there are two well-recognised
indications: (1) the dimunition,or suppression, of the paroxysms;
(2) the modification, or, so far as possible, the elimination of
exciting causes.

Since Toulouse and Richet (1) published, in 1900, the
encouraging results they obtained by combining a NaCl-free
diet with the administration of bromides, many observers have
recorded their experiences of this method, and the consensus
of opinion is that it is of considerable value. The substitution
of sodium bromide for sodium chloride in the preparation of
food is not easily carried out in asylums where means for
specialisation in the kitchens and bake-houses are not provided
for. Moreover, the substitution for the ordinary mixed diet
of a diet of milk and vegetables, as has been recommended by
Zickelbach (2) and others, at once meets with administrative
difficulties when dealing with large numbers of epileptic

362 TREATMENT OF THE EPILEPTIC INSANE, [April,

patients. On the other hand, the simple substitution of sodium
bromide for table salt can easily be carried out, and for the
last eighteen months observations have been made in one of
the epileptic wards at Claybury with the object of testing the
effect of this procedure.

In the first place, all the patients in Ward K, which contains
about fifty-five epileptics on an average out of sixty-two patients,
were treated alike with the substituted salt. Many of the
epileptic patients were at the time taking bromides, and had
been doing so for a long time. At the end of about two weeks
the effect produced was most marked—there was an appreciable
diminution in the number of fits—but the most noticeable result
was the extreme drowsiness of a large number of the patients,
while nine epileptics and three of the non - epileptics were
rendered quite incapable of dressing themselves or doing any
of their usual occupations, some of them being unable to stand
up, and one epileptic passed into a stuporose state, which lasted
several days. All the patients had previously been free from
these symptoms, and were, for the most part, capable ward
helpers. Following on this, the doses of bromides given in
medicinal form were gradually reduced, while observations on
the number, severity, and character of the fits were made ; at
the same time, a few patients, including old and feeble cases
and the non-epileptics, were provided with ordinary salt at
separate tables.

An attempt was made by the writer to estimate the average
amount of sodium bromide consumed by these patients. They
only take salt at their midday meal, and almost invariably
sprinkle their food all over with it, seldom placing any on the
side of the plate. On several consecutive days a known weight
of sodium bromide was placed in the cellars used by twenty
patients, and at the end of the meal the remainder, together
with that which could be gathered up from the plates, was
weighed. By this means an average of 18 gr. was found to
have been consumed. It may reasonably be assumed that the
majority of these patients take 10, or more, gr. per diem , and
that it seldom occurs that any one patient would like more than
20 gr. Toulouse allowed 3 grm.per diem —/>., approximately,
46 gr.—but this was presumably not all consumed.

The results of this treatment are distinctly encouraging. In
the majority of cases the paroxysms have been diminished

Digitized by v^ooQle

I907.] BY G. FOSTER BARHAM, M.B. 363

appreciably, both in number and in severity, and, on the whole,
smaller doses of bromides in the form of medicine have been
required. But the most satisfactory result has been a general
improvement in the condition of this ward, where the patients
are quieter, less irritable, and more capable to help and to carry
on the work of the ward. Moreover, it appears that, whereas
in certain aggravated cases with severe and frequent paroxysms
the dose of bromide necessary for their control was liable to
reduce the patient to a state of incapacity, with drowsiness and
loss of appetite ; under this treatment a more satisfactory result
is obtained, the severity of the fits being lessened without any
symptoms of bromism, though there is the same tendency
towards the replacing of the attacks of grand mal by numerous
attacks of petit mal —sometimes seen under the influence of
bromides. The effect of this small amount of sodium bromide,
given in the place of sodium chloride, is out of all proportion
to its quantity (10 to 20 gr.) as compared with the large
doses (jij to 3iij or more) sometimes required to control the fits
under the usual conditions ; for the dose of bromides given in
addition to the substituted salt varied from 10 to 40 gr. pe>
diem, as much as 60 gr. being seldom required, while a few
patients have been able to dispense with medicine altogether ;
moreover, the total result, which includes the better control of
psychic disturbances and the lessened tendency to disorder,
has proved, in the writer’s experience, most satisfactory. It is
therefore justifiable to say that this experience supports the
contention that the withdrawal of sodium chloride renders the
organism more susceptible to the bromides, so that smaller
doses are efficient in preventing or controlling the fits.

The bromide treatment still maintains its position as the
most potent remedy for idiopathic epilepsy. The potassium
salt has been more widely used, but in the writer’s experience
the bromide of sodium and ammonium are almost equally
efficacious, and are specially indicated where there is much
depression. F£r6 (3) states that gastric disturbance is less
liable to follow the use of strontium bromide ; but this compli¬
cation seldom occurs if due attention is given to the hygiene of
the mouth and to the management of the diet and bowels, and
this salt is stated to be more poisonous

The addition of arsenic, with or without belladonna, unques¬
tionably diminishes the liability to acne and other skin eruptions,

364 TREATMENT OF THE EPILEPTIC INSANE, [April,

and the bromides seem to be better tolerated, especially in large
doses, if given with either or both of these drugs.

The borax treatment recommended by Gowers has not
proved successful, as a rule, in the experience of other observers.
¥ 6 r 6 (4) noticed some improvement in a few cases, but noticed
a liability to gastro-intestinal disorders, eczema, and psoriasis.

Gamier and Cololian (5) observed no good results from its
use. As an adjunct to the bromides it has been extensively
used at Claybury, and a mixture containing

Potass, bromid..

. gr. xx,

Sodi. biborat. .

• gr- x,

Liq. arsenical. .

■ "lij.

Syr. rhceados. .

. 3ss,

Aqua ad .

- 3 j.

has been in use for a long time, but when the borax was omitted
in one ward the result remained about the same. The writer
has not observed any benefit from a trial of the various coal-tar
products, either alone or combined with bromides. Digitalis
as a diuretic and cardiac tonic has a very special value in some
cases. No benefit has been found in the oxide of zinc, which
was tried in several cases with frequent attacks of petit mal.

Of patent medicines “ Bromocarpine ”—a combination con¬
taining bromides and pilocarpine—succeeded in controlling the
paroxysms and maniacal attacks of one patient, who had been
uninfluenced by the bromides alone.

The study of individual idiosyncrasy and the careful gradua¬
tion of the doses of drugs, are points of importance which are,
nevertheless, apt to receive insufficient attention in large institu¬
tions where the number of patients is proportionately large as
compared with that of the medical officers. The method now
in use at Claybury has proved fairly satisfactory: a continuous
record in tabular form is kept in each ward, showing at a
glance the number of day and night fits of each patient,
together with their particular medicine—its dose and time of
administration. The dose is gradually increased until, with
full toleration of the drug, the fits either cease or are reduced
to a minimum. Again, in the course of time the dose is
cautiously lowered—so long as the result is satisfactory. In
this way, and by varying the drugs used, it becomes possible
to discover those conditions which are most suitable to each
patient.

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1907.] BY G. FOSTER BARHAM, M.B. 365

Undoubtedly, by the use of bromides, it is possible in many
epileptics to diminish the severity and frequency, or even com¬
pletely prevent the occurrence, of the paroxysms; but experi¬
ence frequently teaches that in dealing with epilepsy in the
insane, the cure may be worse than the disease, and that this
suppression of the storm will, in many cases, lead to its mani¬
festation in other directions. With the exception of two cases
at Claybury, whose severe and frequently recurring fits have
only been controlled by large doses (3ij to 3iij) of potassium
bromide per diem , and without any toxic symptoms, it has not
been found that large doses are well tolerated. The suppression
of the major attacks, as is well recognised, not infrequently
gives rise to the occurrence of a large number of minor fits,
which are less easily controlled ; and these patients become less
manageable, and are frequently falling down and sustaining cuts
and bruises. Other cases become utterly helpless and incapable,
and, passing into a state of hebetube, or even stupor, neglect
themselves and their natural functions, requiring to be dressed
and fed. Of course, such conditions may arise in the epileptic
insane apart from the use of drugs, but it is evident that in some
instances they are induced more often if the bromides are
M pushed.”

As regards the management of the status epilepticus: in a
few cases the writer has followed the recommendation of Paul
Gamier and Cololian (6) who, considering this condition to be a
state of intoxication, endeavoured to diminish the toxicity, by
(1) lavage of stomach and bowels, and (2) by giving diuretics,
such as milk. In the first place the stomach is washed out
with a weak solution of bicarbonate of soda, and a pint of
warm, peptonised milk is at once given, together with 5 gr.
of calomel. The lower bowel is then washed out by means
of a copious enema and half a pint of warm, normal, salt
solution may be left in the rectum ; this process is repeated
twice a day if necessary. Up to the present no difficulty
has been experienced, and in no instance has vomiting
occurred.

Special attention should be given to the skin, which may be
sponged with warm water, while the flannel coverings are
repeatedly changed if there is much sweating. Gamier gave
subcutaneous injections of artificial serums. The following is
a formula of one of them :

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366

TREATMENT OF THE EPILEPTIC INSANE, [April,

Chloride of sodium . . 5 grammes.

Sulphate of soda (crystallised) 10 „

Distilled water . . . 1000 „

In two cases the writer tried a continuous subcutaneous
injection of a sterilised, normal, salt solution, the nature of the
convulsions permitting the retaining of the “needles” in the
thighs, and three to four pints were slowly injected during
the day. Both cases were extremely severe and prolonged;
one recovered, and the condition of this patient improved under
the injection, but the convulsions continued for many hours
after the injection was stopped. No opinion can be formed on
so limited an experience, and it is difficult to come to any
conclusion as to the best treatment for this grave condition.
Frequently the administration of a large enema, followed by the
injection of chloral hydrate gr. xl, potass, bromide 3j into the
rectum, is sufficient to stop the convulsions. If this fails
chloroform may prove successful, but the paroxysms are apt to
re-commence as soon as the effect of the drug ceases. When
these methods fail, and when, from previous experience, it is
known that the paroxysms are usually persistent and severe, it
is worth trying lavage with injections. This treatment, at least,
fulfils certain definite indications— viz ., the washing-out of the
stomach and unloading of the bowels—the promotion of diuresis
and diaphoresis, and the supporting of the patient’s strength.

With regard to the second indication—the removal of
exciting causes—the effects of peripheral irritation, especially
those which arise from abnormal states of the alimentary tract,
are too well recognised to require further comment. Yet it is
impossible to over-estimate the importance of a systematic
examination of the mouth, especially the condition of the teeth,
which, in the class of patients admitted into county asylums, is
usually deplorable. Not alone are the teeth carious, the gums
soft, and in many cases in a condition of suppurative gingivitis,
but alveolar abscesses, and even pyorrhoea alveolaris, are
frequently met with. Moreover, in the states of hebetude and
stupor into which these patients sometimes pass into for a while,
septic pneumonia is extremely liable to bring about a fatal
termination.

Much benefit has followed the removal of carious stumps,
the introduction of tooth-brushes, and the use of mouth-washes,
of which the following has proved a useful example:

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ACTION OF TOXINS.

367

1907.]

Ol. menth. pip. . . .

Tr. auranti .... nix
Sodi benzoat. . . gr.x

Acid carbol. .... Ttiij
Ol. gaultheriae . .

Saccharin . . . gr. 4

Thymol. . . . gr. £

Aqua ad . . . • 3 J

Careful attention to the diet of those patients who are more
or less edentulous should not be omitted.

Only second in importance to the treatment of the paroxysms
is the observation and management of the psychic manifestations
of this disease and the episodic symptoms occurring in con¬
junction with the attack or its equivalent; attention to the
general health and the study of individual cases and their
reaction to drugs, in order to arrive at that point where, with a
satisfactory diminution of the paroxysms, there is the least
disturbance of the mental equilibrium, will, in the majority of
these incurable cases, meet with the best results.

In publishing these notes the writer has the kind permission
of Dr. Robert Jones, under whose supervision these observations
have been made.

Referbnces.

(1) Revue de Psych., No. I, 1900.

5 2) Ungar med. Presse, February 16th, 1903.

3) Bulletin Medical, 1891.

(4) Revue de Midecine, 1895, p. 750.

(5) Traiti de Thdrapeutique des Maladies Mentales et Nerveuses.
(6) Ibid., p. 385.

A Demonstration of the Lesions, experimentally produced,
in the Spinal Cord and Cranial Nerves by the Action
of Toxins. By Drs. Orr and Rows.(')

In a previous paper we described the lesions in the posterior
columns of the spinal cord in cases of general paralysis, and
pointed out their similarity with those in early tabes dorsalis.
We showed that the degeneration always commenced at the
point where the posterior roots enter the cord. It is here that

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368

ACTION OF TOXINS,

[April,

the sensory fibres become part of the central nervous system
and lose their neurilemma sheath ; and in all cases we found
that precisely at this point degeneration began.

While studying these lesions we had indications that it
would be advisable to inquire into what was known of the
lymphatic system of the posterior roots and columns; and we
found indisputable evidence that there was a continuous flow
of lymph upwards along the nerves to the cord.

Let us briefly review the data on which these assertions are
based. It is well known that tetanus and rabies spread to the
cord by the nerve-paths ; and in this connection we might
mention the experiments of Marie and Morax, who, after cutting
the nerve to the fore-limb of an animal, and, later, injecting a
lethal dose of the toxin into its paw, found that no convulsions
followed.

Homdn and Laitinen, after injection of streptococci into
the sciatic nerve, traced the organisms upwards into the
meninges of the cord ; while Pirrone, experimenting with the
pneumococcus, found changes in the cord, but limited to the
side corresponding to the nerve injected.

But, in addition to organisms, chemical and inert substances
have been used with like results, e.g. y Guillain injected ferric
chloride into the sciatic nerve, subsequently introducing potas¬
sium ferrocyanide into the general circulation, and they found
Prussian blue in the posterior roots. Sicard and Bauer, using
China ink, found after injection into the nerve that the granules
ascended along the nerves towards the cord.

It was evident that, if these views were correct, we ought to
find in the cord of cases in which some septic focus existed,
lesions of the posterior columns occasioned by the presence of
toxins ascending in the lymph-stream. On examining cases
of brachial neuritis (infective), bed-sores, suppurating knee-
joints, septic psoas' abscess, we found in the cord of all the
lesions expected.

We then submitted our theories to experimental test, and
were successful in inducing posterior column lesions in rabbits
exactly similar to those already found in man.

The method we employed consisted in the introduction of
celloidin capsules containing organisms under the gluteal
muscles of rabbits, in close apposition to the sciatic nerve. As
we anticipated, the toxins, escaping through the celloidin, passed

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DRS. ORR AND ROWS.

190;.]

369

upwards, and in the posterior columns of the cord produced
lesions of varying intensity.

Turning our attention next to the pons and medulla, we
found that lesions of the cranial nerves commenced exactly at
a corresponding point to those of the spinal cord in both sensory
and motor nerves ; and by the experimental method we were
able to reproduce these cranial nerve lesions in rabbits. In
this instance the celloidip capsules were placed under the skin
of the cheek.

Conclusions .—(1) Toxins readily travel up spinal and cranial
nerves to the central nervous system. (2) While these nerves
in their extra-medullary portion possess a neurilemma sheath,
and are protected by its vital action, in their intra-medullary
part, having lost their neurilemma, they at once undergo
degeneration. (3) The first change is a primary degeneration
of the myelin ; axis cylinders and nerve-cells are evidently
affected later. By the osmic acid reaction the myelin degene¬
ration is shown in the form of large and small fusiform masses,
isolated globules, and elongated thin threads on which are seen
moniliform swellings.

It seems to us that the results of our investigation suggest
the possible lymphogenous origin of some nervous affections.
We know that tabetiform and cranial nerve lesions in General
Paralysis, and in Tabes itself, are not the result of nerve-cell
degeneration, but are initially a primary affection of the myelin
sheath commencing where the neurilemma is lost. In our
clinical cases and experimentally we have shown similar lesions
starting at the same point, the result of absorption from a
definite toxic focus situated outside the central nervous system,
the toxins gaining access by the lymph-stream. May it not
be possible that the former lesions are also the result of toxins
passing to the cord and pons by the lymph-stream from some
external, but as yet unknown, focus ?

(*) This demonstration was given at the Quarterly Meeting of the Medico-
Psychological Association held at the County Asylum, Radcliffe, on February 22nd,
1907. The experimental portion of this investigation has been carried out under
a grant from the British Medical Association and will be published shortly in
exttnso.

LIII.

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370

OCCASIONAL NOTES.

[April,

Occasional Notes.

Registration of Nurses .

The subject of the registration of asylum-trained nurses is
such an important matter that the following report of the
action of the Association, by Dr. Wood, should receive the
attention of every member. There will no doubt be very
serious opposition to the Registration Bill in the Houses of
Parliament, and it is at the least doubtful whether it will pass
into law during the present session.

This at least is certain, that if nurses are to be registered by
law it is our duty to be in the forefront in pressing the claims
of the asylum-trained nurses, for whose advancement the
Medico-Psychological Association has done so much.

The State Registration of Mental or Asylum-Trained Nurses.

By T. Outterson Wood, M.D.

The question of the State registration of nurses cannot lie
dormant, for it is practically certain that ere long the supporters
of the movement will be endeavouring to induce the House of
Commons to legislate upon the subject.

Whatever views the individual members of the Medico-
Psychological Association may hold upon the subject of State
registration for nurses generally, as a body, it is nevertheless
certain that we have a duty to perform towards our own nurses,
which is to see that in any system of State registration they
shall get full justice, and a due recognition of their claims to
be included in any scheme which is laid before Parliament.

If we ourselves do not move in the matter we may be
perfectly sure that those who have hitherto opposed the claims
of our nurses will not move a hand to help them, and they
may find themselves left out in the cold. More especially is it
our duty to press this matter forward, seeing that the Select
Committee of the House of Commons has included in its report
a special clause calling attention to the undoubted claims they
possess, to be recognised in any act authorising the State
registration of nurses.

Being impressed with the necessity for taking action, and it

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1907.]

OCCASIONAL NOTES.

371

having come to my knowledge that a petition in favour of State
registration had been sent round to obtain the signatures of
asylum-trained nurses by an outside body of hospital-trained
nurses, I addressed a letter to the President and Council of the
Association in February last to the following effect:

February nth , 1907.

My dear Mr. President,

I very much regret I shall not be present at the meeting
at Nottingham. My doctor forbids me to go, and I must obey,
though I do so most reluctantly. Had I been present I should
have proposed that the Medico-Psychological Association,
instead of allowing its nurses to sign petitions for other people,
should itself promote a petition of its own, or at least con¬
jointly with a recognised nursing body, such as the Royal
British Nurses’ Association, which has always helped us as far
as it could. Much better, however, for us to do it by ourselves.
Supported, as we now are, by the recommendation of the
Select Committee, we should have a far better chance of being
recognised by the State than if we mixed ourselves up with
would-be champions of hospital nurses, who squabble and fight
among themselves. We could present a petition which, in
point of numbers, and coming from such a strong and united
Association as ours, would be bound to command attention. I
consider we shall be wasting an excellent opportunity of pro¬
claiming our aims and objects in regard to our nurses if we
neglect to take steps to petition on our own account for their
State registration.

No heterogeneous collection of hospital nurses can present
such a solid phalanx as we can, and I am most strongly opposed
to our joining any clique which may be opposed to the Royal
British Nurses’ Association, which has recognised our claims,
and which, but for a factious opposition, would have enrolled
and registered our nurses upwards of ten years ago in a separate
list, as recommended by the Select Committee.

Our support is far too valuable to be thrown away. We
should retain and use it ourselves for our own nurses.

I am, dear Mr. President,

Yours very faithfully,

T. Outterson Wood.

Robert Jones, Esq., M.D.

372

OCCASIONAL NOTES.

[April,

The result of my communication was, that the matter was
relegated by the Council to the Parliamentary Committee to
deal with. This it at once proceeded to do, and as soon as
possible the following circular was sent to every member of the
Association :

Dear Sir or Madam,

Signatures to a petition issued by “ The Society for the State
Registration of (Hospital) Trained Nurses/* having been
requested from asylum-trained nurses, the members of the
Medico-Psychological Association are earnestly desired to
abstain from supporting such petition, and for the following
reasons:

(a) The petition makes no mention of the special claims of
asylum-trained nurses. It ignores them.

(b) The petition is promoted by those who have hitherto
strenuously opposed the recognition of asylum-trained nurses.

(c) The Medico-Psychological Association is preparing a
petition of its own in favour of the registration of mental or
asylum-trained nurses, in a separate register, as recommended by
the Select Committee of the House of Commons .

(d) It is of the greatest importance that every asylum-trained
nurse, male or female, should sign their own petition in favour
of being included in their own register , or they may fail to obtain
registration.

The form of petition is under the consideration of the Parlia¬
mentary Committee of the Association, and copies for signature
will be forwarded as soon as possible.

Yours faithfully,

Ernest W. White,

March 6th, 1907. Chairman of Parliamentary Committee.

The Parliamentary Committee again met, and after careful
consideration drew up the following petition, which was also
sent to every member of the Association :

To the Right Honourable Sir Henry Campbell-Bannerman,

Bart., etc.

The humble petition of the Members of the Medico-Psycho¬
logical Association of Great Britain and Ireland, founded in
1841, and numbering over 640 medical practitioners, mental or

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I907-] OCCASIONAL NOTES. 373

asylum-trained nurses, male and female, of whom upward of
7000 hold the certificate of the Association for proficiency in
nursing the insane, and who are already on the register of the
Association, and others interested in the welfare of the insane,
sheweth—

1. That the claims for registration of mental or asylum-
trained nurses have been clearly recognised by the Select Com¬
mittee of the House of Commons.

2. That in any scheme for the State registration of nurses,
the recommendation of the select committee to the effect
that mental or asylum-trained nurses who hold the certificate
of the Medico-Psychological Association should be admitted to
State registration in a separate register should be carried out.

3. That the certificate of the Association is only given after a
definite training, and the successful passing of an examination
of one uniform standard throughout the Kingdom.

4. That the Medico-Psychological Association is the only one
which possesses a uniform standard of training and teaching
by systematised courses of lectures, theoretical and clinical,
and an examination which is uniform for every candidate.

5. That the examination is by means of written papers,
practical work, and viva voce , and is conducted by examiners
specially appointed by the Council of the Association, with the
aid of independent assessors.

6. That there are upwards of 7000 trained, examined, and
certificated nurses, male and female, now on the register of the
Association, who are holding with great credit responsible
public appointments, and earning their living in the various
asylums for the insane throughout the United Kingdom, the
Colonies, and the various dependencies of the Crown.

7. The register of the Medico-Psychological Association is
kept by, and under the authority of, the Council of the Associa¬
tion, and under the immediate control and supervision of the
registrar, who is an honorary officer of the Association.

8. For sixteen years this unique scheme of providing an uni¬
form system of training and examination has been in operation,
and it has been in every way successful.

9. That the claims for the State registration of mental or
asylum-trained nurses was fully recognised in a Bill lately before
Parliament, which was one of the causes of the appointment of
the Select Committee.

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374

OCCASIONAL NOTES.

[April,

10. That as far as is known not a single valid objection to
the State registration of mental or asylum-trained nurses in a
separate register has been raised by anyone.

11. Your petitioners most earnestly pray that you will take
this matter into’your favourable consideration, in view of the
fact that the proper nursing and care of the insane of all classes
is of such vital importance to the community, and that none
but efficiently trained, examined, certificated, and registered
men and women should be employed to undertake such respon¬
sible and trying duties.

And your petitioners will ever pray, etc.

The point that I wish especially to draw attention to at the
present time is, that although the form of petition strongly ad¬
vocates the claims of nurses—male as well as female—holding
the Certificate of the Association, it must not be thought I am
unmindful of the large numbers of excellent men and women
nurses who were trained, examined, and certified by the various
asylums both before and since the founding of our Association
Certificate sixteen years ago. In my opinion there can be no
doubt the best course for the Association to adopt is to advo¬
cate the State registration of all nurses, whether trained,
examined, and certificated by the Association or by individual
asylums. I am most anxious to advocate the claims of the
latter as well as those who hold our certificate, and for this
reason, that in all cases in which legislation has followed the
establishment of a system of education (as for instance, in the
Medical Act, the Dentists* Act, the Midwives* Act, and others),
there has been a period of grace allowed during which those
who had been engaged in their occupation for a fixed period
prior to the passing of the Act, and could produce satisfactory
evidence of fitness, should be allowed to register, and this
should be the case with regard to the State registration of our
nurses. We are obliged to petition Parliament on behalf of
those who hold our certificate, but there is nothing to prevent
us doing our best to have those admitted to registration who,
although they do not hold our certificate, can yet bring forward
evidence to the effect that they are trained, and have been
employed as mental or asylum-trained nurses for a certain time
before the Act came into force. I am in favour of using the
claims of our nurses holding our certificate as a lever to open

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OCCASIONAL NOTES.

375

1907.]

the door to the others, who can show by their training, length
of service, and good character, that they are worthy of being
recognised in the same way that the midwives were.

I claim no exceptional treatment for them, but only ask for
the same treatment as has been meted out to others. By so
doing we shall be able to have placed upon the separate register
a large body of deserving and experienced nurses who are
engaged in institutions, both private and public, throughout
the kingdom, and, in addition, many who, having left asylums,
have entered into private work fully equipped and competent
for their duties. The value of these excellent nurses is well
known to physicians in private practice. The care and treat¬
ment of private patients would be well nigh impossible outside
an asylum without them. Indeed, it is a duty we owe to the
public to see, as far as we can, that no nurses shall be employed
who are not thoroughly trained and competent, and the com¬
pulsory registration of those engaged in private work would be
an additional safeguard to the public, who are too often imposed
upon by untrained and incompetent persons passing themselves
off as qualified. Again, it must be remembered the nurses
holding our certificate are but a small proportion of the total
number employed in private and public institutions and doing
nursing on their own account, or in connection with nursing
homes or associations.

Nurses who have not taken our certificate are not altogether
to be blamed; it may be the medical superintendents of the
asylums where they were trained were indifferent, and did not
trouble to go in for the examinations instituted by the Associa¬
tion, or perhaps they thought their own good enough, and
gave their own certificates, but it would be extremely hard
upon the nurses to debar them from registration for no fault of
their own. We must not forget that a large number of asylums
in the first instance did not join our system, but as its excellence
was proved they came in one after another, until now we
practically have all of them.

If, therefore, we can succeed in procuring registration for all
properly trained mental nurses who can prove their right to be
registered by length of service, efficient training, and good
character, assuming that our seven thousand represents but a
quarter of the whole of the nurses employed, we should be able
to open the State register with no less than fifteen thousand

376 REVIEWS. [April,

members if only half of the others qualified, and that would
truly be an excellent beginning. My own belief is that it
would soon be twenty thousand, and in point of numbers alone
it would justify our action.

Part II.—Reviews.

The Hygiene of Mind . By T. S. Clouston, M.D. Methuen & Co.,
Essex Street, London.

Nature produces the possibilities of the individual, but it is left for
Nurture to realise these. By Nurture, Galton means not only the
physical, mental, and moral environment, but also the social, domestic,
and educational, and it is seen what a comprehensive influence is implied
by this term, which is co-extensive with the hygiene of mind, selected
by Dr. T. S. Clouston as the subject of his theme.

It may be asked why a mental pathologist, whose life-experience is
that of abnormal mental phenomena, should presume to discourse upon
the problem of the healthy mind, and how such may be preserved. But
does not the experience of hospitals provide the ordinary physician with
the knowledge of how bodily functions are associated and correlated in
health and disease, howl interdependent they are in the various de¬
partures from health, and how the well-being of the body must depend
upon that of its individual members? Similarly with the study of
mental alienation, it is upon the regular development through proper
training and upbringing that the even balance of the various component
factors of mind is maintained, and mental health is secured. It is the
study of mental disease which points out to the psychiatrist the ill-
balanced judgment, the over-emotional temperament, and the non-moral
conduct which cause failures in life; and may we not often learn more
from our failures than from our successes? Are not all mental ex¬
periences antithetical ? A statement that a line is straight implies that
it is not curved; we know the good from a familiarity with the evil, or
that which is bad, light from darkness, heat from cold, solids from
liquids. It is through a happy combination of all the elements of mind
that a healthy corporate whole can be attained, and, after all, it is the
whole mind that thinks, the whole mind that feels, and the whole mind
that wills. From his unique experience of mental pathology, therefore,
Dr. Clouston is qualified beyond any doubt to deal with the application
of hygienic rules—physiologically and psychologically interpreted—to¬
wards favouring “ mental betterment.” Indeed, the impression left on
our mind, after reading his book, is that it is the work of a great and
good man—an impression which in no whit falls short of actual know¬
ledge of the author as realised by those who have an acquaintance with
his optimism, earnestness, and enthusiasm.

The first three chapters of the book deal especially with the relation¬
ship between rpiqd and matter—/.*., between jnental processes and

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*9®7-]

REVIEWS.

377

physical processes. The author throughout this volume rejects the
idea of any unknown influence, personality, or soul, and is inclined to
brush it aside as a mere metaphysical idea. We are not convinced of
the correctness of this attitude and refrain from discussing the religious
questions involved in this and subsequent passages.

The remarks of the author on p. 190 relating to the religious instincts
in adolescence are clear, clever, and emphatic, but we are unable to
follow him when he lays down the dictum that sex must be eliminated
from the religious instinct.

The fourth chapter lays down the general principles to be observed
in mental discipline, and, as the author divides the age periods of their
hygienic value, there is, of necessity, some repetition, as such a classifi¬
cation implies a consequent overlapping. The author makes full use
of the spontaneity of childhood, and emphasises the functional union
of all sensory impressions in the attention. His aim throughout is to
encourage brain-impressions, which can be made use of afterwards, and
the proper cultivation of the senses with a due deliberation—one thing
at a time, as there is a need to establish associations. The control of
motor co-ordination by exercise and play, the association of mental
impressions for intellectual purposes, and the establishing of proper and
correct habits in nerve pathways are fully entered upon. The whole
volume throughout is delightful reading, and it is a book that should be
of great help to mothers and teachers. At the end there are concluding
chapters upon the decadent period of life, into which are condensed the
wisdom of Shakespeare and Cicero. The price of a happy old age is
“eternal vigilance” in youth, and the secret of a happy youth is
occupation, which will afford the happiest reflections for declining years.
There is no doubt that, even with the best intentions, the climacteric
for both sexes is a period of uneasiness, and the advice to cultivate
“hobbies” deserves more serious attention than it obtains. A time
comes when special pursuits fail, but the man with many “mental
facets” finds years of joyous repose towards the end of his journey.
One fact insisted upon by Dr. Clouston is that grandparents find joy in
their grandchildren, and we know the evil effect upon the mind through
the seclusion of old people in almshouses. In the secluded life of
eleemosynary solitude there are no mental stimuli present to rouse the
decadent faculties into response, and an old-age pension, whatever else
it may effect, will tend to restore to the aged their natural life and sur¬
roundings. In our admiration for this volume, with its direct message
clearly and physiologically expressed, we are convinced of universal
sympathy, and it would not be wide of the mark to state that the dis¬
tinguished author has never produced a better work.

Aliments de Mideeine Men tale appliquis a PJttude du Droit (Cours pro-
fessi a la Faeulte de Droit en 1905). Par le Docteur Legrain,
avec Preface de M. Garcon. Paris : Arthur Rousseau, 1906. Pp.
xxvi, 450. Price 10 francs.

The lectures on mental diseases which Dr. Legrain has published in
this volume, apart from their intrinsic value, are noteworthy from the

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circumstances of their origin. They were delivered during the session
of 1905 to the students of the Paris Faculty of Law as a cours librt y
under the auspices of the Council of the University, and in their book
form they receive a further mark of official recognition in a foreword of
rather timid approval from the Professor of Criminal Jurisprudence.
Their appearance is therefore an interesting sign that the permeation of
the legal mind by the modem spirit has commenced—at all events
amongst our neighbours—and that it is beginning to be realised that
some acquaintance with the physiology and pathology of mind is desir¬
able in those whose avocations require them to estimate the quality and
the motives of diseased conduct.

The object which the author has set before himself in these lectures
is not so much to enlighten his hearers on those specific problems,
regarding which the medico-legal expert is ordinarily called on to give
evidence, as to familiarise them with the aspect under which conduct
and thought appear to the physician who has to deal with their aber¬
rations in crime and in insanity. The volume is not, therefore, a treatise
on legal psychiatry in the usual sense of such a title, but is rather, as the
author himself defines it, an examination of the criminal law in the light
of medical science. This special aim—to bring home to a legal audience
facts and assumptions new to them but commonplace to the alienist—
implies, of course, that the book has no pretention to novelty of matter;
but, none the less, Dr. Legrain has contrived to deal with his subject
in so fresh and original a manner, and has indicated so many suggestive
lines of thought, that the work, in addition to fulfilling its proper end,
as it most admirably does, will appeal also to the wider circle of readers,
lay and medical, who are interested in the new tendencies in crimi¬
nology.

The author’s chief concern being, as we have indicated above, to
inculcate the spirit and method of inductive science as opposed to the
spirit and method of & priori reasoning, he naturally lays particular stress
on the clinical facts most subversive of those preconceived ideas regard¬
ing the freedom of the will and the unity and stability of the ego which
underlie the old doctrines of crime and punishment. In the earlier
lectures, dealing with the growth, the changes, and the decay of the
personality, he seeks his illustrations of the instability of the ego in the
diseased states, such as the dilire chronique of Magnan, where, by a
process of slow evolution, a new personality is gradually built up, or in
the phenomena of hallucinatory insanity, where the changes in the sense
elements of consciousness dominate thought and action, or, again, in
the classic observations of multiple personality. From this introductory
matter he then passes to the consideration of the rdle of the subcon¬
scious mind, to which, under its various aspects, the remainder of the
volume is devoted. The emergence of the subconscious in dreams, in
artistic inspiration, and in other normal phenomena is briefly referred
to, and a description is given at somewhat greater length of its influence
in recurrent insanity. In this connection the author suggests a very
interesting parallel between this category of mental disease and certain
forms of criminal recidivism. As we observe in some cases of insanity,
especially in alcoholic subjects, that a delirium of practically identical
content will repeat itself in successive attacks, vanishing completely

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daring the sane intervals, so we meet with criminals, who, time after
time, in a stereotyped way, will commit the same offence. In one case
it is a disorder of thought, in the other a disorder of conduct, that rises
suddenly out of the subconscious; it seems natural to assume that in
both cases the psychological mechanism must be very similar. And the
author would see further evidence of this kinship in the familiar cases
where the two forms of disorder seem to alternate in the same individual,
who then, according as his disease is more manifest in the sphere of
thought or in the sphere of conduct, will find his way at one time to the
lunatic asylum, at another to the prison.

In these cases of what he terms delires d iclipse and dilits d iclipse ,
there is a subconscious automatism : in the dream-state of the epileptic,
the absinthe drinker, and the alcoholic, the mechanism is the same, save
that the automatism is unconscious; and it is the same also in the obses¬
sions of the hereditary degenerate, with the sole difference that here the
automatism is fully conscious and is accompanied by a lucid but power¬
less intelligence. Even the moral defective may be looked at in the
same light, and viewed as an “ aconscious automaton.”

What, then, is the bearing of these facts on the problem that the
criminal presents to society ? If the personality is thus in a perpetual
flux, where the dominant current at any moment may be decided by
such incalculable forces working in the subconscious, what becomes of
free will and responsibility, and how is their abrogation to be reconciled
with the safety of the community ? To these questions the author gives
only a general reply, indicating merely the direction in which the solu¬
tion of the problem is to be sought, but not entering into the details of
the revolutionary changes which his doctrines would demand. The
effect of slight indefiniteness which is thus left is possibly intentional,
for it is not difficult to imagine that more than once in the course of
these lectures the staid and respectable authorities of the Ecole de
Droit must have felt considerably astonished at their own audacity in
admitting such heretical teaching at all, and that towards the end a
little dilution of the new wine was necessary lest the old bottles should
buret W. C. Sullivan.

A New Journal of Legal Psychiatry .

The appearance of the Revue de Midecine Ugale Psychiatrique et
d Anthropologic Criminelle is an interesting indication of the increasing
realisation in scientific circles in France of the importance of the medical
aspects of criminology. The journal, which is published in connection
with L'Enccphale , is to appear every two months, the contents of each
number being arranged under the following heads: (1) Original memoirs;
(2) medico-legal observations; (3) judicial review; (4) bibliography
and analysis of current literature ; (5) proceedings of learned societies ;
and (6) medico-legal generalities. The editor in chief is M. Antheaume,
of Charenton, and the list of collaborators includes the names of a large
number of distinguished alienists and neurologists.

The first number (February, 1906), contains, amongst other interesting
matter, a paper by Dr. Regis, on “Traumatic Neurasthenia in the Sub-

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jects of Arterio-sclerosis,” and the first of a series of articles by
Dr. Paul Serieux, on “Special Establishments for Criminal Lunatics
in Germany.” W. C. Sullivan.

Ueber Stbrungen des Handelns bet Gehirnkranketi [On Derangements
of Action in the Insane], Von Prof. Dr. H. Liepmann.
Berlin : 1905. Pp. 162, 8vo.

Although much attention has been bestowed upon disorders of speech
under the headings of “ aphasia ” and “ paraphasia,” the different inca¬
pacities amongst the insane in the performance of designed actions
have met with little attention. These have been considered in the
present work under the title of “ Apraxia.” Hindrance to the execution
of voluntary actions may be owing to many causes besides paralysis.
There may be loss of the kinaesthetic sensation or the appreciation of
the amount of effort required, or the loss of memory, or of motor con¬
ception, deranged association, the loss of attention and concentration,
or the failure of a decreasing intellect to direct the complex machinery
of the muscular system, or loss of the correct estimation of distances,
cortical blindness and cortical deafness. These several conditions are
carefully analysed and differentiated by the author, and examples cited
from his own observation as well as from the descriptions of others,
especially Professor Pick. The treatise is permeated by profound
thought, and no one can read it without gaining clearer ideas on
the subject. William W. Ireland.

Dott Montesano Guiseppe ; Awiamente all Educazione e Istruzione dei
Deficientiy Lezioni dettate nella Scuola Magistrate Ortofrenica di
Roma e raccolte da Cesare de Felicis. Rome : 1905.

This little book is designed for teachers in schools for idiots and
imbeciles. It comprises the lessons given and the exercises pursued
in the Training Institution at Rome, founded by the National League
for the protection of deficient children, under the superintendence of
Dr. Montesano. The lessons have been collected by Cesare de Felicis.
The authors give a list of a score of books in French, English, and
German, upon idiocy and imbecility, by the aid of which further study
on the subject may be pursued. They warn the reader that little or
nothing can be found in these works having a practical interest for the
teacher. It is true that many, or most, of the writers cited have been
content to indicate in a more or less cursory manner the divers methods
of exercising the minds of such children and the apparatus useful for
this purpose. The ways of effecting this education are devious ; much
must be left to the invention of the teacher, which should be constantly
on the alert. Yet it may be acknowledged that in no work known to
us has a well chosen course of instruction been so minutely and literally
laid down. The book comprises seventy pages, double columns, medium
octavo. At the same time, the general remarks about the intellectual

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and moral training of the feeble-minded are judicious and philosophical.
Dr. Montesano has a firm grasp of the whole subject both analytically
and synthetically. Some of the devices to attract the attention and
enlist the interests of the pupils are novel and ingenious. The motor
and sensory exercises are displayed by twenty-nine figures. Altogether
this little treatise well fulfils its purpose. It might be profitably trans¬
lated into English for the use of the training schools in Great Britain
and America. William W. Ireland.

Metaphysik. in der Psychiatrie. Von Dr. P. Kronthal. Fischer:

Jena, 1905. Pp. 92, medium 8vo.

Dr. Kronthal has made wide and diligent readings of the works of the
metaphysicians, ancient and modern, English, French, and German.
As Voltaire said, metaphysicians are like ballet-dancers. They skim,
skip, wheel about for a while, only to end at the place they set out.
One learns from their books little else than so many definitions. From
his studies Dr. Kronthal has taken a point of view which leads him to
treat modem psychiatry in an inconveniently sceptical way. He reminds
us that no one knows anything besides his own sensations. What
appears yellow to him may be a quite different impression to another
man. The real method of natural philosophy is to cling to direct
observation, and to be very wary of inferences or general realisations.
All men’s doings are to be regarded as reflexes aroused by stimuli
applied to the sensory nerve tract. No nerve-fibre either begins or
ends in a nerve-cell. The fibre is not a continuation of the cell
or of its fibrillse. The nerve-cell to which such great functions
have been assigned by some pathologists never divides; it is
a dead body and serves to isolate the nerve-tracts. Dr. Kronthal’s
views on this question, founded upon serious microscopical studies, are
given at length in his paper in Archiv fur Psychiatrie , 41 Band, I Heft.
The author blames Kraepelin, Ziehen, and other well-known psycho¬
logists for using metaphysical terms, amongst which he enumerates per¬
ception, association, will, imagination, anger, grief, and fear. To his
mind there is nothing in the living body save reflexes, and the psyche
is the sum of all the reflexes. But to do without these familiar expres¬
sions would be awkward. Metaphysicians will prove to you that there
is nothing save a modification of your own consciousness; but then
there are modifications and modifications. All our doings may be
owing to reflexes, but we need some qualifying adjective to dis¬
tinguish them. There are reflexes, strong, lively, weak, swift, slow,
abnormal, accompanied by pleasure or by pain. It may be an assump¬
tion to guess what another man feels and thinks under the changes of his
countenance, but to act in this world one must begin by assuming
something. Memory, the author tells us, is something which has
happened before, the repetition of similar or identical stimuli. He does
not explain how the repetition of a second impression is recognised.
To awaken the memory one must have a change ; identical impressions
do not rouse us. A man is not like a puppet, moved by pulling strings;

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between the sensory end and the motor end there are a variety of pro¬
cesses with which the psychiatrist has to deal, and for these we must
have expressions, which may be called metaphysical.

While he is a little confident on the affirmative side, Kronthal is dog¬
matic on the negative. He denies free will, reasoning after the manner
of Buckle, who argues that men’s actions are proved by statistics to
depend upon circumstances beyond their control— e. g., the number of
marriages in England is always low when bread is dear. But it may
be replied that men desire to be married under certain conditions.
No sane man will take a wife if he knows he cannot buy for her enough
of bread to eat. The dearness of food does not take away the will to
marry, but the opportunity for doing so.

As conclusions, Dr. Kronthal presents us with his views upon these
grave questions which lie near or beyond the bounds of our knowledge,
and which have been debated for thousands of years. In the universe
he sees an everlasting energy. [Is energy not a metaphysical expres¬
sion ?] Pantheism (Allbeseeltheit) is, he tells us, adopted by the best
thinkers, not only amongst those eminent in the study of natural
phenomena, but by those who are styled philosophers. Spinoza, Leibnitz,
Lotze, Wundt, v. Nageli, Zollner, to name a few of them, hold that
nature is besouled in all her parts, not this or that body. The survival
of the soul after death he considers to be an illusion, for which he
offers an explanation on his last page. We cannot, in a limited
review, discuss the weighty subjects for which Kronthal’s own pages give
insufficient room. He has applied his mind closely to the question
which he treats, and his pamphlet deserves the attention of psychologists.

William W. Ireland.

La Dlmence . By Dr. A. Marie. Paris: Octave Doin, 1906. Pp.

492, 8vo.

The present work forms one of the Biblioth}que Internationale de
Psyehologie Experimental a series of fifty volumes, written by various
authors, under the general editorship of Dr. Toulouse, of Villejuif, the
whole being intended to show the stage at which the various divisions
and applications of experimental psychology stand at the present day.
“ Experimental psychology ” is apparently understood in its widest
sense, and implies the scientific as opposed to the metaphysical method,
rather than the strictly quantitative procedures with which the phrase is
associated in this country.

Dr. Marie sounds the keynote of the whole book in his statement
that “ psychological states are to be regarded as a function of the brain.”
This irreproachable postulate, however, leads him, in many places, to
adopt theories which, founded on the slenderest hypothesis, must be
regarded as unproven and unfruitful. As an example may be cited the
oft-repeated application of the theory of nerve-cell amceboidism to the
explanation of psychical states. The text often tends to give one
the impression that the theory is a matter of established fact, rather
than a centre of heated controversy.

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Dementia is defined as “ a weakening or total loss of the intellectual
faculties, without possibility of return,” and the first part of the book is
devoted to a consideration of its general characters, both pathological
and psychological. The pathological section is mainly founded on the
work of Klippel. The psychology of dementia is fully treated, and this
chapter contains a large amount of interesting matter. The scheme of
questions in use at Villejuif is explained, together with the results
of various quantitative experiments. Among the facts thus established
may be noted the early loss of calculating power in general paralysis,
compared with its relative persistence in vesanic dementias and in
dementia praecox. The modern doctrine of psychological disaggregation
is applied to the various affections of the personality—the loss of the
sentiment of reality, ideas of negation, doubling of the personality, and
the frequent delusional interpretations of the altered ccenaesthetic
sensations. The emotions are somewhat perfunctorily treated, but
considerable space is given to the phenomena of amnesia. In this
section Ribot is largely followed, and some interesting deductions, both
theoretical and practical, are made from his “ law of regression.”

A chapter is devoted to the historical development of the subject,
commencing with Pinel, and Esquirol-Bayle’s differentiation of general
paralysis is described, and the numerous modern attempts to separate
other varieties from the group of the dementias. The diverging paths
of the French and German schools, the development of the concept of
degeneration by Morel, Magnan, and their followers, and the gradual
evolution of dementia praecox by the Heidelberg school, are lucidly
traced out The author concludes the chapter by adopting Duprd’s
view that every age has its dementia, and, in the present state of
knowledge, thinks it better to group his material under the headings—

(1) the dementia of early life (< dtmcncc pricocc)\ (2) the dementia of
adult life (general paralysis); (3) senile dementias. The vesanic
dementias form a link between (1) and (2), the organic a link between

(2) and (3). A pathological basis for this classification is found in
Klippel’s distinction between neuro-epithelial and vasculo-conjunctive
dementias. In the former only the nerve-cells and neuroglia are
affected, in the latter the lesions extend to the vessels and meninges.
The neuro-epithelial group includes dementia praecox and the vesanic
dementias, while general paralysis, organic, and senile dementia are
vasculo-conjunctive in type.

The second part of the book deals with the various dementias in
detail. The chapter on “Demences Prdcoces” includes, not only
dementia praecox in its limited sense, but also the vesanic dementias.
The author makes no attempt to subdivide this group on Kraepelin’s
lines—in fact, the references to the latter are scanty in the extreme.
He erects, however, into a separate entity a primary dementia connected
with puberty, which corresponds, apparently, to the dementia simplex
usually described as a variety of hebephrenia.

The chapter on “ General Paralysis ” is of great interest The author
inclines to Klippel’s view that general paralysis is not a morbid entity,
but “a clinical syndrome common to various toxic processes, with
lesions, may be inflammatory, may be generative, but always characterised
by their diffusion and by their progressive tendency.” He thinks that

384

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[April,

the influence of alcohol and syphilis in the etiology is at least over¬
rated, and ascribes the principal rdle to hereditary factors. Alcoholism
is to be regarded either as an effect of the general paralysis or as a
concomitant effect of hereditary causes. Similarly, syphilis is often the
result of venereal excess in the early stage of euphoria, a contention
supported by the fact that it is comparatively rarely met with in the
antecedents of depressive general paralysis. It may be remarked that
the author’s statistics on this question do not appear to take into
account the interval elapsing between the syphilitic infection and the
incidence of paralytic symptoms, though it should be mentioned that,
in his opinion, the prodromal period of general paralysis is of far longer
duration than is generally supposed.

Considerable space is devoted to the psychical symptomatology of
general paralysis, regarded mainly from the point of view of psycho¬
logical disaggregation, with frequent references to a hypothetical
anatomical basis. Some interesting cases of double personality are
described, and the author thinks that this phenomenon occurs in an
imperfect form with comparative frequency.

The chapter on “ Senile Dementia” is noteworthy for a most excellent
and complete description of the macroscopic and microscopic changes
in all parts of the body, which accompany normal senility. Senile
dementia is regarded as an exaggeration of the final term of normal
senility. The author considers the main etiological factor to be a
primary cell-alteration and a failure of nutrition.

The concluding portion of the book deals with various medico-legal
and administrative details. Many of the defects in French asylum
organisation here pointed out exist equally in our own country—for
example, the increasing number of senile dements and other chronic
cases, which act as a stumbling-block to the effective treatment of acute
mental disease. As a remedy the author proposes the establishment of
chronic asylums, in addition to an extension of the family-care
principle. By such means, he thinks, asylums will merit less the
reproach that they are institutions where one finds “ administration,
culture, even general medicine, but very little mental therapeutics.”

Dr. Marie’s work is a veritable mine of information, and its value as
a work of reference is considerably enhanced by a compendious biblio¬
graphical index, which, by the way, is to be a feature of all the volumes
of this series. The views of many members of the French school are
exhaustively set forth, but the space and consideration devoted to
German writers is certainly inadequate. The repeated attempts to
translate psychological problems into anatomical terms,(which Kraepelin
has stigmatised as ‘‘a crude and unfruitful schematisation of clinical
experience,” have already been noted. Finally, from the psychological
point of view, one would have liked to see a wider application to
dementia and its problems, of the methods and theories of Pierre Janet.

Bernard Hart.

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Gli Uomini Primitive [Primitive Men\ By Angelo Zuccarelli.

Naples: Perrella, 1906. Pp. 125. 8vo. Price 2.50 lire.

Professor Zuccarelli, of Naples, who has lately been the recipient of
a testimonial from pupils and admirers in various parts of the world,
has, during the last quarter of a century, been one of the ablest and
most vigorous pioneers in those new paths along which the study of
abnormal humanity is now moving. He has little in common with the
alienist of the old school, for whom anthropology, and even normal
psychology, in any precise sense, have no existence, and who may, or
may not, have some acquaintance with the abnormal classes living
beyond the frontier of insanity. In Zuccarelli’s work we always feel
that there is a real grip of the psychological and the anthropological
aspects of both normal and abnormal man, so that he is unlikely to
class the individual case wrongly, or to fail to see its salient features.
In his lectures on “Criminal Anthropology” at the University of Naples,
in his Istituzioni , in his little review L'Anomalo (now defunct), which
brought forward so many interesting cases and documents, Zuccarelli
has always consistently maintained this broad outlook. He remains
true to it in the present volume, which is a sketch of the prehistoric
development of man, elaborated from the introductory lecture to the
author’s “Annual Course in Anthropology and Psychiatry.” For the
most part the book is a summary—clear and agreeable, without being
superficial—of more or less well ascertained facts concerning early man,
the maker of flints and the dweller in caves. Now and again the
author refers to interesting points of contact between primitive man and
abnormal man to-day. The general standpoint adopted is that of the
monism of Haeckel.

The most interesting, and also the most novel, portion of the book
is that in which the author describes his own explorations of the Grotta
delle Ossa of Cape Palinuro, near Salerno. This is one of several caves
m the district, long occupied by early man, and now difficult to obtain
access to. Zuccarelli obtained many bones and flint implements, but
is not able to assign their precise epoch. The volume is fairly well
illustrated. Havelock Ellis.

Part III,—Epitome.

Progress of Psychiatry in 1906.

AMERICA.

By W. McDonald, Jun.

For years to come, wherever American psychiatrists are met together
one face and one presence will be missed by all.

On December 7th, 1906, Dr. A. E. McDonald was gathered to his
fathers. Not only here but in other lands will he be mourned. He was
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EPITOME.

386

[April,

an honorary member of the British Medico-Psychological Association,
at whose annual gatherings he was a frequent representative of the
American Medico-Psychological Association, and he will be remembered
by many readers of this journal as a felicitous speaker both in debate
and at the banquet table. At home and abroad his genial personality
had won for him a peculiar place in the hearts and minds of men. He
himself had a heart and mind, and both were great. He was a graduate
in law as well as medicine. His biography is one long story of constant
labour, unflinching adherence to duty and unending usefulness as
physician, jurist, teacher, lecturer, writer, administrator, and alienist. His
fearless, competent, almost militant discharge of these offices bespoke
the mind, the demand for his droll speech and cheerful presence at
social gatherings bespoke the heart, while all his characteristics and
accomplishments bespoke the man. Well does the writer recall the
impression made upon him by our departed colleague only a few short
months ago, at the annual meeting of the American Medico-Psycho¬
logical Association. After a regular meeting a number of the members
were gathered together about a social board when Dr. McDonald
appeared in the doorway. Instantly there was a cry “ The king !” and
ail rose to greet him. And now the king is dead, but we may not call
4 ‘ Vive le roi ,” for although his place is well filled none can fill his
place.

Last year, in the annual letter, the writer deplored the state of medico¬
legal affairs in America. To-day, alas, there is no better news to carry.
The situation is even worse, and the only ray of hope is found in the
thought that we can scarcely sink to a lower level without experiencing
that great upheaval and subsequent reform which in the world’s history
has always followed an era of especial degradation. If we must drink
the cup to the dregs ere the natural nausea and final revolt may occur,
then we pray that we shall quickly see repetitions of such legal scenes
as are being enacted at the present time in New York City, until the
American public in disgust shall have purged itself clean of the toxine
which now goes by the name of medical jurisprudence and medical
testimony. I refer, of course, to the Thaw case.

A number of eminent alienists will testify in this case that the
defendant’s mind was of such and such state before, during and after
the homicide. An equal number of equally renowned experts will
testify to something diametrically opposite. The jury and the public
may, in the meantime, be left in doubt as to the irresponsibility of the
prisoner but will have no doubt whatsoever concerning that of the
experts. In the words of Judge Mattocks in a decision in the Chandler
will case, given last November before the higher court of the State of
Maine, “ These expert opinions illustrate not only how dangerous, but
how unfortunate that men of great knowledge, experience and skill,
should array themselves upon different sides of the same proposition
which can have but one solution in truth and come to absolutely
contrary conclusions. It is evident that such testimony is not only
worthless but insidious and dangerous, for it is impossible for the
layman in the analysis of such testimony to distinguish the true
from the untrue. If the untrue is acted upon, injustice must
follow.”

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We should not, however, be too hasty in judging those experts
engaged in the controversy. First, let us search our own hearts, lest there
should be found some guile within us. How many of us who pose as
experts would have refused to examine the defendant at the request of
the attorney for either side? Many of us would have to admit having
taken part repeatedly in similar medico-legal battles without experienc¬
ing feelings of shame, perhaps even congratulating ourselves upon our
just and dignified attitude. In one such case in which four experts
were retained by each side, all who testified for the defence stated that
they had agreed to go upon the stand for the prisoner only on condition
that after an exhaustive examination they should become convinced of
his insanity. A perfectly correct attitude. But is it not a bit singular
that each of the eight experts was able to make up his mind to testify
exactly as desired by the attorney who called him ? There is no
question but that the great majority of medical experts mean to be
honest when they engage to advise counsel or to give judge and jury
the benefit of their opinions. But at least some cease to be honest
with themselves when they mount the stand. Many of those who are
distressed by the degraded position of American medical jurisprudence
see no hope of better things until we shall have created a professional
sentiment adverse to present methods. The fault is not so much with
the men as it is in the circumstances surrounding their connection with
the cases. When once the expert steps upon the witness stand he is
no longer a learned authority whose opinion is respectively craved by
judge or jury; he is no longer even a partisan witness for defence or
prosecution ; he is placed from that instant on his own defence. He
is interrogated as to his whole professional career, as to the opinions
given in other cases with which he has been connected : he is tempted
by one lawyer to add a jot or tittle to the strength of his testimony or
prevented from presenting the whole truth, and is browbeaten, nagged,
and taunted by the opposing attorney whose whole purpose is to
confuse and discredit him. He is pitted against other experts who are
asked to suggest technical questions difficult to answer, or to which the
answer must of necessity permit more than one interpretation. He is
often forced even by the judge to answer a question with an unqualified
“Yes” or “No,” where such a reply cannot possibly represent the
truth. Finally, he must answer an interminable hypothetical question
in which certain conditions are suppressed while others are exaggerated,
until neither a positive nor a negative answer can give anything to the
jury but a warped conception of the opinion of the expert as to the
facts in the case. The result is that sooner or later the expert scents
the smell of battle, responds to the call to arms and sallies forth to the
charge. Matters have gone so far that every alienist steps upon the
stand with a definition of insanity “ up his sleeve ” ; a definition framed
with greatest care in such a fashion, not that the judge or the jury may
be enlightened as to the nature of mental disorder, but that it may be
sufficiently intangible and abstract as to be invulnerable to the shafts
of opposing counsel.

But enough of criticism. Where is the remedy for such evils? It
will be found only by permitting the expert to remain unbiased while
forming his judgment and while stating his opinion.

388

EPITOME.

[April,

Dr. Mercier( 1 ) has ably discussed the arguments for and against an
arrangement by reason of which medical witnesses might consult
together and agree, if possible, on the evidence that they shall give.

As he says, discussion among the examiners would tend to reconcile
differences. “ It would ensure that a factor, which had been over¬
looked by one, would be brought to his attention by another. It
would place the experience of each at the disposal of all.” Dr.
Mercier suggests, however, that this method would not be without
certain drawbacks, and fears that the experts w r ould not always report
unanimously.

Little Rhode Island, so often a leader in reform movements, has in
this matter of medical testimony again blazed a trail for other States.

On a number of occasions during the last two or three years a judge by
agreement of counsel has appointed an impartial commission of
alienists to which the question of the mental state of the accused was
submitted. The commission was given every facility for the examina¬
tion of the prisoner, as well as the authority to examine witnesses as to
the nature of the unlawful act and the circumstances relating to its
performance. The members were allowed to consult together as freely
as they wished. In each such case the experts gave to the judge a
sworn statement of their opinions. The trial was then begun, and as
soon as a number of witnesses had testified sufficient to establish the
fact of crime and the connection of the prisoner with it, the members of
the commision were asked to give to the jury a clear and simple state- #
ment of their opinions concerning the mental state of the accused and
concerning the question of his legal responsibility. In all such instances,
so far as I am aware, the commission returned a unanimous report In
the first case which we recall, the commission reported that in their
opinions the prisoner was sane before, at the time of, and after the
execution of the crime, and that he was legally responsible for his act.
The trial was brief, the jury promptly returned a verdict of “ guilty,”
and the prisoner received sentence. The judge and both opposing
attorneys expressed satisfaction with the thorough investigation and
unbiased opinion of the commission. Counsel for the defendant moved
for a new trial on techanical exceptions; this was denied and the
prisoner is now serving a twenty year sentence.

In the second case, the commission found the prisoner to be an
imbecile, the subject of epilepsy, and did not believe that he should be
held criminally responsible for his act. They declared that his mental
defects and disturbances were incurable, and recommended that he be
placed for the remainder of his life in the custody of a hospital for the
insane. Both attorneys expressed their willingness to abide by the
decision of the commission. The judge, however, in his charge to the
jury, laid stress upon the hesitancy of the commission to declare that
the prisoner had no knowledge of the difference between right and
wrong, which, according to his interpretation of the law of the state,
formed the standard for deciding as to the criminal responsibility of the
accused. Curiously enough, and to the great surprise of all, the jury
returned in twenty minutes with a verdict of “guilty.” Though there
was clearly a miscarriage of justice in this case, it is not certain but
that the jury would have come to the same conclusion had the medical

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testimony been presented in the usual partisan manner by experts
retained by each side of the controversy.

What enormous expense would have been saved for the City of New
York, and for Thaw’s estate, had the question of his mental state
been submitted to a competent non-partisan commission of alienists.
The prolonged legal wrangle would probably have been avoided to a
large degree; both law and psychiatry would have emerged with cleaner
hands; while the probability would had been infinitely greater that to
Thaw himself would have been meted out adequate justice.

The writer is persuaded that the dignity of the law, the cause of
justice, and the status of medico-legal jurisprudence in America would
be advanced by relieving jurists, and even juries, from the responsibility
of deciding as to the mental condition of persons whose legal account¬
ability is held in doubt by reason of possible or probable mental de¬
rangement or defect, and by placing the burden of such judgment
upon men whose life-study and experience renders them eminently fit
for the task.

How much the physician should have to say concerning the legal
responsibility of the accused is another question. In the view of many
high authorities the physician’s task is ended when he has given a clear
and concise opinion to the judge and jury concerning the defendant’s
mental state, it being the duty of the jury alone to decide whether this
mental state be such as to relieve the prisoner from the responsibility for
bis acts. It is, of course, not proper that the alienest should usurp the
office of judge and jury; the writer believes, however, that the expert
could give still further aid by presenting an opinion as to the degree in
which responsibility is affected by the mental disturbance.

We are already taxing nearly to its limit the place alloted for this
epitome. We have thought, however, it might be of some profit to
speak of the state of medico-legal affairs in America at the present time,
believing the moment particularly opportune in view of the present
world-wide discussion of the subject. We have been greatly interested
in the recent British agitation concerning medical jurisprudence, and
the next number of the American Journal of Insanity will contain a
letter from France, written by Victor Parant, in which there is a highly
interesting comparison between French and American medico-judiciary
customs. Unfortunately, we have little space in which to discuss more
cheerful aspects of our specialty. There has been great activity in
American psychiatry during the past year. We have been fortunate
enough to receive visits from several eminent foreign physicians,
notably, Dr. Pierre Janet and Professor H. S. Fraenkel. Dr. Janet
has given, in Boston, two courses of lectures on hysteria, and has also
lectured and read papers in New York and Philadelphia. Professor
Fraenkel gave a demonstration of his methods in Boston, and also read
a highly interesting paper before the Boston Society of Psychiatry and
Neurology, relating the history of the development of his method
of movements which has become so well known and has been used
with such success the world over. He also gave demonstrations in
New York and Philadelphia.

Many valuable and interesting papers were read at the meeting of the
American Medico-Psychological Association in June, and we are all

EPITOME.

390

[April,

looking forward hopefully to the annual meeting to be held in
Washington during the coming May.

It was our original intention to refer somewhat in detail to the newer
work in neuro pathology, particularly that of Dr. Barrett and Dr.
Southard. We would gladly have spoken also of recent advances in
clinical psychiatry as exemplified in the writings of Dr. Adolf Meyer,
Dr. Farrow, Dr. Franz, and many others. It would have been a
pleasure to have devoted a paragraph to the later opinions of our
“grand old man,” Dr. Edward Cowle, who, though a pioneer in
American psychiatry, has been spared to point the way to vast fields
as yet untouched by the reaper’s scythe. But all this, though not
another story, must remain untold till time shall have given us another
opportunity.

(*) Criminal Responsibility , Charles Mercier, M.B.

FRANCE.

By Dr. Ren£ Semelaigne.

The unity of human neuro-biology. —Professor Grasset, of Montpellier,
President of the XVI Congress of French Alienists, held at Lille last
August, devoted his presidential address to the study of the unity of
human neuro-biology. At the annual congresses in France, those
who devote themselves to insanity or neurology are grouped together.
For far too long have physicians thought as common people, and
carefully separated diseases of the mind from diseases of the body;
but it should be understood that alienists and neurologists study
diseases of the body. They are aiming at the same mark ; they have
the same wish, i.e., to know the normal and morbid working of the
nervous system, to keep society from a progressive invasion of nervous
disease, and to cure, or at least to relieve, the latter. The statues of
Pinel and Charcot, erected first at the gate of the Salp£tri£re, seem to
represent a symbol of such fruitful union which is splendidly realised
inside of that glorious temple consecrated to neurologic science.
Alienists and neurologists do not work in different ways; their sciences
have the same object, the same method, the same purpose, consequently
they do not constitute two sciences, but one.

(1) Psychiatry and neurology have a similar object, —By its etymological
definition, psychiatry seems to monopolise the study of psychical
symptoms, and to be quite separated and distinct from neurology,
which comprises merely nervous disorders. But psychical, motor, or
sensorial functions are nervous functions; one can find psychical
symptoms in many of the disorders especially studied by neurologists,
and many people suffering psychical disorders are not insane; conse¬
quently there is no essential difference between the object of psychiatry
and the object of neurology. No one would deny that there is some
difference between the two sciences, but such difference exists between
two chapters of a book, two branches of a tree, so between the two
aspects of a great science, the human neuro-biology. The psychical,

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391

motor, and sensorial organs constitute parts of the nervous system.
That nervous system is one, and the study of its working or of its
disorders forms the common object of both psychiatry and neurology.

(2) Psychiatry and neurology have the same method .—At first such
a proposition seems a paradox, for it is commonly said that the
neurologist’s reasoning is anatomical, and the alienist’s is physiological.
But the anatomical work of the alienists is considerable. Besides, a
psychological reasoning must be the unique and general method for all
—neurologist or alienist—who study neuro biology. The general clinical
syndromes , constituting what we call diseases of nervous system, are
really not characterised by their own lesion, but by that part of the
nervous system which is affected. Clinical unity in the nervous system
is not the geographical unity of the anatomist, but the functional unity
of the physiologist. The function produces and determines the organ,
consequently the unity of a nervous organ is constituted by its function
and its centre, and one might consider the nervous system as divided
into various organs—such as an organ of mind, a sensitive motor
organ, organs of orientation and equilibrium, of language, of sight, of
hearing, of taste, of smell, of circulation, of nutrition, etc., each of these
organs being composed by elements which might be disseminated
through the old anatomical divisions of nervous system—such as brain,
spinal cord, nerves, etc. All these organs are to be studied in a similar
way. One has to analyse the normal working in healthy people and the
abnormal working in sick people to verify at the post-mortem examination
the position of the lesions producing the observed disorders in the
working of the organ, and from such anatomo-clinical comparison to
ascertain the exact use of that part of nervous system in the general
life. The fruitful method, entirely founded on the psychological
reasoning, is in a same degree indispensable in that study of the nervous
system, whatever is the especial organic conclusion of such investiga¬
tion. Consequently, the bonds between psychiatry and neurology will
be drawn closer by the unity of method, as well as by the unity of object.

(3) Psychiatry and neurology have a same purpose. —In reality, all
those who study the nervous system have a same purpose, i.e. : (a) To
cure, or at least to relieve, people suffering from nervous disease ; (b) to
protect society against an invasion of nervous diseases, or against the
misdeeds of such patients; (c) to increase our knowledge of the nervous
system in normal and pathological states.

Psychiatry and neurology, therefore, do not form two sciences, but
only one, i.e., the physio-pathology of human nervous system or human
neuro-biology.

The senile brain .—According to Dr. Andrd I.£ri, of Paris, old age
and senility are not synonymous, old age meaning the last period of
a life, and senility being a pathological state, most common amongst old
people, but which appears much sooner or much later than the beginning
of old age. There is a previous and a late, a general, and there are
local senilities. One might not find a senile organ, and especially a
senile brain without lesion. The lesions consist in : simple or de¬
generative atrophy of parenchymatous elements, proliferation, more or
less localised, of interstitial elements, and sclerotic disorders of blood¬
vessels

392

EPITOME.

[April,

The author successively studies: (i) The brain in its external and
internal aspect, and its three kinds of diffuse lesions which affect the
nervous tissue, neuroglia, and blood-vessels; (2) the small focal lesions
of the senile brain, such lesions being of two kinds, /. e . 9 lacunes de dis¬
integration from a vascular origin, and itat vermoulu , or cortical ulcera¬
tions, digging like a coin into the convolutions, but generally not
further than the grey tissue; (3) large lesions in foci (softening and
haemorrhagia).

As the anatomical as well as clinical investigation bring into closer
union senile changes and prolonged intoxications, Dr. Leri concludes
that his observations are a new argument in favour of the opinion which
considers senility, in the brain or in other organs, as the ultimate
condition of all the intoxications of life.

Cytological , bacteriological , and experimental study of the blood of
the insane .—According to Dr. Maurice Dide, of Rennes, alkalinity
decreases in the toxic cases, such as mental confusion, early dementia,
pellagra, and epilepsy at the commencement of an attack. Mineral
elements show quantitative variation accordingly to the general rules of
physiological pathology. The increase of urea is slight in the intervals
of epileptic fits, and very considerable during the attack. In early
dementia periods of excitation are accompanied by a slightly increased
resistance of red corpuscles, and periods of stupor offer an inverted
formula. In the fits of epilepsy, there is a diminution of resistance,
while in other mental diseases, and especially in melancholia, the
resistance is normal. Generally there is hypoglobulie in toxic cases,
and hyperglobulie in maniacal states. Transient crises of hyperglobulit
appear during the attacks of epilepsy ; a diminution of haemoglobin is
usual, but there is an increase on the commencement of a fit.

Polynucleose with hyperleucocytose is observed at the outset of toxic
psychoses and in states of agitation ; the mono?ieucleose with a slight
hypoleucocytose seems to be the sign of a definite failing of resistance of
the organism to a long toxic infection.

After much micro-biological, chemical, and physical researches on
serum, the author studies haematology in its relationship to heredity.
Morbid heredity is unquestionable, but not sufficient to produce
delirium or epilepsy; another cause, a toxcemia 9 is necessary. Dr. Dide
thinks that a more complete knowledge of the blood might allow of a
more definite prognosis of hallucinatory psychoses.

Cases of motor aphasia without any lesion of Broca 7 s convolution .—
Dr. Pierre Marie, of Paris, stated at the Sociite Medicate des Hdpitaux,
last July, that motor aphasia is often observed without any lesion of the
third frontal convolution, and that the lesion mentioned as character¬
istic of aphasia is equally verified when no special symptoms have been
observed during the life. Following many anatomical examinations he
was able to conclude that the centre of language is placed in the zone
of Wernicke, at the pli courbe and the first temporal convolution ; and
that the aphasia of Broca, or motor aphasia, does not exist without a
lesion of the nucleus lenticularis or of nucleus caudatus.

During the months of November and December, he presented new
cases, with post-mortem examinations. A man, following a fit, had shown
right hemiplegia and general motor aphasia, and remained eight months

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393

1907 .]

without speaking, but being able to read, to write, and to understand
everything. The lesion was localised in the lenticular area of the left
hemisphere. Two other cases of motor aphasia, one without dementia,
the other with agnosia and dementia, presented lesions of the temporal
convolution and of the lenticular zone, without any lesion of Broca’s
convolution.

Dr. Souques also presented the brain of a young female patient who,
suffering from mitral stenosis, was suddenly taken with an apoplectic
seizure and motor aphasia; she subsequently died from pleuro-pneu-
monia. The post-mortem examination showed a single focus of soften¬
ing in the left hemisphere, which had destroyed the posterior part of
ihe two first temporal convolutions and reached the posterior and
external part of the lenticular zone. Broca’s convolution was intact.

GERMANY.

By Dr. Johannes Bresler.

In my previous reports, I have mentioned the efforts made in
Germany for establishing sanatoriums for patients of the lower classes
suffering from nervous diseases. I can now state that a third sana¬
torium has been erected at Roderbirken, near Leichlingen (Rhein-
provinz); the medical superintendent is Dr. Beyer. The two sanatoriums
already existing, Hans Schofnow, near Berlin, and Rasemiihle, near
Gottingen, have shown by their activity during several years the full
purpose of their existence.

At the University of Greifswald, a new psychiatrical clinique has been
established, and at Johnnisthal, near Tiirktelu, in the Rheinprovinz, a
large general provincial asylum has been erected.

In the larger cities, there is more and more the tendency to erect
asylums for their insane (at least the curable), instead of using the
country asylums. I mention, for instance, the establishment of the
city asylums of Chemnitz (Saxonia), Stuttgart, and Nuremberg.

The efforts to propagate psychopathic knowledge amongst non-
medical laymen have been continued. For example, at Giessen, in the
psychiatrical clinique of the University, a course of medical psychology
with regard to the treatment and education of the congenitally feeble¬
minded took place from April 2nd to 7th, 1906, and was attended by
more than 100 persons, teachers, clergymen, and physicians. Pro¬
fessors Sommer, Weygandt, and others read papers and gave demon¬
strations.

The usual meetings of alienists and jurists have taken place during
the past year. The detailed reports of some of these societies will be
found in the Juristiseh-pshchiatrische Grenz/ragen , edited by Finger,
Hoche, and myself.

In the second half of April, 1907, an international course of medico¬
legal psychology and psychiatry will be given at Giessen for physicians,
jurists, and officers of prisons and houses of correction, etc. Lectures
will be given by the Professors Sommer (Giessen), Aschaffenburg,
Dannemann, and others.

394

EPITOME.

[April,

On the other hand, our alienists are endeavouring to enlarge their
knowledge of other branches of medical science. For this purpose,
courses for the further education of the physicians of asylums in
medicine, surgery, hygiene, pathological anatomy, bacteriology, etc.,
have been arranged at the request of the German Society of Psychiatry.
The first course, lasting three weeks, took place at Berlin in autumn,
1906. It was very well attended. The cost was defrayed by the
Asylum Boards.

To prevent the feeble-minded, or persons of an insufficient psy¬
chical resistance, from being levied for service in the Army, the
Ministry of Prussia has decreed that the discharge of any juvenile
insane or feeble-minded out of the asylums shall be notified to the
recruiting agencies.

Finally, I regret to communicate that in the asylum of Hofheim
(Hessen) in December, 1906, a physician and an attendant were shot
dead by a patient. The patient (suffering from phthisis) had not
shown any delusional or persecutory ideas for a long time, and was
about to be discharged. During a leave of absence, he furnished
himself with a revolver and brought it secretly into the asylum. His
physical health grew worse, also his mental state; he was therefore
ordered to be transferred to another ward, and upon the discovery
of the revolver, he shot the medical officer and attendant who wished to
take it from him.

ITALY.

By G. E. Ferrari.

During the year 1906 the activity of our principal centres of
psychiatrical science (Torino, Reggio Emilia, Firenze, Roma, Napoli,
etc.) has been as remarkable as usual, and the principal reviews of our
speciality—we are pleased to mention particularly Rivista di Patologia
Nervosa e Mentally edited by Professor Tanzi—bear witness to it. How¬
ever, among so many excellently written works, no one publication of such
exceptional merit, or rather, so representative of the progress of any one
school, has been found as to warrant us giving a special account of it in
our annual review. Perhaps this is due, to some extent, to the fact that
psychiatrical centres, both great and small, have concentrated their
attention on the asylums, specially in relation to the new Lunacy Law,
of which we have already spoken in a previous letter. The question is,
in truth, of a law riddled with imperfections, obvious at once when
brought into practice, but which has given a new dignity to the asylum
doctor in obliging the County Councils to provide for the upkeep and
personal safety of every mentally-afflicted individual. The result is that
doctors have now the right to demand from the Councils for the well¬
being of the sick that which only a short while ago had often to be
asked as a favour, even if it remained within the limits of the Provincial
balance-sheets. As a fuither result we now see new asylums built on
the best lines, and in the existing asylums we find the doctors applying
themselves to improve them as much as possible, to train the staff of

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1907.] PROGRESS OF PSYCHIATRY. 395

attendants, to discuss questions of professional technique, etc. If, then,
we owe the silence of so many in the strictly scientific world to this
work, which has for its object the improvement of the internal conditions
of the asylums for the still greater well-being of the inmates, there is
reason, perhaps, to welcome rather than regret it.

A comparative uniformity in the working of the different asylums will
be an additional benefit following the adoption of the new Lunacy Laws.
The Supreme Council of Health has instituted a code of regulations
governing the asylums. Any special rules have to receive the approval
of this body, and they then have the force of law for the asylum for
which they are designed, but they must conform with the code laid down.

Two International Congresses, which will be long remembered, have
been held during the year under review—the Congress of Criminal
Anthropology (Turin, in May), and that of the Care of the Insane
(Milan, in September). The former marked the jubilee of Professor
Lombroso, and resulted in the recognition of criminal anthropology as
an ordinary subject of University teaching.

The Congress for the Care and Treatment of the Insane should be a
landmark in the history of the subject and of psychiatry. The pro¬
position of Dr. Frank, of Zurich, for the foundation of an International
Institute destined to establish exactly the causes of insanity, and the
most direct and efficacious means to combat it, is especially memorable.
The Congress, when held, would be engaged chiefly in discussing the
information gained by such an institution, and would form an inter¬
national committee, which would seek the sympathetic participation of
the various governments and the formation of national committees to
work under its supervision and general direction.

The different national committees would meet from time to time
according to necessity, and each committee would have to report to the
successive international congresses on the progress made, and give their
results for deliberation as to the direction subsequent investigations
should take. The proposition of Dr. Frank was unanimously accepted
by the Congress, and the Congress of Psychiatry, Neurology, Psycho¬
logy, and Care of the Insane, which will be held in Amsterdam from
September 2nd to September 7th, 1907, will decide the future of this
institution, so simple in its organisation, but so lofty in its humane
purpose.

The leading questions of the day in Italy are, as usual, epilepsy and
pellagra. As to the latter disease, we must note with approval the
support which the government has at last given to the National Com¬
mittee for combating Pellagra, which sits at Udine, and of which Dr.
Antonini is the moving spirit. The struggle against this formidable
plague among the working classes of many of our districts would be
doubtless assisted if it were possible to bring into practice the discovery
of Professor Gofio and his assistant, Dr. Palludino, a discovery which
would serve to make clear the first symptoms of pellagra.

This discovery is that of special conditions in the blood of those
predisposed to pellagra.

During the year monographs (edited by Vallardi) will begin to
appear, which will constitute a “ Treatise on Social Medicine,” written
by Professors Tamburini and Celli.

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396

EPITOME.

[April,

This treatise will have for its subject, on the one hand, the different
problems of the treatment of the insane, epileptics, drunkards, weak-
minded, and sufferers from pellagra, etc., of criminal anthropology, of
general anthropology, and medical jurisprudence; on the other hand,
the hygiene of schools, public buildings, streets, etc.

I have alluded in one of my preceding letters to the “ Institute of
Experimental Pedagogy,” which has been founded by Pizzoli, and is
working very well under the auspices of the municipality of Milan. Now
the Italian Minister of Public Instruction, with the object of instituting
something of the same kind in Rome, has authorised de Sanctis,
Professor of Experimental Psychology at the University of Rome, to
organise a two months’ course of lectures to instruct the masters and
mistresses of the primary schools in the elements necessary to judge of
the mental capacity of the children of their schools as well as to train
the staff of the “ Hilfschulen,” which it is always a question of instituting
for the children who are not actually weak-minded, but who are not
able to keep pace with the others because of an arrest (from no matter
what cause) in the development of their intelligence. The instruction
given in this course consists of lessons in pedagogic psychology, and
on the function and education of the organs of sense, etc.

We have already alluded to the school, directed by Montesano,
for those masters and mistresses of schools who are intended for
institutes for the generally weak-minded children.

Finally, I wish to draw attention to the subject of the sensational
publications of Professors Lombroso and Marcelli on so-called “ spirit¬
ism,” although these two eminent professors have only so far published
their ideas in the literary or political journals.

Lombroso has been for some time an ardent observer of all
metaphysical phenomena, to which he has even dedicated a special por¬
tion of his journal Archivio di Psychiatric but during 1906 he has
openly taken up his position against the official world which still denies
the existence of “spiritualistic phenomena,” both physical and in¬
tellectual. Up to this time, however, he has not yet brought forward
a theory of his own to explain them, although he is busy preparing
one.

Morselli, on the contrary, maintains a critical position. He has
been making experiments for a long time, and under the best conditions,
with Eusapia Paladino, and has convinced himself, to his complete satis¬
faction, that all the physical phenomena evoked by this celebrated
medium are objective.

He has published, in a very important political journal, a critical
article on the history and explanatory theories of spiritualism. For
his part he does not give any theory, but he shows an inclination to
explain the “ physical phenomena of Eustacia Paladino ” (he clearly
limits his judgment to that) by a psychical process analogous to that
which gives rise to actual hallucinations.

They would depend on an objectivation of the thought of the medium
Eusapia, haunted by auto-suggestions, or suggested by her surroundings
in the seances .

Morselli is going to publish a volume on this subject. The work
of so brilliant and conscientious a savant will, doubtless, be extremely

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NEUROLOGY.

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397

useful to the progress of science, which will always have uses for all
serious contributions.

Italian psychiatry, during 1906, has suffered sad losses. Two young
men, especially, who would have, done honour to science and the speci¬
ality—Obici and Angiolella—died at the age of 35, when they were near¬
ing the end of their zealous work. And among many others we must
regret the death of Professor Roncati, Professor of Psychiatry at the
University of Bologna, who bequeathed his fortune, of nearly a million
francs, to the provincial administration for enlarging and completing
the urban asylum which he directed for more than thirty years.

Epitome of Current Literature.

1. Neurology.

On the Pyramidal 7 rads of Man [Sul/e vie Piramidali DelTuomo]. (Riv.

Speriment di Freni at., vol. xxxii, fasc. iii-iv.) Ugolotti, F.

This article refers to the much debated anatomy of the direct pyra¬
midal and so-called “ homolateral ” tracts.

In two previous communications Ugolotti fully expressed his view on
this subject; but further investigation has caused him to alter his
opinion as to the origin of the homolateral bundle of fibres.

The dired pyramidal trad. —Marie and Guillain in 1903 asserted
that the difference in extent of the degenerations met with in this
column depended on the seat of the primary lesion. If this was situate
in the brain proper the degeneration was confined to the inner and
posterior margin of Tiirck’s column. While, on the other hand, if the
lesion occurred in the cerebral peduncles or in the pons they main¬
tained that the resulting degeneration extended in the shape of an arc,
“en croissant,” round the anterior margin of the tract. Thus they
divided the degenerations found in the direct pyramidal into two
distinct types, the cerebral and the mesencephalic, depending on the
seat of the original lesion.

The degenerated fibres termed by them “en croissant,” and alleged
to be characteristic of the mesencephalic type of lesion, took their
origin, they believed, from numerous masses of cells in the peduncles,
suhoptic region, and the pons in the vicinity of the pyramidal paths,
and joined the pyramidal tracts on their way from the cortex.

Ugolotti, in one of the papers previously referred to, strongly com¬
bated these conclusions, and claimed that the different forms which
the degeneration assumed in this tract varied according to the level at
which the cord is examined, and followed the anatomical distribution
of the fibres characteristic of each region. Whether the lesion were
cerebral or mesencephalic the anterior pyramidal tract preserved the
same appearance in degeneration, namely, triangular or rectangular in
the cervical, and arc-shaped in the dorsal region. The degeneration as
a rule did not extend to the lumbar region, but when it did, it was

EPITOME.

398

[April,

represented by a few fibres arranged along the side of the anterior
median sulcus.

The “ homolateral ” pyramidal tract .—Ugolotti applies the nomen¬
clature “ homolateral ” to those fibres of the pyramidal tract which, in
cases of a unilateral lesion of the motor centres, are found degenerated
in the position of the “ crossed ” pyramidal tract, but on the same side
as the primary lesion. Several explanations have been put forward to
account for this double degeneration of the crossed pyramidal tracts
following on a unilateral brain lesion: that degenerated fibres passed
from one tract to the other across the white commissure; that it was
the result of compression of the sound by the affected tract at the level
of the pyramidal decussation ; that the degeneration was propagated at
this point by simple contact; that at the point of decussation each
pyramid sent down a bundle of fibres into the “ crossed ” pyramidal
column of the same side ; that it was due to a double crossing of the
pyramidal paths, one at the ordinary level, the other at some higher
point in the interhemispheric commissures.

In a former article Ugolotti favoured this latter view. He concluded
that the double degeneration was the result of the passage of a bundle
of fibres from the seat of injury in the motor zone into the opposite
hemisphere, probably through the corpus callosum, and that these fibres
at the level of the bulbar decussation passed with the crossed pyramidal
fibres coming from the uninjured motor centres into the lateral column
on the same side as the lesion, forming the homolateral tract.
Further investigation, however, has caused him to alter his opinion and
to agree with Dejerine and Thomas that the homolateral bundle of
fibres is detached direct from the degenerated pyramidal tract at the
commencement of the bulb, and instead of decussating pursues a direct
course into the lateral column of the same side. That the point of
origin of these fibres has not been more frequently detected Ugolotti
believes is due to the fact that the fibres are as a rule few in number,
and the number that leave the diseased pyramidal path together at any
one point is small; at times, however, they originate as a bundle of
fibres large enough to be demonstrated with the greatest facility.

The Marchi reaction is the one recommended by the author, who
found the Weigert-Pal method uncertain, and suggests that it is owing to
its frequent employment that several observers have been led to false
conclusions on this subject. A. I. Eadbs.

Contribution to the Study of the Functions of the Frontal Lobe [ Con -
tributo alio Studio delle Funzioni del Lobo Frontale], (Arch, di

Psichiat.y vol. xxvii, fasc. iv, v, 1906.) Roncoroni.

In this paper, the author records in detail a clinical observation of a
traumatic lesion of the prefrontal area, and in connection therewith
discusses the question of the functions of this part of the brain. The
subject of the observation, a man, aet. 50, addicted to alcoholic excess,
but without anything else of special note in his family or personal his¬
tory, sustained a compound fracture of the left frontal bone nine
months before he came under Roncoroni’s care. For fifteen or sixteen
days after the injury he was unconscious; there yjas some loss of brain

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NEUROLOGY.

399

1907 .]

matter, and portions of the fractured bone were removed. The wound
healed without the development of any symptoms of meningitis, and a
few days after recovering consciousness the patient was able to resume
his usual life; he suffered, however, from some degree of aphasia, and
from a more persistent difficulty in writing. Five months after the
injury he had an attack of convulsions, probably connected with the
renewal of his drinking habits. The position of the cicatrix would
indicate that the convolutions injured were the first and second frontal,
and in the absence of symptoms referable to the motor cortex it
appears likely that there was no extension of inflammatory trouble
beyond the area directly damaged.

The persistent disturbances of brain function produced by the lesion
are summed up by Roncoroni as follows : Partial verbal amnesia, shown
in failure to name familiar objects which the patient recognises per¬
fectly, alterations in the psychic content of what he writes spontaneously,
almost total disappearance of mimetic movements of the face, loss of
aptitude to perform even the most simple arithmetical operations, failure
of volitional energy and initiative. No other alterations in nervous
function are observable.

Discussing the case, Roncoroni assumes for the psychic arc the
following stages:

(a) Constituting the afferent branch : (1) pure, primary sensations,
having their seat in the primitive sensory areas ; (2) complex sensations
of higher evolution, as, e.g. y tne symbolic representations in written
language.

(£) Constituting the efferent branch of the reflex arc : (1) re evocation
of the psychic image corresponding to the movement required, as, eg.,
in speaking it is necessary to associate the several images, visual,
auditory, etc., relative to the object, with the verbal image corresponding
to it; (2) re-evocation of the sensory image corresponding to the move¬
ments required ; (3) motor impulse proper. The stage in this diagram¬
matic view which the author would locate in tjie prefrontal area, is the
third or preparatory process in immediate relation with the more highly
evolved motor functions. This theory would explain why lesions of
the prefrontal area do not produce either gross disorders of motor
function or distinct disturbances of sensation or intelligence, and why
also the results of experimental interference with this area are negative.

W. C. Sullivan.

3. Etiology of Insanity.

Inquiry into Race and Heredity \Ueber Geschiechterforschung und
Erblichkeits hygiene]. {Allgem, Zeits. f Psychiat '., B. lx Hi ,
H. 1.) Lundberg.

Dr. Lundberg has been making some investigations in a quiet district
in the south of Sweden where the family history could readily be traced.
In the last half of the eighteenth century, the race seemed to have been
flourishing, and many of the inhabitants gained distinction, some
becoming members of Parliament. At the beginning of the nineteenth

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EPITOME.

[April,

century, the times were hard, the people took to drinking, and symptoms
of degeneration began to appear, which were probably intensified by
numerous close marriages. Now, a hundred years later, the race is in
such a sad condition that it looks as if it might become extinct in some
places. Alcoholism and consanguine marriages still prevail. There is
still great fertility; it is not uncommon to find from eight to ten children
in a family. The parents do not welcome this, and the mothers con¬
tinue to nurse their infants for two or three years, which, however, does
not always act as a preventive. While nursing they sometimes use too
much alcohol, and often drink strong coffee adulterated with chicory.
During the last ten years, there has been a considerable emigration to
America and Australia, and as it is generally the healthy individuals
who leave; those of lesser vigour are left behind to continue the race.
Dr. Lund berg has noted the tendency in some families to regeneration,
and the study of these rising families is of even greater interest than
the observation of the degenerated ones. Certain nervous diseases,
though unlike in symptoms, seem to have a relation to one another; for
example, one frequently finds in the same family the children affected
by epilepsy, dipsomania, and migraine. On the other hand, periodic
psychosis, chronic mania, and dementia praecox are seldom met with
in the same family. To have a well-grounded theory about heredity
one must proceed slowly, examining individual after individual, family
after family, and generation after generation. For a research of this
kind Sweden offers many opportunities. The race is unmixed, speaking
only one language; the population is in many places stationary in the
country, so that a great many members closely akin may be met with.
In many places, the weeds have grown and flourish unchecked, so that
they choke the good seed. Dr. Lundberg adds that there are whole
states in Europe in which degeneracy takes more and more the upper
hand. Fie does not mention what these countries are, but some German
writers have assumed that this is the case with France, of which we
think there is no sufficient proof. William W. Ireland.

Bischoff on Family Insanities \Ueber familiare Geisteskrankheiten |

(Jahrbuch f Psychiat . und Neurol ., B. xxvi, H. 2, u. 3.) Bischoff.

Dr. Ernst enumerates as hereditary nervous diseases Freidreich’s
ataxia, cerebellar ataxia, the family form of spastic spinal paralysis, pro¬
gressive muscular atrophy, amaurotic family idiocy, Huntington’s
chorea, and myotonia congenita (Thomsen’s). The subject of his
paper under consideration is that form of insanity affecting several
members of the same family. Bischoff separates induced insanity from
those cases where several members of a family become insane. Being
under the influence of one another in induced insanity, the derangement
often subsides when the secondary member is withdrawn from the
powerful influence of the other. He cites instances, where, without any
influence of the one brother or sister being exerted upon the other,
they become insane often about the same period of life. This some¬
times occurs with twins, of which some instances have been cited. In
such cases, we are forced to believe that the insanity is hereditary.
Vorster and Sioli held that manic-depressive insanity and dementia

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ETIOLOGY OF INSANITY.

401

1907.]

praecox succeeded one another through several generations. Later
inquiries have favoured the theory of polymorphism or transformation
in which the hereditary disposition shows itself through several distinct
forms of mental or nervous disease. Bischoff describes insanity in two
families, in neither of which was there a marked neurosis in the ascen¬
dants, but in the first family four out of five brothers and sisters were
insane. In the second family, there were ten children living; of these a
son and a daughter, soon after puberty, quite independently of one
another, became demented. Two others, males, were affected by the
same malady, though in a less degree. The remaining members of
the family were sane. William W. Ireland.

On the Danger to Posterity of Neurotic Diseases in the Ancestors [Die
Gefdhrdung der Nachkommenschaft durch Psychosen Neurosen und
verwandte Zustdnde der Aszendenz]. (A//gem. Zeits. f Psychiat.,
B. /xiii, H 3.) Tigges.

Dr. Tigges, of Dusseldorf, has made an elaborate inquiry into the
diseases of the ascendants of the patients received into the asylums of
Germany and Switzerland. The cases in which the father or mother
were insane he styles direct heredity, where the grand-parents, uncles,
and aunts were affected, indirect heredity, and where the sisters and
brothers were affected, parallel heredity. He inquired into the number
of deaths in these families and the members who remained healthy.
These statistics are compared with the history of an equal number of
healthy families, and the bearing of the figures very carefully analysed.
The information thus obtained has been reduced to statistical tables.
Nothing less than a translation of Dr. Tigges’ paper would make a fair
presentation of his results. In general, it may be said that they give
a solid confirmation of the views which have been reached by most
experienced physicians, of the frequent transmission of insanity and
nervous derangements to the descendants. Those families affected
with hereditary insanity have, according to some observers, more
children to a marriage, but these children are not so healthy and there
are more early deaths. This has been especially shown by Marandon
de Montyel, though the evidence has been weakened by the Sachsenberg
statistics. Moral defects accompany these neurotic families, and even
the sound members often show decided peculiarities. Insanity, even
when not inherited, has more tendency to be propagated by descent
than any other abnormalities.

On inquiring into the ascendants of drunkards, comparatively few
nervous diseases are found amongst the indirect and collateral relations.
The proclivity to drunkenness is propagated from the parents in the
direct line. The commonest legacy of drunken parents is epilepsy and
delirium potatorum. There is a tendency in such families to die out in
three or four generations. The mortality amongst the children in those
families is abnormally great. Legrain has given some striking statistics
supporting this.

Certain nervous diseases, especially apoplexy, common organic affec¬
tions of the brain, and lesions at birth, are not liable to transmit insanity
to the descendants; but epilepsy, hysteria, hypochondria, are liable to
LIII. 27

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402

EPITOME.

[April,

beget further disorders. The evil influences of heredity are most
marked in general paralysis. Tigges presents a number of these
genealogies which show the hereditary transmission of nervous diseases
in a striking manner. The following has been given by Jorger:
Andreas Zero was born in 1639; both he and his son Ernst married
women of the Lauter family. With these two men there was nothing
abnormal on record. In the Lauter family, in 1713, one woman
became insane and committed suicide. In a branch of the same
family two sisters and three brothers were either insane or nearly so.
The children of one of the brothers were most erratic—one daughter
dull of hearing, besides this one was dumb, one weak-minded, one
idotic, one insane. It was this Lauter family that brought the heredity
taint into the Zero family. While the eldest son of Andreas Zero and
the youngest of Ernst Zero, by a second marriage, were the progenitors
of a flourishing family of from seventy-six to ninety members, the son
of Ernst Zero, by his first wife Lauter, Paul Alexius, was the progenitor
of an abnormal family. He himself led a vagabond life with his wife.
They had six sons and one daughter; from these seven children came
a progeny of over 200 vagabonds, drunkards, thieves, prostitutes,
idiots, weak-minded, beggars, murderers, infanticides, homicides, besides
a series of lunatics, epileptics, paralytics, many squinting children
—in one family eight of them. The feeble-minded members married
several times and had a large number of children, amongst whom
the mortality was great. Some of the children of the Zeros were
boarded into private families, without any benefit.

Assuming that there is in the general population one insane person
for 250 inhabitants, it would be only those who are married, widowed,
or divorced who could give opportunities for hereditary transmission to
their descendants ; these constitute about 50 per cent, of the admissions
into asylums. This proportion must be lower in the population outside,
as the idiots form one half of the total insane, and it is only the more
intelligent imbeciles, about 10 per cent. , who become married. We have
thus to reckon with one insane person in the 500. If these abnormal
persons had the average number of children as the sane, the proportion
would be 0*2; instead of this the direct cases of insanity in German
asylums give us 10 to n percent of insane children. Calculated at
10 per cent ., the incidence of insanity with those who have a direct
hereditary predisposition is ten times 0*2, equal to fifty times more
insane persons than occur in families without hereditary predisposition.

William W. Ireland.

On Nervous and Psychical Injuries through Electrical Discharges from
the Telephone. (Allgem. Zeits. f. Psychiat ., B. Ixiii, H\ 1.)
Kurella.

Dr. Kurella described to the Psychiatric Society of the Rhine
provinces seven cases which he had observed from 1900 to 1904 in
which mental or nervous injuries had been experienced by professional
telephonists. Five of these cases were owing to high electric discharges
from the telephone, three being from a strong electric current and two
of them through an atmospheric discharge. None of these cases ended

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1907.] CLINICAL PSYCHIATRY. 403

fatally, but in one there was atrophy of the muscles affected in the left
arm. Kurella cites other observations, going to show that multiple
sclerosis and an affection like general paralysis has been occasioned by
the discharge of an electric current from the telephone, in opposition to
Gellinek, who treated such injuries as of nervous or mental character.
Kurella contends that the strong currents used have actually caused
physical lesions of the heart and nerve tissues, especially small ruptures
and haemorrhages.

Kurella’s paper, which has been published in a separate form by
A. Barth, Leipzig, led to a discussion in which Dr. Hoffmann argued
that these effects following the use of the telephone were of mental
origin. Steiner sustained Kurella’s view, but he does not consider that
lightning passes through the telephone wire. There was a little
epidemic in Cologne in which many telephonists suffered injury, but
there was no thunderstorm at the time. William W. Ireland.

3. Clinical Psychiatry.

Contribution to the Clinical Study of the Pharyngeal Reflex [Contributo
alio Studio Clinico del Rifles so Faringeo\ (.Annali dell Instituto
Psichiat. della R. Univ. di Roma , vol. iv, 1905.) Forli, Vand
Guidi , G.

That the pharyngeal reflex is not by any means a constant phenomenon
is very well known to users of the laryngoscope.

The authors of this paper first examined 98 subjects free from any
nervous disorder, with the object of finding out the influence of age on
its appearance, with the following interesting results :

In the subjects under fifty the reflex was well marked in nearly 50
per ant., absent in 15 per cent , and feeble in the remaining 35 percent '.

In those over fifty, it was well marked in 40 per cent., absent in 31
per ant., and feeble in the remaining cases.

They next give the results of examination of 331 cases suffering from
some functional or organic form of nervous disease. Most notably in
hysteria# and to a lesser extent in hysteroid neurosis, was there a great
alteration in its exhibition.

Kattiwinkel, in a recent publication on the same subject, gave the
results of his examination of 104 cases of hysteria. In 100 of these the
pharyngeal reflex was abolished. He at the same time noted that the
pharyngeal sensations of touch, temperature, and pain, were unimpaired,
and deduced from this that the abolition of the reflex for nausea did not
point to anaesthesia of the mucosa, as was generally held, but was a sign
of interruption of the reflex arc, and of cerebral origin.

The authors’ experience in their hysteria and hysteroid cases was
very similar, more especially in the graver forms of hysteria. In
epilepsy, also, the absence of the reflex was frequently noted, and that
this was not due to the bromides was proved by control experiments.
The same results were found in neurasthenia. In patients suffering
from tabes and chronic alcoholism, there was little apparent alteration,
and the same applied to the early forms of general paralysis. In the

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TO
-1

! 'i.

v u t! ]

404 EPITOME. [April,

later stages of the latter disease, however, the reflex was very frequently
absent, as also was the case in cases of cerebral tumour.

In cases of hemiplegia, the reflex was much weaker on stimulating
the pharynx on the paralysed side.

The authors hold that these facts confirm Sahli’s hypothesis that all
the “ complicated ” reflexes, such as nausea, should be considered as
cortico-nuclear, and hence may be altered by any lesion of the cerebral
cortex.

They think, in conclusion, that their researches show that the altera¬
tion of the reflex is not the result of a morbid condition of the motor-
paths, but is due to some lesion of the centripetal branch of the reflex
cortical arc. A. I. Eades.

Research on the Blood-pressure , Pulse , and Temperature in Epilepsy
[Ricere he sopra la Pressione Sanguigna , il Pulso e la Temperatura
degli Epilettlci]. ( Riv . Speriment. di Preniat., vol. xxxii t fasc. Hi -
iv.) Besta , C.

The author finds that the blood-pressure is raised in a large percentage
(63 per cent.) of the epileptics he examined, but experiences a difficulty
in giving an exact explanation for this. He was able to exclude any
direct pathological cause, as cardiac or renal disease. The pressure-
curve was extremely irregular. It was not modified by the number of
fits, nor by the mental or physical condition of the patient; in those
cases where the pressure previously happened to be above the normal,
after the fits no lowering or return to the normal occurred. Many
writers maintain that the epileptic convulsions represent an attempt on
the part of the organism to eliminate the convulsive toxins circulating
in the blood, and that the toxic power of the blood is greater before the
fit occurs, while the opposite holds good of such secretions as the urine
or sweat. If this were so, it would be expected that after the fits there
should be a return to the normal of the organic functions, such as the
circulatory system, more strictly in connection with the disease. That
this is not so is shown by the continued high blood-pressure in those
cases where this obtained before the onset of the convulsions.

As regards the chemical condition of the urine after a series of fits,
there is much difference of opinion. While some authors hold that its
toxic properties are much increased, others contend that the experi¬
mental results obtained are too inconstant to be of any real value.

The results of the author’s experiments on the state of the blood-
pressure before the onset of the fits are worthy of note. In no case was
there any modification of the general blood-pressure preceding an epi¬
leptic seizure, which shows, in his opinion, how different is the mechanism
here involved from that occurring in a uraemic attack, which is always
characterised by vaso-constriction and marked rise of arterial pressure.

The pulse rate had no direct relationship with the state of the blood-
pressure ; nor was it modified by the epileptic convulsions, except that
it was increased temporarily during these. Like the blood-pressure it
followed no regular course, but each case showed some distinctive
peculiarity. There were frequently variations in its pulse-rate of from
30 to 40 per minute without any appreciable cause, quite independent

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CLINICAL PSYCHIATRY.

I907.]

405

of digestion or sleep or emotions, which frequently affect the pulse-rate
of normal individuals.

As regards the temperature changes present in epilepsy, the author is
in complete accord with the results obtained by Ceni. He, however,
has never found the temperature fall below 35 0 C. In 66 per cent . of
the cases examined the temperature was found to be subnormal, and
this more frequently among women than men. The hypothermic crises
varied in duration, at times lasting from eight to twelve hours, or even
longer, and had no connection with the number or intensity of the fits,
or with the variations in blood-pressure or pulse-rate previously referred
to.

The author has shown that all these modifications of the blood-
pressure, pulse-rate, and temperature pursue an autonomous course,
and are independent of the cortical manifestations of epilepsy. He
maintains that this disproves the theory that the alterations in function
of the central nervous system represent an organic reaction to eliminate
toxins from the circulation. He holds the belief that in epilepsy we
have to deal with an irritant that is continually acting on the central
nervous system, to which the nerve-centres react quite independently of
one another.

The cortical reaction manifests itself in the classical signs of the
disease—fits, and alterations in the psychical state; while the alterations
in blood-pressure, pulse-rate, and temperature are the results of the
action of the same irritant, be it mechanical or toxic, on the bulbar
centres. A. I. Eades.

On Agrammatism and Derangements of the Inner Speech [ Ueber A gram-
matismus und die Storung der Inneren Sprache ]. (Arckiv f Psychiat.
u. Nervenkrank ., Bd. 41, Heft 2.) Heilbronner y K.

Agrammatism may be regarded as an approach to aphasia, consisting
in a loss of the power of constructing correct sentences. Dr. Heil-
bronner, of Utrecht, describes a case of this kind. A young man had
received an incised wound in the left temporal region, which was
followed by loss of blood, and unconsciousness which lasted for four
weeks. After this time he began to speak, but with difficulty. He
was received into the Psychiatric Clinique at Halle, where he was
under observation for fourteen months. On admission there was noted
right facial paralysis and deviation of the tongue, with spastic paresis of
the right side. He wrote with the left hand with much readiness. In
the ward he spoke little, and with difficulty, as if he had some
mechanical stop. Although he had a sufficient vocabulary and under¬
stood complicated sentences, he used ungrammatical phrases in speak¬
ing as well as in writing, like the pigeon English spoken by the Chinese,
or the Hindustani attempts of the British soldier, which are mostly in
the imperative. Specimens of his composition are given in the des¬
criptive paper, filling thirty pages. The author presents at the end the
following conclusions : (1) Agrammatism can follow a slight motor dis¬
turbance of speech; (2) it can continue for years, even under conditions
which favour the recovery from the symptoms of aphasia; (3) agram¬
matism with aphasies is not necessarily connected with mental weakness;

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40 6

EPITOME.

[April,

(4) agrammatism with motor aphasia is not a secondary result of the
motor speech deficiency, but a distinct affection; (5) a considerable
degree of agrammatism may be combined with a slight loss of the
apprehension of small sentences and their import, perhaps without any
loss of this apprehension ; (6) the result of a slight motor disturbance
may injure the construction of sentences more than the inner appre¬
hension of spelled words; (7) in agrammatism the injury to the power
of expression as shown in writing is greater than the loss of the receptive
power in reading ; (8) the power of finding the right word can, not¬
withstanding the loss of fluency in speech, remain intact in agrammatism;
(9) the recurrence of the same fault in the analysis of words observed
in experiments repeated at different times justifies the hope that some
law and order may be yet discerned in pathological derangements of
speech. William W. Ireland.

On Defective Children [Leicht Abnorme Kinder\ ( Allgem . Zeits. f.

PsychiatBd. Ixii , IL 4.) Thoma E.

Under this title Dr. Thoma, of Illenau, Baden, considers the case of
children weakminded or under the burden of nervous diseases, excluding
the graver forms of imbecility, idiocy, and cretinism, as well as severe
and recurrent epilepsy. Above these there is a grade of children who
have recently come into notice owing to the establishment of schools
for pupils of deficient intelligence in some of our large towns. Dr.
Thoma treats these cases under the heads of neurasthenia and hysteria.
Emminghaus has described the first of these affections in children as
a neurosis of the cerebrum, with some weakness of the intellectual
faculties, alteration of the temper, and anomalies of innervation. It
may be acute or chronic, often coming on suddenly, and showing itself
in great listlessness and the loss of the usual brightness and playfulness
of children. In the school, they are inattentive, learn with difficulty,
and soon lose what they have been taught. The pupils are wide and
react readily, the conjunctiva is injected. There are a great variety of
other symptoms, such as flushing of the face, bleeding at the nose, cold
hands and feet, feeling of heat in the head, noises in the ear, palpitation
at the heart, and dyspnoea. The sleep is bad, with night terrors. As
all these symptoms do not occur in one case, it is difficult to give a
general description. Sometimes there is only a single symptom to
guide the physician. Characteristic of neurasthenia in children are
what is called the phobies, terrors easily excited by slight causes, such
as monophobia, the fear of being alone, or the fear of some animals, as
spiders, mice, or toads. Thoma mentions one case of a woman, set. 22,
who, on the occasion of a search being made in the. school for some
stolen chocolate, was ever after haunted with the idea that she should
always have with her some friendly person as a witness of what she did.
Against this weakly yielding to dominant ideas, the author prescribes
a careful diet, withdrawing the child from pressure at the school,
gymnastic exercises, and manual work; as medicines, he recommends
valerian and the bromides. Such children are often affected by what
the French call Tics convulsifs , uncouth or jerky motions, such as
winking, shrugging the shoulders, hawking, snorting, biting the lips or

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CLINICAL PSYCHIATRY.

407

1907.]

the nails, and plucking the skin. These are often treated as simply
bad habits, whereas they may indicate a deeper neurotic affpction.
Such children at school are often inattentive and absent-minded, even
when they do not fail in intelligence. In the graver forms, they are rest¬
less and disorderly, prone to cruelty and stealing. When they grow up
they may become vagabonds and prostitutes.

The most recent description of hysteria in childhood and youth is
given by Bezy and Bibent. Symptoms of this affection in early infancy
are often ascribed to dentition ; often they commence with only one
symptom which would be regarded as a warning signal. Amongst these
are the starting of the muscles of the face, movements of the eyes,
stuttering, pain in the breast, cramp in the stomach or vomiting.
Thoma, during the past year, has seen two cases of hysterical dumbness
following upon disorder of the bowels. The author remarks that the
best prophylaxis would be to forbid marriages between neuropathic
persons, but as this is seldom practicable, treatment should begin as
early as possible. He recommends residence in the country, cold
baths, careful diet and exercise, avoiding all severity in teaching. In
some cases he has seen advantage from hypnotic suggestion. Some¬
times the hysterical fits are very severe, coming on suddenly, and
changing the whole character of the child. There is movement of the
hands, sudden redness of the face, grimaces, stretching out of the
tongue, roaring, and other distressing symptoms. Choreic motions are
common with hysterical children ; more frequent with girls than with
boys, in the relation of three to one. Thoma would have physicians to
inspect the schools, discriminate the cases, and withdraw such pupils as
need a special education or give directions how they should be treated;
their capacity for sustained application without weariness should be
especially tested. He cannot recommend schools for idiots as good
for children of merely weak capacities. For this class, small special
schools are the best if the parents are able to bear the cost. He recom¬
mends massage, gymnastics, Slojd’s work. Hydropathy is sometimes
useful. Prophylactic measures are advisable against possible attacks
of insanity or epilepsy. William W. Ireland.

On Subcortical Sensory Aphasia \Ueber Subcortical Sensorischc Aphasie],
(Jahrbuch f. Psychiat. und Neurol ., B. xxvi, H. 2, 3.) Bonvicini.

Dr. Giulio Bonvicini has, in an article of above one hunded pages,
given a complete survey of the information about sensory cortical
aphasia. When this form was conceived by Lichtheim, on theoretical
grounds, he was only able to produce one case in support. In his
view there were lost the understanding of spoken words, the capacity
to repeat words, and to write to dictation, while there were retained
spontaneous speech and writing, the understanding of writing, and the
power to read aloud. Thus the whole inner speech apparatus and the
understanding of words are intact, while the comprehension of spoken
words is suspended, the hearing being unaffected.

Bonvicini presents a case of this affection carefully studied. A man,
ast 63, previously healthy, with no affections of the hearing, had sensory
aphasia, which quickly passed away in the reverse order—the word-

408

EPITOME.

[April,

deafness, then the paraphasia, then the bad grammar, lastly, the difficulty
of finding the proper words. A second attack, with symptoms of left¬
sided hemiplegia, again brought back these speech disorders, which
again subsided, leaving behind a persistent word-deafness. The
description of this case occupies thirty-five pages, in which the
whole power of language and appreciation of tone are most carefully
analysed.

Bonvicini presents the following conclusions : Word-deafness may be
caused both by peripheral and central lesions affecting the middle ear,
the labyrinth, both acoustic nerves, and the nerve-tracts leading to the
cortex, as well as of the auditory zones at both sides of the brain. In
all these cases we have to do with a false, sensory, acoustic word-deaf¬
ness which is different from the pure speech-deafness described by
Wernicke and Lichtheim. If, on examining the power of hearing, one
finds a sufficient perception of tones, he may conclude that the word-
deafness is independent of a general impairment of hearing, and if the
power of repeating words and of writing to dictation be lost, while the
spontaneous use of the voice, reading, and writing remains intact, we
have the clinical form of subcortical sensory aphasia.

The cause of this pure word-deafness lies either in a one-sided affec¬
tion, when a lesion in the white matter of the left temporal lobe occa¬
sions a sub-cortical interruption of the auditory projection path and of
the connection of the auditories’ spheres through the corpus callosum,
or it consists in an affection of the temporal lobe on two sides of the
brain, which disturbs the paths without injuring the cortex. We can
only cite two instances of sub-cortical sensory aphasia from a unilateral
lesion—Liepmann’s case, of which we have the anatomical investiga¬
tion, and the case described by van Gehuchten and Goris, which went
no further than clinical observation. We cannot produce from the
literature of the subject a single unimpeachable instance of word-deaf¬
ness of bilateral origin, for the cases hitherto presented as such either
fail in the symptoms of pure word-deafness or are attended by difficul¬
ties of speech which seem capable of hindering the apprehension of
speech. Bonvicini considers the case described by him, although the
anatomical confirmation is wanting, to be the only one where the sym¬
ptoms of sub-cortical sensory aphasia are decided and uncomplicated.
They have persisted unaltered for years, and the tests show a scarcely
appreciable diminution of hearing. Heretofore the cases of word-deaf¬
ness examined by Bezold’s method have all shown an equal though
slight impairment of the perception of tone in all the octaves of the
scale. William W. Ireland.

Upon the Influence of Mental Processes upon Metabolism \Ueber den

Einflluss psychischer Vorgdnge auf den Stoffwechsel\ ( Allgem .

Zeits. f. Psychiat ., Bd. Ixiii , H 3. Rosenfeld.

In a paper of above thirty pages Dr. Rosenfeld considers this subject
both in its physiological and pathological aspects. He cites the labours
of many investigators, from which it appears that it is difficult to prove
that the quantity of blood in the brain is increased in mental activity.
In nerve-tissue the changes are small and the restitution is speedy.

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CLINICAL PSYCHIATRY.

409

The difficulty of separating the share of the excretions from the total
furnished by the muscular and nutritive activities is too great to allow
of a definite conclusion. Rosenfeld observes : “ It has not been
shown that the chemical changes in the brain, which are not neces¬
sarily processes of oxidation, have a recognisable influence upon
common metabolism, nor can it be proved that the changes in the
composition of the urine noted by some inquirers are the direct result
of these chemical changes.”

Rosenfeld then goes on to inquire whether alterations in the com¬
position of the urine have been found to follow pathological conditions
of the brain.

He cites many investigations by various authors; amongst others
Koppen has constantly found albuminuria in acute deliria and some¬
times propepton. The specific gravity was about 1030, but there was
no constant relation between it and the quantity of albumen. Albumi¬
nuria was in delirium tremens and other cerebral disorders. Pepto¬
nuria has been frequently observed in general paralysis, but in this
disease Rosenfeld has neither found this nor albuminuria constant.
Tuzek could find no albuminuria in insane patients during periods of
abstinence, and Schafer failed to find it in circular insanity. Aceto-
nuria has been observed in some cases of paralysis and other mental
derangements, probably the result of low nutrition. Glycosuria has
been frequently observed in insane patients, but not in any special
form of insanity. Raimann has made inquiries into the assimilation of
sugar in different forms; he has experimented on the assimilating
power shown by the appearance of glycosuria after the administration
of so much grape sugar calculated upon each kilo of the body weight.
In idiocy this assimilative power was calculated at 47 ; in maniacal
patients it was from 3*9 to 6’6. In acute confusional insanity from 27
to 1*4, and in melancholia from 1*2 to 1*9. This low grade in melan¬
choliacs he regards as owing to the slowness of the vital processes.

William W. Ireland.

Mental Degeneracy [De la Digtntrescence Men tale]. {Rev. de Psychiat .,
October , 1905.) Marc hand.

Morel employed the term “ degeneracy ” to indicate any departure
from the primitive human type, apart from such as resulted in a better
adaptation to the environment. He considered its principal character
to be hereditary transmission, and that it became progressively more
accentuated in the descendants, ultimately leading to sterility. The
cause was to be found in various ancestral diseases and intoxications.
He classified the cases into two groups : those with physical malforma¬
tions and intellectual enfeeblement (idiots, imbeciles, cretins); and
those with various psychical affections (obsessions, eccentricities, distor¬
tion of moral sense, etc.), but without intellectual enfeeblement.

Magnan attaches less importance to heredity. He thinks that all the
manifold varieties are reducible at bottom to one psychopathic mode—
a failure of psychical equilibrium.

The term “ mental degeneracy ” is accepted by modern psychiatry,
nevertheless it is difficult to apply in practice. One must recognise

4 io

EPITOME.

[April,

that it groups together disparate states, completely opposed in their
anatomical formulae. This is due to a confusion between degenerate
and “abnormal.” Every degenerate is an abnormal—but the converse
is not necessarily true. Certain abnormals are not, strictly speaking,
suffering from disease—the anatomical basis is simply a deficiency of
cerebral tissue without real lesion. In the degenerate, on the other
hand, the mode of development often differs completely from the
common form. .Thus there are degenerate idiots and abnormal idiots.

It is generally taught that whether or no an individual is a degenerate
is to be determined by examination of—(i) hereditary antecedents; (2)
physical stigmata; (3) mental stigmata. The author, however, does
not think that heredity plays the same rdle in mental degeneracy as in
insanity proper, nor that degeneracy is necessarily progressive from one
generation to another. Individuals without taint arise from degenerate
parents, and degenerates occur in otherwise irreproachable families. In
these cases some morbid condition of the mother during pregnancy is
often an important factor. Charrin and L£vi found numerous spinal-
cord lesions, principally haemorrhages, in the children of women ill
during pregnancy. Charrin and Delawarre have also shown in these
children the presence of various abnormalities—diminution of the
alkalinity of the blood, hypothermia, increased toxicity of the urine,
cellular alterations, etc.—which allow a more definite conception to be
substituted for the vague word “predisposition.” Certain affections of
childhood may also cause similar constitutional alterations.

The author, therefore, concludes that the clinical syndrome “mental
degeneracy” may sometimes arise from causes to which the term “de¬
generation,” in its generally accepted significance, is not applicable.

Bernard Hart.

Eschars in General Paralysis \Les Escarres dans la Paralysie Genirale\
(Rev. de Psychiat., October , 1905.) Vigouroux, A.

In general paralysis eschars of various kinds occur—different in their
aspect, seat, and evolution. What is their relation to the primary
disease ?

Till recent times eschars were considered to be trophic affections,
forming part of the clinical picture of the last stage of general paralysis.
Voisin pointed out that they often occurred in parts not subject to
pressure—and opinions have latterly varied considerably as regards the
rdle to be assigned to tropic changes and to lack of hygiene. The
author considers that this diversity is due to the fact that eschars have
been considered en bloc , without reference to differences in aspect and
position.

Eschars on the buttocks. —These sometimes appear as a sequel to a
seizure, and are then analogous to the “ acute decubitus ” described by
Charcot in various brain diseases.

Sacral eschars .—Less deep, but of greater superficial extent than
those occurring on the buttocks. They are usually connected with foci
of acute myelitis in the region corresponding to the second sacral nerves.
This view is corroborated by the fact that concomitant lesions have been
described on the antero-external surface of the leg and the dorsum of
the foot—regions likewise innervated by the second sacral.

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CLINICAL PSYCHIATRY.

I907.]

41 I

Neuritic eschars .—Due to a peripheral neuritis. If occurring in the
sacral region they are difficult to differentiate from the last type.
Lesions of this nature have also been described as a sequel of certain
abdominal operations in women, and have been proved to be due to a
subsequent neuritis.

Chemical and physical agencies (irritation, contusion, pressure) can¬
not be regarded as the sole causes. Eschars do not occur with the
same frequency in patients other than general paralytics, though these
may have similar habits, and be treated in the same manner. Similarly,
they occur in parts not subject to pressure, and even in patients who are
not bedridden.

As regards the trophic factor—are these centres devoted to the nutrition
of the skin, or are the vaso-motor centres those chiefly concerned ? The
existence of the former, upheld by Samuel and Charcot, has been
denied by Chantemesse. The vaso-motor theory has been defended
by Durante.

The author reaches the following conclusions : General paralytics, as
a result of the general alterations in the nervous system, viewed
especially in their vaso-motor aspect, are predisposed to gangrenous
cutaneous lesions—which occur under the influence of occasional
causes (pressure, maceration, local infections, etc.). Eschars of this
nature are preventable by antiseptic and hygienic measures. But there
are eschars of another type, arising from myelitis and peripheral neuritis.
These are apparently independent of the secondary causes above men¬
tioned—and are not preventable. Bernard Hart.

Hysterical Laughter [Le Eire Hystirique\ (Journ. de Psychol . norm,
et Path., November , 1906.) Ingegnieros , J.

(I) General psychology of laughter. — Laughter is not a simple
phenomenon, but a complex, and its elements may be combined in
various ways. These elements may be divided into three main groups :
(a) Expressional, ( b ) emotional, (c) intellectual, (a) The expressional
dement consists of certain movements of the muscles of physiognomy,
together with short expiratory movements, apparently depending on
reflex contractions of the diaphragm. In the child, the idiot, and the
dement, laughter may be limited to this expressional element, as a phe¬
nomenon of cerebral automatism determined by imitation, or as a
simple reflex. Such a laugh is a motor phenomenon without psycho¬
logical significance. (£) The emotional element consists in a certain
special state of the organism determining an emotion of pleasure, (c)
The intellectual element consists in a perception of the ridiculous, or
laughable in the exciting, idea. It may be accompanied by neither of
the preceding elements, and, according to Ribot, is the highest stage in
the evolution of the laugh.

(II) General psycho - pathology of laughter. — (a) Pathology of the
expressional element ; Here should be placed the spasmodic laughter
of hemiplegics, tics, the hysterical laugh, etc.; ( b) Pathology of the
emotional element: cases of dissociation or disproportion between the
emotional state and its expression, e.g. y the laugh which occasionally

EPITOME.

412

[April,

accompanies grief; (c) Pathology of the intellectual element: laughter
due to morbid logic or morbid perception, obsessions, etc.

(III) Clinical classification of hysterical laughter .—It may be divided
into two groups according as it occurs: (1) as an epiphenomenon of
the convulsive attack; (2) as the sole phenomenon. In the first group,
the laugh may occur as an aura, as a complication of the fit, or as a
symptom of its involution. In the second group, the laugh may alternate
with convulsive attacks, or may altogether replace them.

(IV) Differential diagnosis . — One frequently encounters forms of
laughter in degenerates, neurasthenics, and psychasthenics, which may
cause some diagnostic difficulties. The distinguishing features of
hysterical laughter are its irresistible and uncontrollable nature, the
fact that the disturbance is limited to one functional centre, inde¬
pendently of the rest of the personality, the subsequent existence of
amnesia, and the presence of other hysterical symptoms.

(V) Treatment by hypnotic suggestion. —The author describes an

illustrative case in detail. After the induction of hypnosis it was
suggested to the patient that an attack would be produced by pressure
on the temples, and inhibited by grasping the wrist. This was com¬
pletely successful, and, by a further suggestion, the patient was induced
to voluntarily seize her own wrist, and thereby abort the attack.
After hypnosis had passed off the same suggestions were repeated in
the waking state. Under this treatment the attacks gradually diminished
in number, and finally ceased. Bernard Hart.

Metital Diseases in Tropical Climates [Les Maladies Mentales dans les
Climats Troficaux], (XV e Congris International de Midicinc ,
Lis bourne, 1906.) Moreira, and Peixoto , A.

Medical geography has lost much of the significance which was at
one time ascribed to it. Formerly, each region of the earth was sup¬
posed to possess diseases peculiar to itself, but this view has been
largely dissipated by a better clinical and etiological knowledge. There
are, therefore, no essentially tropical mental diseases—we are only
entitled to assume the existence of clinical varieties.

In the present paper, tropical regions are understood to be those
intervening between the isotherms of 20° C. north and 20° C. south.
Most of the observations referred to have been carried out in Brazil.

Esquirol thought that insanity was less frequent in hot climates
than in the temperate zones. The authors do not agree with this, nor
have they been able to substantiate the view that, in a given district,
changes in temperature and in weather produce definite effects in the
insane.

As regards idiocy, degeneracy of various kinds, and the senile
psychoses, the cases do not differ, either in frequency or in form, from
those occurring in Europe. The number of imbeciles amongst the
descendants of individuals suffering from ankylostomiasis is very note¬
worthy. Hysteria is frequent in Brazil, but not more so than in Europe.
Occasional epidemics of astasia-abasia have been described. Epilepsy
is widespread, and the authors have noted the frequency of alcoholism
in the parents. Paranoia, taken in the limited sense employed by

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SOCIOLOGY.

413

1907.]

Kraepelin, accounts for 11 per cent . of the total cases, while alcoholic
forms include 28 per cent .—a frequency comparable to that of Paris.
The cases assigned to manic-depressive insanity (6 6 per cent.) differ
from the European statistics in that rather more women are affected
than men, and in the generally later age of onset. Dementia praecox
is common, 12 per cent. , as compared with Kraepelin’s estimate of 14
to 15 per cent .

General paralysis is comparatively rare, but is becoming more preva¬
lent Very few cases were observed in women. The authors consider
its frequency to depend on the state of civilisation and not on climatic
or ethnological conditions. Syphilis is widespread, but seems to tend
to relatively benign skin lesions, and to spare the nervous system. It
was present as an antecedent condition in 80 per cent . of the general
paralytics.

Latah and amok are not really distinct morbid entities, nor are they
peculiar to tropical climates. Latah is a variety of hysteria, and similar
manifestations occur in European countries. The term “ amok ” is
vaguely employed for any form of impulsive violence followed by
amnesia. In most cases it is to be regarded as a manifestation of
epilepsy.

As regards the influence of the tropics upon emigrants, the authors
consider that the health of an individual is mainly dependent upon
adhesion to the rules of life necessitated by the climatic conditions.
They have not observed the frequency of insomnia described by
Daubler and Rasch. Bernard Hart.

4. Sociology.

On the Belief in Demoniac Possession \Uber den Glauben an die

Besessenheit\ (. Allgem . Zeits. f Psychiatry Bd. Ixiii , H. 1.) Be hr.

Dr. Albert Behr has a learned paper of forty pages upon the medical,
religious, and metaphysical aspect of this ancient belief. The influence
of bad spirits upon men’s minds was unknown to the Greeks and
Romans. It came from the East, and was accepted by the Christian
church. Dr. Behr considers that such a notion is no essential part of
Christianity, in which he follows Schleiermacher. The belief that bad
spirits can affect the minds of men is, however, accepted both by the
Catholic and Protestant churches. Exorcism is still practised in the
Catholic church. Behr mentions a case in Austria where a layman was
employed to drive demons out of a woman at the rate of two-pence-half-
penny for each devil. In the year 1896, a person believed to be pos¬
sessed was fettered and the exorcists knelt upon the unfortunate, chanting
loud prayers till death released him. In 1848, near Dantzic, a witch
was thrown into the sea and drowned, and in Mexico, as late as 1874,
a sorcerer was burned.

The belief in Satan, and the mischief which he works, still holds good
in Protestant Germany, especially amongst the country people. Demoniac
possession has been defended by some modern theologians. Behr cites
a book by P. Oern, in which the author, who is not unacquainted with

414

EPITOME.

[April,

psychology, argues that it still occurs. A strange will, more or less dis¬
tinct, comes between the body and the mind of the subject, always
aiming at the disquiet and destruction of men and opposing Christ and
his word.

Against, beside, or under this foreign will may be recognised the will
of the real Ego. It is not always those who might seem most disposed
to such influences who become possessed. Sometimes they are persons
who do not talk or indulge in fancies about the devil. Oem regards
opposition to religion as due to the action of a strange will—a Satanical
power. He gives an instance of what he believes to be demoniac pos¬
session in a lunatic, and, indeed, one setting out upon his hypothesis
would soon find more in any asylum.

Such influences are scarcely recognised in modern psychiatry. Yet
there are many cases where a sejunction of the personality takes place.
The patient recognises impulses different from his own, has new tastes,
and unwonted feelings, and his character undergoes a change. Some¬
times he attributes this to bad spirits, sometimes to electricity,
magnetism, hypnotism, telepathy, or other occult influences.

Dr. Behr gives a good example : Mrs. B—, whom he has observed
for seven years, was subject to religious delusions and a lively sense of
sinfulness ; later on she believed that a bad spirit lived within her
occupying especially the cavity of the heart. This spirit compelled her,
to do everything which he ordered ; she felt him within her and heard
him speak. He does not speak in her ear, but clearly and distinctly
using her own vocal organs. There are disputes between the bad spirit
and the woman ; she speaks and the spirit answers. She believes that
she has been bewitched by three bad women, and has asked the
assistance of a physician to get escape. Dr. Behr, with great analy¬
tical skill, explains these symptoms as follows: In all men, there are
many organic processes which go on below consciousness, but in certain
nervous conditions these functions lose their unconscious character, and
push themselves into notice, and influence the course of ideas. As long
as the intellect retains its activity the patient recognises these as the
results of disordered sensation; but when the intellect becomes impaired
these disorders—sensory impressions—become the origin of false con¬
clusions and delusive impressions. Under the influence of diseased
mental activity are evolved the errors of the hypochondriac or the
paranoiac, according to the disposition of the subject.

In this patient, there are also observed movements in the muscles of
expression and articulation—the outward manifestations of the delusions
and deranged activity within. Lehmann has shown that in any vivid
thought there is a tendency to accompany the ideas with articulate
words. This is done in a tone so low as to be almost imperceptible.
In other cases there is a slight motion of the vocal organs, which can
only be ascertained through very close examination.

With some minds, there is an irresistible longing to grope into the
unseen, which, in default of Satanic agencies, men have sought to
gratify by animal magnetism, clairvoyance, telepathy, spirit-rapping, and
other curious inquiries. There is a large and widely diffused literature
treating of these subjects. As Behr observes : “ Both Satanology and
transcendental mysticism have this in common—that they teach the

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SOCIOLOGY.

4*5

invasion of an invisible agency into our world. In Satanology there is
recognised the hostile attacks upon men through the Prince of the
World and his emissaries. In occult lore, the main doctrine is the influ¬
ence of the transcendental subject upon living men.” As DuBrel ex¬
plains in the journal called The Sphinx : 4< Man lives at once on this
side as a living man and on the other side as a transcendental subject.
This side and that side are not separate in space, but divided at the
threshold of perception (Empfindungsschwelle). That side is this side
in another aspect. In exceptional circumstances, as in somnambulism,
the powers and capacities of the transcendental subject become known
to us, and we can recognise the earthly and the transcendental halves
objectively and examine them experimentally. The magical powers of
the transcendental subject are exerted in particular directions, as in
consciousness of the supersensible (the clairvoyance of the somnam¬
bulist) and the magic of the will. This shows itself as the black, harmful
magic in sorcery and witchcraft and as beneficent magic in the religious
mysticism of saints and prophets.

Thus the churches and the occult philosophers have some grounds
on which they may agree, though the latter have wandered beyond the
paths of orthodoxy. In fact, a mystic may be defined as one who has
the capacity for believing what he wants to believe in spiritual matters.
Dr. Behr complains that too little attention is paid to the professors of
occult philosophy, who have accumulated a large number of observations,
which, in default of criticism, are allowed to pass. Esquirol devoted a
large chapter to demonomania, whereas in modern handbooks it is
passed off with a few lines. He recommends for study the work of
Jung— Zur Psychol^ m. Pathol . Okkulter Phanomenc, 1902—which con¬
tains an account of the whole literature of the subject.

William W. Ireland.

Ten Years 1 Family Care of the Insane in the Province of Saxony
( Allgem . Zeits. /. Fsychiat., Bd. Ixiii, H 3). Alt.

Dr. Alt, of Uchtspringe, gave to the Psychiatric Society of Lower
Saxony and Westphalia the result of his experience of the boarding out
of lunatic patients in families. He recalls that ten years before he had
maintained that in this province there were many hundreds of patients
who would be more fitly treated in selected families than in the best
regulated asylum. He considers that the boarding out can be put in
use in most districts if the leading physician is willing to take an active
interest in it During the ten years trial the number of boarded out
patients in the Province of Saxony has risen to 475. At first the
practice was confined to families in the village of Vilhelmseich, in the
neighbourhood of an asylum, and gradually spread to the surrounding
districts. In February, 1900, the Land-Tag voted an extension of the
permission to board out into further localities. Dr. Alt remarks that
the question whether suitable patients are better treated when boarded
out amongst families than in a good asylum may be answered by a visit
to these family colonies. He does not specify the kind of patient cared
for in them. William W. Ireland.

416

EPITOME.

[April,

Medico-legal Report on the Menial State of a Poisoner [.Expertise
Midico-ligale au Sujet de PEtat Mental de la Femme De K —,
Privenue cP Empoisonnemcnis\ {Bulletin de la Soc. de Mid, Ment.
de Belgique , No. 126, Aprils 1906.) De Boeck andde Rode.

The case reported in this paper is chiefly interesting on account of
the length of time which intervened between the morbid impulses
leading to the crime and the development of obvious intellectual
disorder. The criminal, whose age is not stated, poisoned her three
children with arsenic, which she had purchased three weeks previously
under the pretence that she wanted it for rats. From the date of her
last confinement, which occurred about four and a half or five months
prior to the crime, she had been in low spirits, believed that she was
suffering from phthisis, talked of her impending death, and of her
intention to take her children away from misery with her. The day of
the crime, after a sleepless night, she went to church, where her pre¬
occupied appearance attracted the notice of her neighbours. She
attended to her usual household duties for some hours, and then gave
the poison to the children. When they began to be ill she admin¬
istered remedies and sent for the doctor. At first she pretended that
the affair was an accident, but soon after admitted her guilt, stating
that she had bought the arsenic for the purpose of killing the children,
but that the idea had left her mind until that morning.

There was nothing of note in the family history, except that her
mother died of phthisis. Nor did the woman’s own history present
any remarkable features. She had suffered, however, from a good deal
of worry owing to the adulterous relations of her husband with her
sister, but this liaison had been broken off some considerable time
before the crime. Beyond a very marked degree of facial asymmetry
and a defective frontal development, she presented no stigmata of
degeneracy. Her physical health appeared good, but there was some
rough breathing at right apex. Questioned on the subject of her
crime, she replied with clearness and accuracy, though rather hesi¬
tantly. She explained her action as she had done immediately after the
affair, saying that her children were sickly, that she was not going to
live, that by killing them she was sending them to Heaven; she added
that she did not take the poison herself because she would have been
damned. For two weeks no change occurred in her mental condition,
but she then rapidly developed symptoms of hallucinatory confusion of
an acute type. As the case is in many respects of much psychological
interest, it is to be regretted that the authors have not reported it in
more detail, especially with regard to its later phases.

W. C. Sullivan.

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* 907-3

NOTES AND NEWS.

417

Part IV—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN
AND IRELAND.

A Quarterly Meeting of the Medico-Psychological Association was held at
the Notts County Asylum, Radcliffe-on-Trent, on February 22nd, 1907, at 3 p.m.,
under the Presidency of Dr. Robert Jones.

Among those present were Drs. T. S. Adair, M. T. Archdall, H. T. S.
Aveline, Bedford Pierce, C. Hubert Bond, David Bower, James Chambers,
Maurice Craig, Thomas Drapes, A. J. Eades, A. Ewan, W. J. A. Erskine,
H. Hayes Newington, C. L. Hopkins, C. R. Hitchcock, Robert Jones, T. L.
Johnstone, C. H. G. Lyall, A. Miller, H. J. Mackenzie, P. W. MacDonald, David
Orr, M. E. Paul, R. G. Rows, R. C. Stewart, R. H. Steen, A. R. Turnbull, F. R. P.
Taylor.

Apologies were received from Drs. Bruce, Bolton, Clouston, Mercier, Marr,
Menzies, McDowall, Nolan, Outterson Wood, Percy Smith, Seymour Tuke,
Urquhart, Whitwell, Yellowlees.

The minutes of the previous quarterly meeting were read and confirmed.

The following were elected ordinary members: Jex-Blake, Bertha, M.B.,
Ch.B.Univ. Edin., Assistant Medical Officer, County and City Asylum,
Hereford (proposed by C. S. Morrison, Robert Jones, and C. Hubert Bond);
Rivers, William Gregory, M.B., Ch.B.Univ. Edin., Assistant Medical Officer,
Cornwall County Asylum, Bodmin (proposed by Francis Dudley, Geo. Harman,
and C. Hubert Bond).

The President made sympathetic reference to the death of Dr. McDowall, of
Menston, and acknowledged the help he had received from him in the opening
of Claybury Asylum. He also made mention of the severe domestic trouble that
had befallen Dr. Needham in the recent death of Mrs. Needham. It was resolved
that votes of condolence from the Association be conveyed to the widow of Dr.
McDowall and to Dr. Needham. It was also resolved that to Dr. Percy Smith
and Mr. Harold Urmson (Legal Lunacy Commissioner) the sincere sympathy of
the Association be conveyed in connection with the severe illnesses that have
overtaken them.

The President announced that the dates of the Annual General Meeting had
been fixed for the 25th and 26th of July, and that it would be held in London. He
also intimated that the date of the next quarterly meeting had been altered to
Thursday, May 16th.

The President said he thought members might like to know that reprints of Dr.
Bevan Lewis’s address “ On the Formation of Character,” which was delivered to
nurses at the York Retreat, may be obtained on application to the publishers,
Messrs. Adlard and Son.

At the request of the President, the Honorary General Secretary showed a
complete set of the “ Compilation Forms” which have been prepared to facilitate
the compilation of the new Tables, and also a complete set of the new Tables
themselves, printed on a sufficiently large scale to enable compilers to enter the
figures in manuscript. He explained how it was intended they should be used in
connection with the new Registers, namely, the Medical Register, the Discharge
and Transfer Register, and the Death Register, which in England and Wales
have become statutory.

In reference to the resolution submitted by Dr. Clouston “ That the meetings of
the Council for the future be held either on Saturdays or Mondays,” the President
said that Dr. Clouston suggested this on account of the difficulty there was in
getting a cheap return ticket allowing of a stay of two or three days in London.
The matter, he said, had had the full consideration of the Council that morning,
and the Council had asked the Treasurer to go fully into the matter, and to make
LIIL 28

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418

NOTES AND NEWS.

[April,

inquiries of the various railway companies in the United Kingdom to see if they
would allow facilities in the middle of the week corresponding to those they now
allowed from Saturday to Monday or Friday to Tuesday. He hoped this would
meet the views of those who came from Scotland.

Dr. David Orr and Dr. R. G. Rows, Pathologists to the Prestwich and
Lancaster Asylums, then gave their joint lantern and microscopical demonstra¬
tion on the “ Experimental Production of Spinal and Cranial Nerve-lesions by
Toxins,” see page 367. The importance of their contribution was fully appre¬
ciated.

Before separating the President said there were two further matters he should
like to refer to, first, they had lost by death in America, Dr. A. E. MacDonald. He
was in great sympathy with their Associaton, and at the time of his death a corre¬
spondence was going on between him and Dr. Bond with regard to the establishment
of a joint meeting of the two Associations—the British and the American. He was
sure they would unanimously pass a vote of condolence with his widow. Secondly,
they must be grateful to their host, Dr. Jackson, and also to his sub-committee, for
the privilege they had had of seeing over this new asylum. He thought that these
provincial meetings of the Association were a very happy way of forming acquaint¬
ances and of strengthening ties of friendship. The Association had afforded to
members, for many years past, opportunities of seeing friends and talking over
their work and the progress which science was making in their fuller understanding
of mental diseases and their treatment. He had himself walked through the
asylum under Dr. Jackson’s superintendence, and he was able to compliment him
on the comfort and the excellent appearance of his asylum, showing that not only
was he doing good work, but that he was supported by very able officers. He
trusted that they would unanimously agree to pass a cordial vote of thanks to the
Sub-committee of the Asylum, and also to Dr. Jackson, and to ask the latter to
convey the same to the governing authorities.

Dr. Stewart (Leicester) seconded. He said he had had the pleasure of visiting
the Asylum four times, and he should like to say that Dr. Jackson had had very
uphill work in bringing the Asylum into the condition in which they saw it, and
he congratulated him on such an excellent result.

The resolution was carried unanimously.

Dr. Jackson, in acknowledging the vote of thanks, said that he very highly
appreciated the honour the Association had done him by visiting the Asylum.

In the evening between twenty and thirty members dined together at the George
Hotel, Nottingham, and entertained several guests from the neighbourhood.

IRISH LUNACY LEGISLATION.

At a meeting of the Lunacy Legislation (Executive) Sub-committee held at the
rooms of the Association, 11, Chandos Street, Cavendish Square, W., on
Wednesday, April 3rd, 1907, it was resolved unanimously—

“That in view of pending Legislation for Ireland, likely to affect Lunacy
Administration, the following considerations should be placed briefly before the
Chief Secretary:

“1. That the usual method of Certification for admission into the Public
Asylums in Ireland is unsatisfactory and requires amendment.

“ 2. That facilities should be provided for the Admission of Voluntary patients
or boarders into all Asylums in Ireland.

“3. That provision should be made for Boarding out Pauper patients in
private houses as is done so successfully in Scotland.

“ 4. That the Chronic Insane of the harmless class should be treated in Annexes
to existing Asylums in preference to workhouses or other institutions
with separate administrations both on the ground of efficiency and
economy.

11 5. That the provisions of the English Idiots Act, 49 and 50 Viet. c. 25, should
be extended to Ireland.

“6. That the qualifications of the Resident Medical Superintendent of an
Asylum set out in S. 24, clause 2, of the Local Government (Ireland) Act
of 1898 should be retained, and the mode of Election of Asylum Medical

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1907.] NOTES AND NEWS. 419

Officers, together with their status and powers should be clearly defined
by Statute.

“7. That in order to secure a better class of Nurses and Attendants, and thus
promote the better care and supervision of the patients under their charge
the Superannuation of the Officers and Staff of every Public Asylum in
Ireland should be made compulsory, and—

“8. That with their extended duties and responsibilities an increase in the
numbers and powers of the Inspectors of Lunatics in Ireland is
necessary.”

OBITUARY.

F. K. Dickson, M.D.

By the death of Dr. Francis Kennedy Dickson, of Wye House, Buxton, the
Association loses one of its senior and widely respected members, who, by his
character and social position, reflected honour upon it. Dr. Dickson was not
alone the successful superintendent of a private asylum, but a man who took a
strenuous part in all the social work of his district. He was an active Justice of
the Peace for the county of Derbyshire, second in seniority on the Buxton Bench,
and Chairman of the Licensing Committee. He was Senior Consulting Physician
to the Devonshire Hospital, an active supporter of the Buxton and District
Nursing Association, and took an active part in many other local movements and
interests.

Dr. Dickson was Honorary Acting Medical Officer to the Devonshire Hospital
and Buxton Bath Charity from 1865 to 1878, and succeeded his father as proprietor
of Wye House, which post he held for upwards of thirty years.

His death occurred suddenly on the evening of February 2nd, after a brief
indisposition of two days only, in his sixty-fourth year, and the great esteem in
which he was held was manifested by the attendance at his funeral of representa¬
tives of the many public bodies with which he had been associated, as well as by a
very large number of friends.

James Edmund Huxley, M.D.St.And.

It falls to my lot to record the death in February last at Maidstone of this
gentleman who, in point of age, was the doyen of public asylum superintendents
in England. . He was the elder brother of the late Prof. T. H. Huxley, President
of the Royal Society. He was in his eighty-seventh year, and had been in receipt
of a pension of ^300 a year from the Kent County Authorities since the year
1863, and during that long period of retirement had resided at 39, Upper Fant
Road, Maidstone, near the scene of his former labours. I believe he commenced
his professional career as Medical Superintendent of the old Marylebone Infirmary,
then became for a short time Medical Superintendent of the Gloucester County
Asylum, from which he was elected Medical Superintendent of the then compara¬
tively new Kent County Asylum at Banning Heath, near Maidstone, where he
was often visited by his two brothers—the late Professor Huxley, and the youngest,
a rising barrister, who died at a comparatively early age. All were highly talented
men, but of the three the youngest was the most gifted, and I have heard that to
spend an evening in their company was a great intellectual treat. Dr. James
Huxley was an original member of our Association, and his name appears
frequently in the first number of the Journal of Mental Science, then designated the
Asylum Journal , to which, among other contributions, he communicated a paper
on the Kent Asylum at Banning. Being of a retiring disposition he did not
take an active part in the official work of the Association, and later on, when his
Health failed somewhat, his interest also declined. Amongst his Assistant Medical
Officers were the late Dr. Wm. Charles Hills, afterwards, for many years,
Medical Superintendent of the Norfolk County Asylum, and the late Dr. Robert
Spencer, the first Medical Superintendent of the Kent County Asylum at
Chartham. Dr. James Huxley retired at an early age (43) in consequence of ill-
kealth, and lived the quietest and most secluded of lives. He was twice married
and leaves issue.— Ernest W. White.

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420

NOTES AND NEWS.

[April,

Ebenezer Toller, M.R.C.S.Eng.

We regret to record the death of Mr. Ebenezer Toller, formerly Medical
Superintendent of the Gloucester County Asylum. Mr. Toller received his
medical education at King’s College Hospital, and took the diplomas of
M.R.C.S.Eng., 1857, and L.S.A., 1858. He forthwith devoted himself to the
study of mental diseases, and held in succession the posts of Assistant Medical
Officer at St. Andrew’s Castle Licensed House and Colney Hatch Asylum.
Thereafter he was appointed Medical Superintendent of St. Luke’s Registered
Hospital, and later of the Gloucester County Asylum. The latter post he held
from 1863 to 1882, when, owing to ill-health, he was compelled to resign.

Mr. Toller strongly advocated the carrying out of the treatment of the insane in
as home-like surroundings as possible; he did much to popularise the provision of
entertainments for the inmates of asylums, and he himself was musical and
athletic. He was a Fellow of the Royal Meteorological Society, and during his
residence at Gloucester he made systematic meteorological observations. He had
five sons, of whom only one survives him.

NOTICES BY THE REGISTRAR.

List of the successful candidates at the examination for the Nursing Certificate
held in November, 1906.

Pretoria, S. Africa. —Males: Percy William Robert Smith, William Herbert E.
Stanford, Harry Thomas. Females: Elizabeth C. Forsyth, Catherine Boothwick.

Valkenberg, S. Africa. —Male: Stephen H. Creaghe. Females: Frances May
Scott, Hilda Domarns, Helena Hume.

Londonderry. —Males : James Mullan, John McBride.

Omagh. —Male: James Kelly. Females: Minnie Duffy, Maggie J. McEntee,
Catherine Coyle, Susan E. Patterson.

Portrane. —Females: Alice Culverwell, Lissie Donoher, Mary Gaffney, Nora
Murphy, Mary Ryan, Delia Duffy.

Birmingham , Rubery Hill. —Males: Robert J. Hardwicke, Robert James Downes,
George Greaves, Edwin James Dyer, John Henry Timings.

Derby Borough. —Males: George Barlow, Edwin Hill. Female: Gertrude
Shaw.

Leavesden. —Males: James Ubut Stayton, Albert James Yendell, Charles
Hammond, Robert V. Youens. Female: Florence E. Batchelor.

Retreat , York. —Male: John Duff. Females: Jessie C. Vowles, C. Annie
Atkinson, Lucienne J. Chaure.

Holloway Sanatorium. —Males: George Read, Gilbert L. Robinson, Charles
Oakey. Females : Edith E. Cornell, Mary H. Bennett, Annie M. B. Macartney.

Fife and Kinross. —Males : John Honeyman, William McDougall.

Gartloch. —Females : Annie Christie, Isabella S. Moir, Bella H. Drummond,
Marion McDonald, Elizabeth McHarg, Margaret Ann McDonald.

Glasgow District. —Male: Archibald Macdonald. Females: Annie Spalding,
Georgie S. Coventon, Hannah Graham, Christina McLuckie, Mary McDougall
Hemphill.

Inverness District .—Male: John Henderson. Females: Annie Connolly,
Margaret Helen Reid, Mary McMillan, Isabella W. Drummond.

Lanark District. —Male: John McDonald. Females: Beatrice Bell, Agnes M.
Gourlay.

Perth District. —Female: Christian MacGlashan.

Riccartsbar. —Male: Robert Gow. Females: Clara Leighton, Jennie T. Sim.

Stirling District. —Female : Elizabeth B. Reid.

Bangour Village. —Female : Jessie C. Forsyth.

Craig House. —Males: Neil Lockhart, Edward McMunn. Females: Mary
Scrimgeour, Agnes Haston, Martha P. Pearson, Margaret Ann Pollock, H.
McEndoo.

Morningside. —Males: James Cameron, David Coghill, William McHardie,
Alexander McLeod. Females: Kate M. Leighton, Annie Low, Jessie McPherson,
Agnes Simpson, Mary Strachan.

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NOTES AND NEWS.

421

1907 .]

Sir James Murray's House , Perth. —Female : Isabella Rutherford.

Private Nurse. —Female: Tina M. McLennan.

Essex County. —Female: Elizabeth James.

Salop County. —Female: Rebecca Davies.

Warwick County. —Males: Wilfred S. Hall, Frank Dimmock. Females: Mary
J. Banahan, Annie Davies, Maggie J. Donoher, May Handley, Annie Ward, Anna
Muller.

Private Nurse. —Female: Florence E. Royston.

The following is a list of the questions which appeared on the paper :

1. Enumerate the bones which enter into the formation of the Thorax, and
state what organs that cavity contains.

2. Describe generally the structure and function of Muscle.

3. What is meant by reflex action, and how is it distinguished from voluntary
action ?

4. What symptoms occurring in a patient would point to the possible existence
of Heart Disease ?

5. Indicate the chief points in the modern nursing of a case of pulmonary con¬
sumption.

6. What symptoms are likely to arise in a case of General Paralysis requirin g
special care on the part of a N urse ?

7. What routine measures would you use in order to see that patients have not
escaped from observation ?

8. Describe the management of a patient in an Epileptic fit.

9. Describe the application of the wet pack.

10. What is meant by exaltation of blind, and how is it shown ?

Examination for the Nursing Certificate.

The next examination will be held on Monday, May 6th, 1907.

The last day on which schedules can be received will be Monday, April 8th,

1907.

NOTICES OF MEETINGS.

Annual Meeting .—The next Annual Meeting will be held in London on July
25th and 26th, 1907.

Quarterly Meeting. —The next meeting will be held in London on Thursday,
May 16th, 1907.

South-Eastern Division. —The Spring Meeting will be held, by the courtesy of
Dr. Taylor, at the East Sussex County Asylum, Hellingly, on April 17th, 1907.

South-Western Division. —The Spring Meeting will be held, bv the courtesy of
Dr. Morrison, at the County and City Asylum, Burghill, Hereford, on April 18th,

1907.

Northern and Midland Division. —The Spring Meeting will be held, by the
courtesy of Dr. Perceval, at Prestwich Asylum, on April 18th, 1907.

APPOINTMENTS.

Donaldson, R. Lockhart, B.A., M.D.Dublin, Resident Medical Superintendent
of the Monaghan and Cavan District Asylum, Monaghan.

Edgerley, Samuel, M.D.Edin., Medical Superintendent of the West Riding
Asylum, Menston.

Garden, W. Sim., M.B., B.Ch.Aberdeen, Second Assistant Medical Officer,
Menston Asylum, Leeds.

Lord, John R., M.B.Edin., Medical Superintendent of the London County
Asylum, Horton, Epsom.

Martin, H. C., M.B., Ch.B.Edin., Assistant Medical Officer at the Newport
Borough Asylum, Caerleon, Mon.

Smith, Win. M., M.D., M.R.C.P.Edin., Senior Assistant Medical Officer at
Barnsley Hall Asylum, Bromsgrove.

LIII.

THE

JOURNAL OF MENTAL SCIENCE

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

No. 223 [X’lST] JULY, 1907. Vol. LI 11.

Part I.—Original Articles.

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

PART III.— DEMENTIA [continued).

PAGE

[Introduction . lii. 221]

(the general pathology of mental disease and the functional regions of

the cerebrum . .lii. 224]

[Menial confusion and dementia .lii. 428]

[Varieties of dementia . lii. 711]

Group I —Primarily neuronic dementia ...... lii. 716]

[(a) Senile or ** worn-out ” dementia . lii. 717]

[(b) Presenile or " climacteric" dementia . liii. 84]

[(c) Mature or “ adult” dementia ...... liii. 107]

(d) Premature dementia (dementia preecox) ..... 423

(1) Approximately “ hebephrenic ”.440

(2) Approximately “ catatonic ”.451

(3) Approximately " paranoid ”.463

Group II —Progressive and secondary dementia ......

Group III — Special varieties of dementia ....

Group I.—Primarily Neuronic Dementia.

Class (d).

Premature Dementia (.Dementia Preecox).

The present class, to which is here applied the term “ premature
dementia,” differs from the three classes of primarily neuronic
liii. 30

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424

AMENTIA AND DEMENTIA,

[July,

dementia, which have already been considered, in the fact that,
owing to its re-cognition by Kahlbaum and to the attention
drawn to it by Kraepelin, its types and their symptomatology,
even to the minutest detail, have been described and detailed
in an extensive literature. It is not the purpose of this paper
to give a complete historical account, or even a general descrip¬
tion, of this variety of dementia; the object of the writer is
rather to treat it as the compeer of the other three classes of
primarily neuronic dementia which have already been dealt
with. He therefore proposes to limit himself to a general
reference to those especial details of symptomatology which for
his purpose are of importance, and to certain generalisations on
the entire subject of premature dementia. Where he agrees
with the observations and conclusions of previous writers he
does not claim priority by omitting references to these, for he
takes it for granted that readers of the present paper are neces¬
sarily familiar with, at any rate, the more important literature
on the subject, and where he differs from present opinion he
trusts that the general trend of this communication will uphold
the views he expresses. Such a course is the only possible one
to adopt in a contribution which has already become of inordi¬
nate length. The relative baldness of the descriptions, in view
of the immense literature available, is thus intelligible, and he
hopes excusable, for his account of the variety of primarily
neuronic dementia at present under consideration is merely
intended to run pari passu with those of the preceding classes,
which classes are, in his opinion, equally important from the
psychiatric aspect, though they have hitherto not received
adequate recognition.

The term “dementia praecox” has of late years been employed
so extensively with reference to almost every type of insanity
occurring between puberty and maturity, and so much doubt
therefore exists as to its exact connotation, that the writer has
considered it desirable to here make use of the alternative
cognomen of “ premature dementia.”

Many cases of adolescent insanity, with relatively little
mental confusion, recover sufficiently for discharge either as
“ recovered ” or to the care of their friends, and are then often
able, on a lower mental level, for long periods of time, or per¬
manently, to sustain without injury the ordinary environment
of the sane. Other cases, which are really examples of high-

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1907] BY JOSEPH SHAW BOLTON, M.D. 425

grade amentia of relapsing type—though, except for the absence
of mental confusion, they bear a close resemblance to certain
of the confused cases—also recover, at any rate for the time.
Further, a few examples of the “ hysteria ” class of high-grade
amentia, which exhibit cataleptoid phenomena but no mental
confusion, also recover, and thus even the grave symptom-
complex commonly referred to as “ catatonia ” is credited with
a number of recoveries. The first only of these types furnishes
examples of mild premature dementia, but cases belonging to
all three are often referred to as “ recoveries ” from dementia
praecox, and thus certain writers object to the employment of
the term “ dementia ” to connote a symptom-complex which
furnishes a quota of cures.

As will be seen later in this section, the writer is strongly of
opinion that uncomplicated examples of premature dementia
(in which the preliminary mental confusion is not precipitated
by a primarily toxic, and therefore removable, cause) invariably
exhibit a degree of mental confusion during their initial phases,
which is roughly proportionate to the grade of dementia which
ensues, and that recovery without some grade of dementia
does not occur. He therefore employs the term “ premature
dementia,” as a co-ordinate of the terms “ mature,” “ presenile,”
and “senile or ‘worn-out* dementia,” to describe the cases of
primarily neuronic dementia which occur during the period of
life which is limited by puberty on the one hand and maturity
on the other, and which exhibit during their initial phases a
certain, and often a severe, grade of mental confusion.

The class of premature dementia, as thus defined, includes
all cases which undergo a greater or lesser degree of neuronic
dissolution, with consequent stationary dementia, between the
ages of puberty and maturity.

A large proportion of these cases break down, not only under
the influence of the metabolic disturbances which are associated
with the former and “critical” period of life, but also, and
probably more often, under the mental “ stress ” involved in
the general change in the functions of the cerebrum from the
mere acquisition of information to the performance of the higher
processes of mind—namely, the orderly aggregation and selec¬
tion of facts, the co-ordination of these into suitable sequences
of ideas to enable judgments to be evolved, and the turning of
acquired information to practical uses—which change of cerebral

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426 AMENTIA AND DEMENTIA, [July,

function also commences about the period of puberty. Under
this “ stress,” cases possessing higher cortical neurones of
deficient durability go to the wall.

It is thus readily intelligible, in fact obvious, that this class
must include, not only cases of relatively high mental capacity,
whose cerebra have, by over-study and intense application, been
strained beyond their breaking-point, but also numbers of
degenerates who, under the influence of “stress,” which would
be sustained without injury by normal subjects, have similarly
over-strained what, in this instance, are deficiently durable
cortical neurones.

The former type of case occurs, not only in asylums, but also
in the outside world. It is, for example, common knowledge
that only a proportion of the brilliant students of medicine,
who, during their course of study, carry all before them, attain
in later life to emirlence, this term being employed in a scientific
rather than in a popular or a pecuniary sense. In the remainder,
over-strain has reduced their mental powers to a more ordinary
level, and though of, perhaps, average intelligence, “ push,” and
business capability, they are nevertheless, in a strict sense,
examples of premature dementia. This condition is not, how¬
ever, limited to individuals of unusual mental power. The
writer is not aware that he is stating anything original when he
remarks that he has seen many examples of premature dementia
in men in the possession of ordinary mental powers, who, by
dint of exceptional perseverance, have obtained the more coveted
medical qualifications, and who afterwards exhibit, not more,
and often less, ability than is possessed by quite ordinary
individuals. He is convinced that such cases are true examples
of premature stereotypism or premature dementia, which has
developed under the influence of mental strain that could not
be submitted to by these individuals without irretrievable
damage to an appreciable number of their cortical neurones;
and that the phenomena referred to are not, as is so commonly
stated, due simply to the absence of what is often described as
a “ capacity for affairs,” ora practical, in contra-distinction to a
theoretical, mind.

Between such cases and those who require asylum regime ,
and often develop enough dementia to require their permanent
detention, there is merely a difference of degree.

In the case of definite degenerates, the onset of insanity.

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1907 ] BY JOSEPH SHAW BOLTON, M.D. 427

followed by premature dementia, is more readily intelligible,
and is, in fact, appreciable even to the layman : and during the
past few years the question of the care and control of the
“feeble-minded ” has attracted much attention. It is unneces¬
sary, therefore, from its general aspects, to enter into a discus¬
sion of this subject, though a few remarks on the origin and
course of the particular type of case which commonly drifts into
asylums is, perhaps, not out of place. Of such patients, some,
after leaving school, pass from situation to situation, becoming
duller after each change, either until no employer will keep
them, or until definite symptoms of insanity supervene ; others,
under the influence of stronger minds, leave home for the large
towns, or even for distant countries, and return some years later
as premature dements ; others, by morbid introspection and the
(in many instances secondary’) development of masturbation,
acquire perverted sexual and hypochondriacal ideas, which under¬
mine their powers of application and result in their isolation in
asylums; etc. In other cases the resistance of the cortical
neurones is exceeded by intemperance in alcohol, and, in the
case of girls, married or unmarried, by the “ stress ” involved
in ordinary or illegitimate pregnancy and confinement. Any
variety of mental or physical “stress ” may, in fact, act as the
last straw, or precipitating agent, in determining the onset of
an attack of insanity, and the question of whether or not enough
dementia for the permanent detention of the patient supervenes,
depends entirely on whether a sufficiency of cortical neurones
have, or have not, undergone irretrievable damage.

Many cases of the kind recover sufficiently to gain their dis¬
charge from confinement, and return to their former environ¬
ment with mental powers of a feebler order than they possessed
before their attack of insanity. It is needless to state that such
cases usually in the course of time return to the asylum, and,
according to circumstances, repeat the process or remain as
permanent inmates with dementia. Such cases, it may be
remarked, are not to be confounded with examples of true
recurrent* insanity who do not develop dementia, but return
again and again to their accustomed avocations with unimpaired
mental powers, commonly, it is true, when in later life retro¬
gression of the cortical neurones occurs, to become permanent
inmates with, however, relatively little dementia. The remainder
of the cases under consideration do not recover, but develop

428 AMENTIA AND DEMENTIA, [July,

either a mild or a moderate degree of dementia, remaining in this
condition, owing to the absence, whilst under asylum regime , of
enough “ stress ” to produce further mental deterioration, until
normal retrogression or “ wearing out ” of the cortical neurones
ensues. Such cases differ from the types of pure high-grade
amentia referred to in the second part of this paper, solely in
the fact that the latter still possess cortical neurones in a gener¬
ally unimpaired structural condition, whereas the cerebra of the
former have undergone a greater or a lesser degree of dissolution.

It is not the purpose of the writer to deal in an exhaustive
manner with the preliminary symptomatology of premature
dementia, as the subject of the general relationship of mental
confusion to dementia has already been considered at length in
a previous section ( Journ . of Ment. Set., July, 1906, pp. 427-
490). It is, however, necessary for the purpose he has in view
to introduce certain general remarks on this subject in order to
emphasise some of the especial characteristics of the dementia
of prematurity.

Mental confusion, in the experience of the writer, exists to a
greater or a lesser degree in all premature cases which are
about to develop dementia, provided that the psychic state of
the patient is not such (1 e.g ., in certain cases of deep stupor,
etc.) as to preclude, for the time at least, the exhibition of this
symptom-complex. He has, in fact, observed, as his experience
has year by year increased, that the proportion of cases exhibit¬
ing negative motor symptoms, in which it is not possible to
determine the existence of mental confusion, has steadily
decreased as he has paid more and more attention to such
motor phenomena as the patient has been capable of originating.
It has been a relatively rare experience to meet with cases of
stupor which, on recovery, have been able to clearly describe
what has happened whilst they were in a condition of lethargy,
during which they were unable to initiate any motor response,
even to intensely painful stimuli: and such cases have hitherto,
been examples, not of premature dementia, but of recurrent or
relapsing insanity. He thus feels justified in expressing the
opinion that mental confusion exists to a greater or a lesser
degree in the preliminary stages of all cases of premature
dementia. Further, he considers that mental confusion is a
symptom of especially grave import in cases of premature
insanity, and, except in the small proportion of cases in which

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I 907 -] BY JOSEPH SHAW BOLTON, M.D. 429

primarily toxic and, therefore, removable causes ( e.g intem¬
perance in alcohol and puerperal toxaemia, etc.) exist, is invari¬
ably the precursor of a degree of dementia which is roughly
proportionate to the amount of mental confusion present. He
is thus of the opinion that the exhibition, with the above-
mentioned restriction, of mental confusion by cases of premature
insanity is of such significance as to justify an unfavourable
prognosis, and at the same time to remove the most important
objection to the employment of the term “premature dementia,”
or “dementia praecox,” provided that this cognomen be em¬
ployed, as here, solely to denote cases of premature insanity
which exhibit a more or less marked degree of mental confusion
as part of their “ acute ” or “ recent ” symptomatology.

Whilst premature dementia, from this particular aspect of
preliminary symptomatology, falls into line with the other
classes of primarily neuronic dementia which have already been
considered, it differs from these in the frequent exhibition of
such characteristic phenomena, that it is not a matter for
surprise that its study should have vastly overshadowed, both
in extent and in detail, that devoted to these other varieties, with
the sole exception, perhaps, of that particular well-known
symptomatological type now usually designated by the name of
44 Korsakow’s symptom-complex.”

Though the necessary references to these characteristic
phenomena will be made under the appropriate sub-classes into
which the cases of premature dementia under consideration
will for convenience be grouped, the writer purposes to here
interpolate a few remarks which are intended to suggest a
probable reason for their especial exhibition by the cases
belonging to this class.

This is, in brief, in the opinion of the writer, to be found in
an immature condition of the centres of association of the
cerebrum. In cases belonging to the previous classes of
14 senile,” “ presenile,” and 41 mature ” dementia, whatever be the
respective degrees of involution or dissolution which later on
result, the centres of association, both lower and higher, have
by frequent repetition necessarily acquired a capacity for
relatively stable neuronic groupings as the physical basis of the
psychic processes performed by the respective patients; and
this statement especially applies to the neuronic groupings in
the psycho-motor area, which serve as the physical basis for the

430 AMENTIA AND DEMENTIA, [July,

performance of “ skilled ” voluntary accomplishments. In
other words, in these classes, considered for the moment from
the purely physical aspect, the cerebra are completely built and
thoroughly tested machines in full running order at the time
when the breakdown is precipitated by too rapid running or by
“ wearing out.”

In the case of the class of premature dementia under present
consideration the state of affairs is very different. Here there
is, in the first place, a highly-deficient durability of the cortical
neurones; or, to continue the simile, imperfectly tempered
material has been employed for the construction of the parts:
and the neurones, or the parts themselves, are, in many instances,
imperfectly constructed. Further, though most of, or all, the
individual parts are placed in preparatory juxtaposition, even the
simpler complexes of construction have only recently and ex¬
perimentally been grouped into series. This is, in fact, the
case even in the more highly endowed patients, in whom the
higher complexes of neuronic association have already been
tentatively produced.

It is thus only to be expected that, when such a machine is
set running at high speed, all kinds of local breakdown will*
ensue. In the human cerebrum, owing to a structure which in
its complexity of construction overshadows any machine of
human manufacture, and to the numerous sources of motive
power which exist through the medium of the different varieties
of sensorial stimulation, complete breakdown is relatively rare,
though local stoppages, local anomalous groupings of the
simpler complexes, and particularly local repetitions or irregu¬
larities of action, are of common occurrence. This is especially
obvious, though not peculiar to these, in the case of the more
fundamental motor exhibitions, the patient either performing,
or not performing, or often repeating, certain actions, and
exhibiting, as the essential characteristics of these motor per¬
formances, on the one hand a tendency to uncertainty, and on
the othej a tendency to repetition, of action.

' It is an obvious deduction from the above considerations
that a more scientific classification of the types of premature
dementia should be possible than obtains in the case of the
“ senile,” “ presenile,” and “ mature ” classes of primarily
neuronic dementia. In the latter, some, at least, of the sym-
ptomatological sub-classes are without a real, or even perhaps

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BY JOSEPH SHAW BOLTON, M.D.

431

a possible, pathological basis— e.g., such symptom-complexes
as mania or melancholia, which are probably merely gross
exaggerations of the normal emotional tone of the individual
patients,—though they sufficiently serve the purposes of clinical
description. In the case of premature dementia, however, it is
possible to make a subdivision of the cases into those which do
and those which do not exhibit phenomena which originate in
sub-evolutional or dissolutive conditions of the psycho-motor
area of the cerebral cortex. It is doubtful whether a further
subdivision of the latter class into simple hebephrenic and
paranoid types possesses, in the present state of our knowledge,
an equally trustworthy pathological basis; but, in spite of a
gradual shading of the cases into one another, such a separation
of types is, at least, justifiable, and is at any rate convenient,
from the clinical standpoint.

In the present section, therefore, the cases under considera¬
tion will be approximately classified into the commonly accepted
“hebephrenic,” “catatonic,” and “paranoid” types.

The descriptions which follow, as has already been stated,
are not intended by the writer either to illustrate the general
symptomatology of the types, or to include all the more obvious
clinical features which they present. They merely contain such
details as he especially desires to bring into prominence in order
to serve the purpose he has in view—namely, to demonstrate
that premature dementia is not a simple clinical entity or a
specific disease of the cerebrum, but is merely the dementia
which develops at the earliest of the four most common periods
of life at which primarily neuronic dissolution of the cerebrum
occurs.

The class at present under consideration contains 112 cases,
which will be classified as follows:

i t.

j centage.

j Sub-class (1), approximately “ hebephrenic ”

! 57

j Subclass (2), approximately “ catatonic ” .

Sub-class (3), approximately “ paranoid ” .

4 | 2

1 6

Total of cases of “premature dementia”

1 57

1 112

100

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432

AMENTIA AND DEMENTIA,

[Ny,

As might be expected in primarily neuronic dementia at the
premature period of life (and as is also illustrated in the
analogous but progressive dementia of juvenile general paralysis),
the sexes are approximately equally affected, for at this period
the predisposing factor—deficient durability of the cortical
neurones—overshadows in importance the various exciting
factors, which later in life not only acquire a greater relative
value but differ both in kind and in degree in the two sexes.

The average age on certification, which is the only age available
in the whole series, differs little in the several sub-classes,
being as follows:

Sub-class (1) .

Sub-class (2) . . . 1

Sub-class (3) .

Sub-class (i).—The age on certification varies from 15 to 30
years in the males, and from 16 to 30 in the females. The
earliest age of onset, on such information as is available, is 15
years in the case of the males and 14 years in the case of the
females.

Sub-class (2).—The age on certification varies from 15 to 29
years in the males (with the exception of one patient, who was
kept at home from the age of 28 years to that of 34 years, at
which age he was sent to an asylum), and from 19 to 27 years
in the females. The earliest age of onset, on such information
as is available, is 15 years in the case of the males and 17 years
in the case of the females.

Sub-class (3).—The age of certification varies from 20 to 22
years in the males, and from 23 to 28 in the females. Owing
to the small number of cases in the “ paranoid ” sub-class, these
ages are, however, valueless for statistical purposes.

It is probable that few of these figures possess much real
value, as the time of certification depends so much on the degree
of trouble caused by the patient in his home or workhouse
environment, and as the writer had few opportunities of obtain¬
ing really satisfactory personal histories, for in the case of
admissions consisting of chronic patients the obtainable infor-

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1907.] BY JOSEPH SHAW BOLTON, M.D. 433

mation varies in amount conversely with the duration of the
certification of the individual patients.

Previous attacks .—The ascertained number of cases which
had been previously certified is as follows:

Males.

Females.

Total.

Percentage. 1

Sub-class (1)

7 in 32

3 in 32

10 in 64

Sub-class (2)

8 in 23

5 in 18

13 in 41

3 2 i

Sub-class (3)

0 in 2

1 in 5

1 in 7 ,

i ’ 4 1

Total . . .

15 »n 57

9 »n 55

24 in 112

2' |

| Percentage .

Though this information is necessarily incomplete, the error
of omission is presumably equally scattered throughout the
series, and hence it may be deduced, as a crude observation,
that previous certifications are more common in the male sex
than in the female.

It may also be inferred that previous certifications are more
common in the “catatonic” than in the “hebephrenic” and
the “ paranoid ” types, and this inference is supported by the
common clinical observation that “ catatonic ” cases often pro¬
gress in a relapsing manner rather than as a slowly advancing
mental deterioration, and are therefore more likely to be sent
out “ recovered ” or to the care of their friends.

Heredity of mental disease .—The ascertained heredity of mental
disease, though it possesses no actual value, leads at least to
the inference that little or no difference in this respect exists
between the different types. It is as follows :

Males.

Females.

Total.

Sub-class (1) .

34 per cent.

Sub-class (2) .

26 per cent.

44 per cent.

34 per cent.

Sub-class (3) .

1 50 per cent.

20 per cent.

29 per cent.

Total .

j 32 per cent.

1 36 per cent.

34 per cent.

Though the percentages differ in the two sexes, it is probable

434 AMENTIA AND DEMENTIA, [July,

that no deduction can safely be drawn from these, as it would
not be justified by the number of available cases.

The average duration of residence in an asylum at the time of
observation is as follows:

Males.

Females. j

Sub-class (1)

Sub-class (2)

Sub-class (3)

10 years
(i—34 years)

8 years

(1—21 years)

9 years

(7 —11 years)

10 years
(1 — 29 years)

9 years
(1—30 years)

12 years
(2—27 years)

These figures demonstrate that the average duration of life is
not appreciably affected by the clinical type of the symptoma¬
tology, for the H2 cases represent the “premature dementia*’
population of an asylum at a particular time, and are not a series
of cases selected during a special period of time .

As has already been stated earlier in this paper (Journ . Ment.
Sci., April, 1905, p. 337), one of the most frequent symptoma¬
tologies associated with the development of tuberculosis is
one presenting many resemblances to stupor. This is probably
the explanation of the fairly common opinion that cases of
“ catatonia 99 are especially prone to the development of tuber¬
culosis—a view contradicted by the above data, which show that
the average duration of residence of these cases differs little
from that of the other types of premature dementia.

Degree of degeneracy .—Important conclusions have been
derived from a study of the 112 cases from the point of view of
physical and mental degeneracy, as the three types differ
markedly in this respect.

In the following table are given the actual numbers and the
percentages of degenerates— i.e., of high-grade aments who
exhibit marked stigmata of degeneracy, and in many cases
evidence of developmental feeble-mindedness, which is almost
sufficiently marked to cause them to be classed as cases of
imbecility (the mildest type of low-grade amentia).

From this table the following inferences may be drawn:

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BY JOSEPH SHAW BOLTON, M.D.

435

* 907 .]

Males.

Females.

Total.

Proportion
of degene¬
rates.

Percentage.

Proportion 1

of degene- Percentage,
rates. |

Proportion
of degene¬
rates.

Percentage.

Sab-class (i),

” hebephrenic ”

20 in 32

■ '

625

13 in 32

40*6

33 in 64

516

Sub-class (2),
“catatonic”

7 *n 23

30'4

7 in 18

39 'o

14 in 41

34'1

Sub-class (3),

“ paranoid ”

j 2 in 2

lOO'O

1 in 5 20‘0

3 in 7

429

| Total

I -

1 29 in 57

509

21 in 55

382

50 in 112

J 4 -f 6

(1) In the 112 cases under consideration, the proportion of
degenerates is greater in the male sex than in the female.

(2) The proportion of degenerates is greater in the “ hebe¬
phrenic ” type than in the “ catatonic.”

(3) In the u hebephrenic ” type the proportion of degenerates
is especially high in the male sex.

It is doubtful if the number of cases justifies more detailed
deductions, and this remark especially applies to the “ para¬
noid” type, which includes but 7 of the total of 112 cases.

The relative proportions of degenerates in the four classes of
primarily neuronic dementia will now be considered. After what
has already been stated in earlier sections of this paper it is
hardly necessary to remark that important differences exist in
this respect.

From the aspect of pure high-grade amentia, as has been
remarked in the introduction to the second part of this paper
( Joum . Ment . Sci., July, 1905, p. 510), the age on certification,
or the age at which the degenerate with neurones of average
durability becomes unable to withstand the normal environ¬
ment of sane individuals, depends on two factors—the resistance
of the individual cerebrum, and the “ stress ” to which this is
subjected—and is therefore an accidental detail which is of
slight importance from the point of view of classification. In
such cases an attack of certifiable insanity either adds another
non-demented permanent inmate to the asylum population or
results in the return to the outside world of a potential lunatic
who is liable, under the influence of a relatively slight degree
of“ stress,” to again become an asylum inmate.

436

AMENTIA AND DEMENTIA

[July,

When, however, the degenerate also possesses neurones of
deficient durability, it is obvious that age-incidence possesses a
greater significance, and that the proportion of degenerates to
non-degenerates in the demented insane must be smaller at
each successive period of life. In such degenerates a perma¬
nent loss of mind results from an attack of mental alienation,
and therefore necessitates their certification sooner or later,
whereas pure high-grade aments, with neurones of average dura¬
bility, may suffer and recover from many attacks of insanity in
their home environment before their friends are tired of the
trouble they cause, or become unable to look after them.

The proportion of degenerates is therefore greater in pre¬
mature dementia than in the other classes of primarily neuronic
dementia. This is clearly shown in the following table :

Males.

Females.

Total.

Primarily neuronic
dementia.

Proportion
of degene-,
rates.

Per-

centage.

Proportion
of degene-j
rates.

Per¬

centage.

Proportion
of degene¬
rates.

Per¬

centage.

Class (A), “ premature ”

29 in 57

509

21 in 55

382

50 in 112

44-6

Class (B), “ mature ”

6 in 26

230

3 >" 34 !

9 in 60

150

Class (C), “presenile”

2 in 18

III

5 47

io*6

7 * n 65

10 8

Class (D), *' senile ”

20 in 53

37 7

24 in 70

34'3

44 »n 123

358

In the above table the “ senile ” or “ worn-out ” class con¬
tains a high proportion of degenerates, as it not only includes
the ordinary senile cases and senile high-grade aments, but
also the hitherto non-demented old asylum inhabitants and the
cases of hitherto stationary “ premature,” “ mature,” and “ pre-
senile ” dementia, who, with the onset of senility, have deve¬
loped “senile” or “worn-out” dementia ( Journ . Ment. Set.,
October, 1906, p. 717). As it is impossible to satisfactorily
distinguish between all these types, the senile class is thus a
mixed one, and the percentages given represent the proportion
of physical and mental degeneracy which existed at a particular
time amongst the cases of primarily neuronic dementia who
had arrived at the senile period of life.

Degree of dementia .—The degree of dementia existing in the

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BY JOSEPH SHAW BOLTON, M.D.

I907.]

437

class of premature dementia under consideration is represented
in the following table :

Premature dementia.

Males.

Mild.

Sub-class (1), “ hebephrenic” . 15

; Sub-class (2), "catatonic ”

Mode¬

rate.

6 | 17
23

Sub-class (3), “ paranoid ” . 1 I 1

I 2

:!' . •4

j" 1

Total . . . . ; 22 | 35

I 57

Females.

Mild. !

Mode¬

rate.

14 ! 18
32

5 I i3
18

23 I 32
55

Total.

Mild.

Mode¬

rate.

29 35

ti 130
4 l

5 I 2
7

45 I 67

I 12

Total per¬
centage.

Mild.

Mode-

rate.

C n

-7

1 0

Hence the “ catatonic ” form contains the highest percentage
of cases which exhibit a moderate grade of dementia, namely,
73; the “ hebephrenic ” shows the lower percentage of 55, and
the “paranoid” possesses the least proportion of the three,
namely, 29 per cent. The total percentage of cases exhibiting
a moderate degree of dementia in the class of “premature
dementia ” is thus no less than 60.

The relative proportions of cases possessing a moderate degree of
dementia in the four classes of primarily neuronic dementia .—As
has already been stated in the introduction to the description
of this variety of dementia, and under the headings of the
different classes which it contains, the actual amount of
dementia is greater in the “ premature ” than in the “ mature,”
and in the “ mature ” than in the “ presenile ” classes. The
“senile ” class, as has already been stated above, under the
subject of degeneracy, falls under a different category, including,
as it does, not only ordinary senile cases and senile degenerates
with “worn-out” neurones, but also hitherto non-demented
old asylum inhabitants, and cases of hitherto stationary “pre¬
mature,” “ mature,” and “ presenile ” dementia, who, with the
onset of senility, are also suffering from “ worn-out ” neurones.

43 8 AMENTIA AND DEMENTIA, [July,

The actual amount 6f dementia in the senile class is thus
relatively high.

For simplicity of description, as the dementia in all the cases,
with the exception of a small number belonging to the senile
class, in which it is well marked, is of a mild or moderate grade,
the number and the percentage of cases which exhibit a
moderate degree of dementia will alone be detailed in the
following table:

Number of cases

Primarily neuronic dementia.

exhibiting moderate

Percentage

dementia.

Class (D), “premature”

Class (C), “ mature ”

67 in 112

28 in 60

Class (B), “ presenile ” .

21 in 65

Class (A), “ senile ”

68 in 123

1 Total ....

184 in 360 1

A further question will now be briefly considered—namely,
whether degenerates or ordinary patients develop the greater
proportionate amount of dementia. The ordinary high-grade
ament, as has frequently been stated, but especially in Part II
of this paper, develops an attack of insanity so readily under
the “ stress ” of “ normal ” environment that he does not over¬
reach the durability of his cortical neurones, and consequently,
according to circumstances, either recovers or becomes a per¬
manent asylum inmate without the development of an
appreciable degree of dementia. When, however, the high-
grade ament does overstep the limit of neuronic durability, it is
a matter of uncertainty as to whether a greater or a lesser
degree of dementia ensues than that which occurs in an ordinary
“ normal ” individual who has similarly overstepped the limit of
neuronic durability. It is with the object of furnishing a reply
to this question that the following data are inserted.

In the table which follows the cases of primarily neuronic
dementia are grouped, under the four classes into which this
type of dementia has been subdivided, into “ normal ” patients
and high-grade aments. As all the cases, except a few of the
senile class in which the dementia is well marked, suffer from a

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1907 .]

BY JOSEPH SHAW BOLTON, M.D.

439

mild or a moderate degree only, the latter grade alone has been
considered in the figures and percentages, as the former is
merely its complement.

Primarily neuronic
dementia.

Proportion of “ normal M
cases exhibiting moderate
dementia.

Proportion of high-grade 1
aments exhibiting
moderate dementia.

Class (A), “ senile ” .
Class (B), “presenile”
Class(C), “mature” .
Class(D),“premature”

37 in 79 = 47 per cent .
20 in 58 = 34 per cent.
23 in 51 =45 per cent.
j 38 in 62 = 61 per cent.

31 in 44 = 70 per cent.

1 in 7=14 percent.

5 in£ 9 = 56 per cent.
29 in 50 = 58 per cent.

Total

|i 18 in 250= 47 per cent.

66 in 110 = 60 per cent. J

The above data sufficiently indicate that high-grade aments,
as a group , when they develop dementia, pass more frequently
to the moderate grade than do “ normal ” individuals.

This conclusion is especially evident in the “ senile ” or
compound class, and it is not supported by the “ premature ”
cases, in which the neurones of both “ normal ” and degenerate
patients have apparently suffered equally commonly from a
moderate degree of dissolution.

The table further illustrates the relative rarity of degeneracy
in the “ presenile ” and the “ mature ” classes, which observa¬
tion renders it probable that such degenerates as have not
succumbed to cerebral dissolution at the “ premature ” period
of life have continued relatively unaffected until the “ senile ”
period has been reached.

It is probable, therefore, that the cause of the main conclusion
deduced from the data contained in the table is to be found in
a greater tendency to “ senile ” or “ worn out ” dissolution of
the cortical neurones on the part of the degenerates than exists
in the case of the “ normal ” individuals. This explanation is
rendered the more likely by the common observation that low-
grade aments, as a rule, attain to senility at a comparatively
early age, e.g ., even at forty years; in other words, that the
cortical neurones of well-marked degenerates are especially
prone to undergo early senile involution or “ wearing out,”
even in the absence in many cases of an appreciable degree of
“ wear and tear.”

It may, therefore, with a reasonable probability that the
deduction made from the data contained in the table is correct,

LIU. 31

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440

AMENTIA AND DEMENTIA,

[July,

be stated that the presence of physical and mental degeneracy
(high-grade amentia) does not, until the “ senile ” period of life
is reached, influence in any way the grade of dementia which
follows an over-stepping of the limit of neuronic durability.
When, however, the “ senile ” period has been attained, the
presence of high-grade amentia in cases which have overstepped
the limit of neuronic durability results in the more frequent
development of a moderate grade of dementia than occurs in
patients with “normal** cerebral development; and this result
is due to a greater tendency to “ senile ” or “ worn out ” involu¬
tion of the cortical neurones on the part of high-grade aments
than exists in the case of “ normal ” individuals.

Class (d).

Sub-class (i) —Premature Dementia—approximately “Hebephrenic”

This sub-class contains sixty-four cases, of which thirty-two
are males and thirty-two are females. It includes the cases of
premature dementia in which “ loss of mind *’ is the essential
clinical feature, and which exhibit neither pronounced motor
phenomena nor definite semi-systematised delusions. Further,
in such examples as show a tendency to perform, or to repeat,
certain acts, these (c/., No. 595, p. 450) are usually “ skilled ”
in nature, and are presumably mechanical remainders of what
has formerly been learned and practised, rather than the results
of imperfect learning or deficient practice, which are such
obvious features of certain of the motor phenomena exhibited
by cases of “ catatonia.”

The average duration of residence, in the case of either sex,
is ten years; and the individual duration varies from one to
thirty-four years in the males, and from one to twenty-nine
years in the females.

Both owing to the duration of residence and to the existence
of dementia, the cases fall into the category of “ chronic ” ; and
therefore, apart from the reasons adduced in the early part of
the present section for the mode of treatment of the subject
which is being adopted, no detailed description of precursory
or “ acute ” symptomatology will be attempted. It suffices,
with reference to this, to remark that, in the experience of the
writer, all such cases, during the earlier stages of the attack of

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1907.] BY JOSEPH SHAW BOLTON, M.D. 441

insanity which resulted in their “chronic” mental condition,
exhibited a greater or a lesser degree of mental confusion, and
that the severity of this, in uncomplicated cases, bears a direct
relationship to the grade of dementia which ensues (Journ.
Mcnt. Set., July, 1906, pp. 427-490).

The symptomatology exhibited by the cases contained in this
sub-class is that of stationary dementia, namely, “ general dul-
ness and apathy, a loss of initative, and an indifference to their
surroundings ; a marked degree of stereotypism of all the mental
processes, and an inability to learn new acquirements; a
mechanical method of performance of known acquirements, a
general stupidity and inability to understand when an attempt
is made at correction of any kind, and a tendency to revert to
accustomed modes of speech and action; finally, a tendency to
the repetition of accustomed actions, which often shows that
these have been performed in the entire absence of intelligent
volition ” (ibid., p. 488).

This symptomatology is due, in the opinion of the writer
(Journ. Ment. Sci., April, 1906, pp. 221-271), to a more or
less extensive dissolution of the centre of higher association
and co-ordination in the prefrontal region, which is the latest
developed and most important portion of the grey mantle of
the cerebrum, and the first part to undergo dissolution under
“stress” or normal involution; and the cases in the present
sub-class, as a whole, exhibit, in probably a purer form than is
seen in any of the varieties of primarily neuronic dementia, the
results of this dissolution.

As will be seen from the illustrative cases inserted at the end
of this description, the contents of the present sub-class include
examples both of amentia, chiefly of the high-grade type, and
of what were originally presumably “ normal ” individuals. Of
the 32 males, no less than 20, or 62*5 per cent, are degenerates;
and of the 32 females, no less than 13, or 40*6 per cent. Hence
33 of the 64 cases, or 51*6 per cent, are examples of low- or high-
grade amentia—a larger proportion than occurs in the “ cata¬
tonic ” and “ paranoid ” sub-classes of premature dementia.

Whilst this observation points to the desirability of suitable
(State) provision for the care and control of the feeble-minded,
many of whom, under the ordinary environment of the “ sane ”
members of the race, are liable to suffer from cerebral dissolu¬
tion with resulting dementia, the corollary that 48*4 per cent .

442

AMENTIA AND DEMENTIA,

[Ju'y.

of the cases were presumably of “ normal ” cerebral develop¬
ment shows that exceptional “ stress ” is equally harmful to
these, and produces its quota of cerebral dissolutions. The
latter point is probably the more important of the two, as such
(non-demented) “ normal ” individuals would be of more use to
the race than would such (non-demented) degenerates, and
hence is suggested the desirability that greater attention should
be attracted to the often disastrous results of over-training,
even in subjects who are apparently of “ normal ” cerebral
development.

The amount of dementia existing in the cases included in
this sub-class is high, as many as 55 per cent . exhibiting a
moderate grade. This, though considerable, is rather less than
the percentage of 60 in the entire class of premature dementia.

Of the sixty-four cases in the sub-class forty-four were workers
(twenty-five good, eight ordinary, and eleven poor), six refused
to work, and fourteen were incapable of useful employment.

The following fourteen cases are inserted for illustrative
purposes:

Congenital Feeble mindedness ; Mild Premature Dementia ; certified six

years.

Case 539.—A. A—, male, single, aet. 35. Of no occupation. Feeble¬
minded from birth. Certified since the age of 29. Notes taken three
days after admission.

A dull-looking man, of sleepy appearance. Forehead prominent,
head large, ears small and without lobules, mouth small and lips thin.
He gives his name, and states that his age was 27 on April 3rd
last. He knows where he is, where he has come from, when he came,
the present day, and the approximate date. He is very slow in giving
replies to questions. He does not know the present year. He tells
me, in reply to leading questions, that he went to school, and that he
was in the eighth standard at the age of 15. When asked to multiply
12 by 9 he tries to work it out by counting on his fingers, and
eventually says “ 10.” To a question of 4 x 3 he replies “8,” after
counting the same method. He however, again in the same way, gets
2* x 2 correctly, but says that 3x3 = “ 6.” When asked to say the
alphabet he inserts two “ Vs ” and misses out “ u ” and “ v.” He
spells “horse”and “cow” correctly, but “elephant” is “eofin,” and
he does not attempt “asylum.” He reads like a very young child,
and, even after spelling them, entirely fails to make anything of such
words as “ attendant ” and “ commencing.” He is dull and slow in
all his movements, and exhibits none of the wayward intelligence and
erratic or rapid movements and actions of the non-demented imbecile.

Whilst under observation he was a useful mechanical worker, and

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I907.] BY JOSEPH SHAW BOLTON, M.D. 443

was able to attend entirely to such personal matters as washing,
dressing, the calls of nature, etc.

Note. —The patient differs from the imbecile and approximates
to the dement in his general dulness, his sleepy appearance
and the slowness of his movements, and in the general absence
of initiative, either with or without the stimulus of sensorial
excitation.

High-grade Amentia ; Mild Premature Dementia ; certified five years.

Cask 542.—T. W. C —, male, single, set. 23, errand boy. Certified
since the age of 18. Father insane. Notes taken two days after
admission.

A dull, sleepy-looking boy, who is biting his finger nails. Palate
very high and chink-like. He gives his name with a slight lisp, and
states that his age is 18. When asked to do so, he slowly and
carefully writes his name. Many of the letters, and even parts of
letters, are written singly and laboriously. All the dots are inserted,
weak parts of certain letters are touched up, and a full stop is inserted
after his Christian name. He seems then unable to put down the
pencil, and after a long pause adds, in similar writing, “ 18 years old.”
During the writing he frequently pauses to lick the pencil. He reads
well. He knows where he is and when he came. He states that the
day is Friday (Saturday), and that the time is 2.30 p.m., after which he
seems to remember the clock as he turns round to look at it (1 p.m.).
He knows neither the month nor the year, and states that he was
seven years (really five) in his previous asylum. He states that
4x5=“ 20,” 9x6 = “ 42,” 7x2=“ 14,” 4x5 = “ 20,” 4x7
= “28,’* 7x5 = “35,” 9x6 = ?, 6x9 = “78.” His memory
frequently fails during these and similar replies, and he then adds up, at
times incorrectly, to aid himself to the result. He spells fairly well, such
words as “house” and “elephant” being correctly rendered. He
states that previous to going to an asylum he earned fourpence a week
as an errand boy. During his residence he has “ tried to do bed¬
making and house-cleaning, and sweeping and cleaning chambers.”

Whilst under observation this patient was quiet and well behaved,
and, though dull, a useful worker.

Note .—This case is a good example of mild premature
dementia in a high-grade ament. The method of writing his
name is sufficient in itself to enable a diagnosis to be made, and
the evidence produced of his present attainments and previous
education, though brief, for reasons of space, is more than
enough for the same purpose. The present case thus differs
from the previous one, in which, for a clinical diagnosis, a
general knowledge of the behaviour and habits of imbeciles and
of dements, rather than a special study of symptomatology, is
needed.

444

AMENTIA AND DEMENTIA,

[July.

High-grade Amentia ; Moderate Premature Dementia ; certified twelve

years.

Case 544.—G. H—, male, single, set. 37. Certified since the age of
25, and stated to have been feeble-minded since birth. Notes taken
two days after admission.

A dull, heavy-looking man, with a large and protruding lower lip,
deep horizontal fissures on the forehead, and a vacant and expression¬
less stare. He is able to give his name, but does not know his age.
He has come from “another place,” and has been “in places like this
a long time.” He says that he has been to school, but does not know
in what standard he was when he left. He cannot read or write. He
volunteers the information that he has two brothers, and replies to a
question that he has no sisters. On being asked why his front teeth
are missing he says, “ Too many sweets I expect.” He states that he
does no work and does not smoke. When asked to frown he is unable
to do so. When asked why he has a slight contracture of his little
finger he replies, “ Squeezed in school door, a boy done this thing, a
boy, pinched.” He is dull and slow in all his movements, and walks
with his head bent forward and with a very slow, shuffling gait.

Whilst under observation he was at times restless, shuffling about
the ward, and being irritable if interfered with. He was quite unable to
work, was dirty and untidy in his appearance, and, unless prompted
and at times assisted, was unable to attend to his personal wants.

Moderate Premature Dementia; certified six years.

Case 547.—W. H. B—, male, single, set. 32, labourer, and in army
reserve. Certified since the age of 26. Notes taken two days after
admission.

A fatuous-looking man who laughs in a silly manner when addressed.
He takes little notice of his surroundings. When asked to frown he
looks up and says, “That’s all right” He notices that I am taking
notes. When asked his name he replies, “ Nothing, same as yours.”
Where have you come from ? “ You shouldn’t make fools of people

like you do.” How old are you ? “ About 40.” Married ? “ Yes.”

Children ? “You needn’t make a fool of us you know,” and he then
laughs in a foolish manner. He takes his food well, goes to the
lavatory with the other patients, and dresses himself. He sits in the
same place all day long and is quiet. He at times looks slowly
around, and at others grins fatuously to himself.

Whilst under observation he was dull and listless, paid little attention
to his surroundings, and was entirely unoccupied.

High-grade Amentia ; Mild Premature Dementia ; certified eight years.

Case 550.—W. H—, male, single, set. 29, boatman. Certified since
the age of 21. Maternal aunt insane. Notes taken three days after
admission.

A dull, sleepy-looking man. The cranium is low, the base of the
skull is broad, the ears project, the mouth is large, the lips project,

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1907.] by JOSEPH SHAW BOLTON, M.D. 445

and the palate is high and narrow. He gives his name, and when
asked his age replies, 44 Asked yesterday I said 25 and he said I was
more than 25.” He knows where he is, but pronounces the name
of the place incorrectly, and in a shortened and incomplete manner.
He knows the day on which he came and the present day and
date. He knows where he has come from, and states that he was
there seven or eight years. When asked why he was incarcerated he
replies, “ Was sent there I suppose.” When the question is repeated
he says, “ I don’t know.” When asked to write his name he does so in
a slow and laborious manner. He corrects the imperfect letters and
dots the 44 i’s.” Nearly every letter is written separately and in copy¬
book style. When I ask him to add his age, he slowly and carefully
writes 44 25,” the 44 curls ” at the beginning of the 44 2 ” and the end of
the “ 5 ” being elaborately made, and the 44 dash ” at the top of the
latter being long and well curved. I then ask him about the work he
did in his previous asylum, and he replies that he wheeled coal and
got “pretty fair” of tobacco for doing so. He does not know why he
has been incarcerated for such a long time, and 44 it don’t trouble me
much.”

Whilst under observation patient continued dull and apathetic and
showed a marked lack of initiative, but he was a useful mechanical
worker.

Chronic Mania; Mild Premature Dementia; certified six years.

Case 551.—G. S—, male, single, set. 28, railway porter. Certified
since the age of 22, and showed symptoms a year previously. Grand¬
father and uncle insane. Notes taken two days after admission.

A dull-looking young man with an expressionless face and projecting
ears. He gives his surname, and when asked his Christian name
replies, “ Suppose we say Claremont, there’s a fortune there I believe.
Take the evidence and obtain the notes ” (apparently from noticing
that I am writing in a book). Asked where he is. he says “ cover
place.” When the question is repeated, he replies 44 There were a few
pictures on the hill when I first knew it.” When I ask if he has ever
heard of C—, the asylum from which he has been transferred, he says,
44 Yes, I was employed there in the railway.” When asked why he was
incarcerated he states, 44 1 expect I lived in a tower for a couple of
years without anything to eat and that weakened my mind.” He says,
that it is 13 years now since he left the goods’ office at H—
(improbable). He knows the present day, the day when he came, and the
date within a day. He then tells me that he was here one evening in
March two years ago. (Certainly untrue.) In his previous asylum he
“did a little wiping and washing up and did pillows and beds.” He
was there five years (six). His age is 44 70 to 80 years.” He was 70
when he went to the asylum, “ something like an old countryman, you
know.”

Whilst under observation he was on the whole dull and apathetic,
but at times he became excited. He was a useful worker but showed
great lack of initiative.

446 AMENTIA AND DEMENTIA, [July,

High-grade Amentia; Chronic Mania ; Moderate Premature Dementia ;
certified thirty-three years.

Case 562.—G. H—, male, single, aet. 54, seaman. Certified since the
age of 21. Notes taken three days after admission.

A smiling man with bright eyes. The left eye is placed lower than
the right and there is facial asymmetry. There is marked intermittent
contraction of the orbicularis palpebrarum. The tongue is enormous.
The palate is within normal limits. The patient frequently makes
clucking noises with his glottis and jerks his lower jaw forwards. He
also frequently eructates. He laughs, mutters, and talks to himself.
He gives his name indistinctly, and when the question is repeated he
shouts out the reply at the top of his voice. He states that his age is
70. He knows the day and the day when he came. When asked
where he came from he replies, “Train.” When the question is
repeated he says, “ Off the metals.” When asked if he has come from
H—, he replies “ Yes,” and to a question as to how long he lived
there he says, “ Years, 70 years.” Whilst there he worked at “ lugging
solids—coals.” He does not smoke. All his replies are jerked out
suddenly.

Whilst under observation he remained quite unchanged. He paid
little attention to his surroundings and showed much lack of initiative,
but he was a useful mechanical worker.

Note. —The habit-tricks of this patient, and his mode of
speech, suggest that the case should, perhaps, have been
included under “ catatonia ”; but a careful study of the case as
a whole led to its inclusion in the present group. (See also note
on Case 595.)

Mild Premature Dementia ; certified six years .

Case 564.—D. D—, female, single, set. 25, general servant Certified
since the age of 19. Maternal aunt insane. Notes taken two days
after admission.

A pale, anaemic girl. Teeth irregular and badly enamelled. Palate
narrow and deep. Some degree of red oedema of extremities, elbows,
etc. Faint skin-cracks on abdomen.

Patient lies quietly in bed and bites her right hand and sucks her
fingers. She rarely stirs, but speaks rationally, though childishly,
in reply to questions. She knows where she is, and, roughly, how long
she was in her previous asylum ; and in reply to a question, she informs
me that she did washing there. She has, at times, suffered from
auditory hallucinations—voices “asking me to be good and that.”
She used, at first, to think that she had done wrong, and “did not do
my work properly sometimes.” She would have liked to go home, and
used to try to work, etc. She often makes use of the word “try.” She
knows that she had a child some time ago, or thinks she had, but can¬
not give any information about it. She does not know whether it is
alive, and “I do feel sometimes as if I would like to know if it is alive.”

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I907-] BY JOSEPH SHAW BOLTON, M.D. 447

At times, when lying quietly, she moves her lips as if whispering to
herself.

A few days after admission she began to do a little ward work. She
was willing but extremely dull and slow.

Whilst under observation she became stout, but continued anaemic.
She was dull, heavy, and phlegmatic, and had absolutely no capacity of
initiation, though she answered questions readily enough. She was a
willing worker but was better able to understand what was wanted of her
than to perform it. She was slow and clumsy, and when, e.g. t she washed
a floor, she often slopped the water about, wet her dress, and wiped
very little of the water up again. She was, therefore, of little use except
for unimportant and purely mechanical employment, and even then
she required constant supervision.

High Grade Amentia ; Moderate Premature Dementia; certified thirteen
years , and previously at the age of twenty four . Sister of Case 576.

Case 575.— E. J —, female, married, set. 41, of no occupation.
Certified since the age of 28, and previously at the age of 24. Sister
of Case 576. Great-grandfather insane. Notes taken on the day
after admission.

Patient is a dull, apathetic woman, who shows fewer and less marked
stigmata of degeneracy than occur in the case of her sister (Case 576).
Forehead free from lines of any kind, hair light grey, palate high and
narrow in front, teeth poor, skin cracks on abdomen.

She at times laughs in a silly manner, and on these occasions her
forehead remains unaffected. She states that her age is six. When asked
her name she says that she does not know and then adds, “an invalid.”
When asked if she is married she shows me a button on her night-dress
and mutters something inaudible. She then asks “ would you like me
to put my name on that little bit of biscuit ?” She later makes such
remarks as “the publisher wants his money, the Prince of Wales,”
“glad you got home,” “sixteen years since,” and “don’t you feel all
right like that,” and tries to cover herself up in bed.

Whilst under observation patient remained dull, apathetic, and un¬
interested in her surroundings. She occasionally talked a little to her¬
self. She was unable to perform work of any kind, and was only
imperfectly able to attend to herself.

High-grade Amentia; Echolalia; Moderate Premature Dementia;
certified three years, and previously at the age of 27. Sister of Case
575-

Case 576.— E. A. B— , female, single, set. 34, of no occupation.
Certified since the age of 31 and previously at the age of 27. Sister of
Case 575. Great-grandfather insane. Notes taken on the day after
admission.

Patient is of similar type to Case 575, but is of much more markedly
degenerate appearance. Forehead receding, hair very grey, palate very
high and square at the canines, teeth fair, mouth large and open,
lower lip very pendulous, ears lobuleless. She is extremely narrow
between the anterior superior iliac spines.

448

AMENTIA AND DEMENTIA,

[July,

A dull, stupid-looking woman, who appears to be much older than her
stated age. She calls herself “ E. A. W.” She is not married but wants
to be. She scratches her face and smiles, or at times sighs. To ques¬
tions she replies, “ yes, yes,” “ what’s matter,” “I don’t think it’s my fault,”
etc. She says that her age is 60 and that she is “ at Hampstead in
John Street.” To a further question she replies that she was at Hamp¬
stead yesterday and therefore does not seem to remember anything
about her journey here. To a later question she says she does not know
where she is now. She names the day correctly and says that “ it looks
like winter ” (August) when asked the month. The year is “ 1888,
i860, 1880,” (1903). She is “5 years old yesterday ” (cfi her sister’s
remark that her age is 6). She differs from her sister in exhibiting well-
marked echolalia, repeating, with alteration of pronoun, practically every
question put to her.

Whilst under observation patient was dull, listless, and apathetic, and
took absolutely no interest in her surroundings. She was unemployed
and was hardly able to do anything for herself. She thus exhibited a
somewhat greater degree of dementia than her sister.

Chronic Melancholia ; Mild Premature Dementia ; certified five years.

Case 578.—A. M. M—, female, single, aet. 28, cook. Certified since
the age of 23. Notes taken on the day after admission.

Upper lip prominent. Nostrils thick and round. Palate shelves
forwards markedly. Well-marked lateral spinal curvature. Breasts
virginal. No skin cracks on abdomen.

A very depressed and apathetic woman, who, when asked if she is a
cook, states that she was a nurse at G— hospital for ten months in the
surgical wards. She broke down with the work and returned home.
She stayed at home for two years, and then went out again to nurse a
lady who was suffering from influenza. She herself contracted the dis¬
ease, fell into a low state of health, and attempted suicide by cutting
her throat. She was then removed to the asylum. She was at that
time about 24 years of age, and was 29 on her last birthday.
When asked how she became a probationer in that particular hospital
at such an early age, she states that she led the authorities to suppose
that she was a good deal older than she was. Ever since she went to
the asylum she has been “ dull through being physically and morally
ruined.” She has been “more sinned against than sinning.” When
then asked as to immoral relations with men, she replies, “ Yes, several.”
She feels that she will never recover from her dulness and depression.
She does not suffer from hallucinations. Her knowledge of time and
place is accurate and her general memory is practically normal. She is,
however, dull, slow, depressed, and apathetic, is very slow in her mental
processes, and shows much lack of initiative.

Whilst under observation patient continued mentally unchanged.
She showed much mental hebetude but was a useful worker. Judging
from her education and mode of speech it is probable that she had
developed at least a slight degree of dementia, and had been originally
of more than average intelligence.

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I907-] BV JOSEPH SHAW BOLTON, M.D. 449

High-grade Amentia; Moderate Premature Dementia; certified fifteen

years .

Case 583.—A. E—, female, single, jet. 39, domestic servant. Certi¬
fied since the age of 24. Notes taken three days after admission.

A blank-faced woman, with bright eyes, ears without lobules, and a
high palate. She has a pleasant but fatuous smile. She takes very
little notice of me and cannot be got to reply to questions. She can¬
not handle a pencil, and she holds her hands as if she had not used them
for years, which is also probable from their general appearance. When
pressed by questions she eventually remarks, “Get away,” and then
gabbles on to herself in an entirely unintelligible manner, saying a few
words at a time, playing with her dress, her fingers, etc., and taking no
further notice of me.

Some months later she showed very little, if any, change in her
mental condition, which was as follows : She mutters in a partially
intelligible and nervous manner. She plays with her fingers and dress,
and jerks her arms about like a nervous child. She can speak plainly,
as she says, “I don’t want to sit down, I don’t want anybody.” “Jack’s
not Jack”; “no material feeling.” She appears to have talked so much
to herself that it has eventually become a habit not to articulate clearly.
At times she laughs, but she soon relapses into such, at times monkey¬
like, habits as examining her fingers or the buttons on her dress,
blinking, gazing down on the floor, etc.

She is fairly tidy and dresses herself, but she does not make her bed.
She is at times noisy. She is occasionally wet in her habits. She is
unemployed, except for doing a little rubbing sometimes, and on these
occasions she tends to work at the same place unless she is moved on.

Chronic Mania; Moderate Premature Dementia; certified eight years ,
and twice previously sittce the age of 17.

Case 585.—E. L. T—, female, single, set. 30, of no occupation.
Certified since the age of 22 and previously on two occasions, the first of
which was at the age of 17. Paternal uncle and maternal great-aunt
insane. Notes taken two days after admission.

A frowning, untidy girl, who rapidly settles down to complete apathy
with her head bent on her chest. Her palate is high, and deep in
front, and her extremities are cold and blue. She gives her name and
states that her age is 27. She speaks very childishly and looks about
20 years old at the most. When asked to write her name and age she does
so in exactly the manner characteristic of cases of premature dementia,
which has already on more than one occasion been referred to, in the
description of Case 550 for example. She says that she has come from
the West Indies, and that she came “a long time now” ago. She has
beard of the name of her last asylum but does not know how long she
was there. She has an extremely dull appearance, but she frequently
frowns. She takes little or no voluntary notice of her surroundings, and
is wet in her habits.

Four months later there was little or no change in the patient. This
is evident from the following description: Her face is screwed into

450

AMENTIA AND DEMENTIA,

[July,

an almost perpetual frown. She gives her name and states that her age
is 22. She knows neither the day nor the date, but thinks that it
is winter (February). She replies, “I don’t know” to practically every
question put to her. She usually sits all day long with her arms
folded and her eyes shut, and with her head bent forwards, and her chin
touching her sternum. Her extremities are blue and toneless. She is
occasionally wet in her habits. She dresses herself and at times makes
her bed. She never reads but she has written two letters to her friends.
Sometimes she is very excitable, spiteful, and impulsive, and she has
smashed more than once. She also, on these occasions, uses foul
language. At times she has worked very well for about a week, and she
can make beds very nicely, although she rarely does so.

Verbigeration . Moderate Premature Dementia ; certified eleven years.

Case 595.— J. C—, female, single, aet. 36, housewife. Certified
since the age of 25. Cause stated to be “confinement.” Sister insane.
Notes taken two days after admission.

A dull, sullen woman, who sits quietly and takes no notice of her
surroundings. She is stout, and is phlegmatic in appearance and
behaviour. No skin-cracks on abdomen. Marked corns on knees.
She gives her name, and, when asked her age, replies, “ 10 years old, 10
years old. I’m 10 years old, 10 years old ... 10 years old

. . . 1899.” Where are you ? “ I know what you want to know,

nothing, all right.” Who is that? (a patient). “That’s Jane Potter
. . . . nothing” (untrue). Who is this? (a nurse). “That’s
Ethel, Alice, Alice, Alice” (untrue). What is the day to-day?
“ Saturday. To-day is Saturday, Saturday, Saturday " (correct). She
rocks to and fro as she talks. Where do you live ? “ Where’s Peter,
poor old Peter? Yes, all right, Peter, poor old Peter.” Where have
you come from? “H—s, H—s, seaside, H—s. . . . H—s.
H—s. . . . H—s. . . . Came from H—Hh asylum. That’s
right. H—Hh asylum, you devil. H —Hh asylum. . . . H—
Hh asylum.” When not asked questions she laughs and whispers to
herself.

The following notes were made some months later: She is dull and
phlegmatic, and sits and plays with her fingers or a bit of thread. She
replies in a similar manner to questions, e.g., Do you sleep ? “ Me, I

don’t sleep. I never sleep. I never do nothing. Oh 1 dear, dear, I
never do nothing.” In playing with the string one notices that she
does it in a mechanical but “ skilled ” manner. The action is, in fact, a
mechanical remainder of what she has formerly learned and practised.

As regards her general behaviour, she is at times inclined to be
spiteful. She often makes grimaces, and laughs to herself. She has a
habit of throwing out of the windows everything she can lay her hands
on, on the ground that it is dirty. She, in fact, thinks that everything is
dirty and should be thrown away. She often repeats one or two words,
e.g. y “ beautiful,” “ Pretty Eliza ”; and when irritated she repeats one
or two phrases, e.g . 9 “Dirty looking thing, I’ll make you run,” and
“ I’ll cut your ear-holes off.*” She is clean in her habits and fairly tidy,

Digitized by v^ooQle

1907 ]

BY JOSEPH SHAW BOLTON, M.D.

45 *

and she attends to herself. She is a bad bed-maker, but is moderately
useful at sweeping and dusting. If asked to do anything she invariably
replies “ Yes, all right.” She sews if everything is got ready for her,
and she is very fond of unpicking.

Note. —Like Case 562, this case approximates somewhat to
41 catatonia ” in symptomatology, especially in the verbigeration
and the tendency to mechanical repetition of certain actions.
As, however, the 44 Frankenstein ” or 44 mechanical model ” is
not suggested by these actions, both cases have been included
under the present sub-class. The detail that the insanity of
Case 595 was apparently precipitated by confinement is, in the
opinion of the writer, as has already been stated, merely an
unimportant etiological episode, for such a factor, even if
followed by a general toxaemia, has no necessary bearing on
general symptomatology.

Class (d).

Sub-class (2). Premature Dementia—approximately 44 Catatonic .”

This sub-class contains 41 cases, of which 23 are males and
18 are females. It includes those cases of premature dementia
which, in addition to 44 loss of mind,** are further characterised
by the exhibition of pronounced motor phenomena.

The age on certification varies from 15 to 29 years in the
case of the males, and from 19 to 27 years in the case of the
females. The earliest age of onset, on such information as is
available, is 15 years in the case of the males and 17 years in
the case of the females.

The average duration of residence is 8 years in the males and
9 years in the females, and is thus only slightly less than that
in the preceding sub-class. The individual duration varies in
the males from 1 to 21 years and in the females from 1 to 30
years. There is, therefore, no evidence that the average dura¬
tion of life in the cases belonging to the present sub-class is
appreciably affected by the clinical type of the symptomatology.

All the cases exhibit, to a greater or a lesser extent, the
symptomatology of stationary dementia, which was briefly
summarised in the preceding sub-section, and, in addition, show
certain characteristic motor phenomena. It is not proposed
here to give a complete list of these motor phenomena, but

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452

AMENTIA AND DEMENTIA,

[July,

merely to briefly enumerate such as are exhibited by the illus¬
trative cases which are cited at the conclusion of this description,
as these are sufficiently varied to serve the purpose the writer
has in view.

They are as follows:

Anergic stupor , where the limbs are absolutely flaccid, and
from which the patient may, however, awaken to perform such
lower voluntary functions as attending to the calls of nature,
taking food, etc.

Simple cataleptoid states , in which the limbs may purposively,
accidentally, or by outside influence, assume all kinds of un¬
natural positions, and maintain them for lengthened periods of
time.

Semi-voluntary cataleptoid states , in which the positions are
partly under voluntary control and are largely maintained by
an effort of attention. As an example of the simpler type, if
one arm be raised by the observer, it remains where it is placed,
but gradually falls under the influence of gravity; if the second
arm is then raised the first at once falls. As an example of the
more complex type, one arm may be raised and remain so;
when a second is raised both remain as placed; when the
mouth is then opened by suggestion to the patient by one of
the several methods in vogue, it remains open and the arms
continue immobile; when, finally, a particular leg is raised,
either by the observer or at his suggestion, the mouth com¬
pletely relaxes, and the arms partially relax. [In many such
cases persistent prompting enables much useful mechanical
work to be performed.]

Resistive stupor and stubbornness , in the former of which the
patient forcibly resists every extraneously attempted movement,
and in the latter almost invariably does the reverse of what is
suggested or required.

The sudden striking of attitudes and the performance of forced
movements and actions 9 which in chronic cases are stereotyped
and habitual; also the perpetual exhibition of such muscular
positions as frowning or pursing the lips .

Repetition of such movements and actions as are performed,
and an apparent inability to cease .

Impulsiveness and aggressiveness .

Hebetude and delayed replies to questions; also echolalia 9 with
or without change of pronoun, this last being apparently a

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I 907 -] BY JOSEPH SHAW BOLTON, M.D. 453

similar phenomenon to what is in some persons a normal mode
of assisting themselves to the understanding of a question, by
the aid of further centres of lower association.

A tendency to reply to questions and then to spell out the reply ,
and even to repeat the reply; also verbigeration .

Extraordinarily rapid cerebration , with instantaneous replies to
questions, or with no reply at all if the question is not abruptly
and rapidly put.

A peculiar method of writing , which includes one or more of
the following characteristics: Delay in commencing to write,
and hesitation as to where exactly to start; great care both in
writing and in correcting, completing, and “ touching-up ”
what has been written ; a tendency to write without performing
the normal movement from left to right; inability to leave off
writing and put down the pencil; and, finally, a tendency to
repeat the writing, or certain letters or words, over and over
again.

A general absence of smoothness and refinement in all the move¬
ments and actions which are performed.

The above symptoms indicate, in the view of the writer, a
functional disturbance, and, in most of the cases, a partial
dissolution of the neurones of the psycho-motor area of the
cortex cerebri, and also demonstrate that the different associated
groups of neurones, by insufficient exercise, owing to the age of
the patient, are imperfectly organised into stable complexes,
and, for the same reason, are under incomplete or imperfect
voluntary control. The pathological condition is thus, on the
one hand, one of sub-evolution of function, and, on the other,
one of dissolution or involution ; and a more extensive tract of
cortex cerebri is therefore involved in the pathological process
than occurs in the “ hebephrenic ” type of premature dementia.

The motor phenomena resemble, in brief, those which would
occur in a “ Frankenstein ” ( l ) or “ mechanical model,” in which
certain parts were imperfectly fashioned; in which certain
groupings of parts were imperfectly tested and not in proper
running order; in which the higher mechanical complexes
were imperfectly controlled and co-ordinated into series, and,
therefore, tended to stop, to repeat action, or to go by fits
and starts; and in which, owing largely to the existence of
several sources of motive power {i.e., from the different organs
of sensation), certain mechanical complexes tended to run

454 AMENTIA AND DEMENTIA, [July,

independently in consequence of an imperfect general co¬
ordination of, and control over, the whole mechanism. The
motor phenomena are thus varied, and are, on the whole, of a
distinctly positive or a definitely negative nature; and repeti¬
tion, wayward and grotesque action, etc., are common.

In chronic cases the phenomena are often still further com¬
plicated as regards an immediate explanation, but simplified as
regards their actual exhibition, by a more or less extensive
dissolution of neurones, which results in stereotyped motor
remainders of former “ skilled ” accomplishments. These,
occurring on the dissolution side of the scale, differ in character
from the erratic, grotesque, repeated, mechanical-model-like,
and often “ unskilled ” movements which occur on the sub¬
evolution side and are due to imperfect control and insufficient
practice.

The above remarks on the general pathology of the “ cata
tonic ” sub-class of premature dementia, point, in the opinion
of the writer, to a more extensive process of neuronic dissolution
than occurs in the “ hebephrenic ” sub-class ; and this view is
supported by the amount of dementia which is found in the
cases belonging to the former. Whilst in the “ hebephrenic ”
sub-class the percentage of cases which exhibit at least a
moderate grade of dementia is 55, this percentage amounts in
the “ catatonic ” sub-class to no less than 73, which is at the
same time much higher than the percentage of 60 in the com¬
plete class of premature dementia.

The writer thus feels justified in regarding the " catatonic”
form of premature dementia as merely a more extensive grade
of cerebral dissolution than the “ hebephrenic ” ; and in holding
that it exhibits such distinctive motor phenomena on the one
hand through immaturity or sub-evolution of—and consequent
deficient stability of, and incomplete higher control over—the
neuronic complexes of the psycho-motor area, and on the other
to the existence of stereotyped motor remainders of a “ skilled ”
nature consequent on the survival, during the process of cerebral
dissolution, of local and relatively stable neuronic complexes.

From the latter (dissolutive) aspect in mental disease gene¬
rally, and from the former (developmental) aspect in many of
the types of high grade amentia but especially in the class of
“cranks and asylum curiosities,” the homology between these
motor phenomena of catatonia and the psychic phenomena

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BY JOSEPH SHAW BOLTON, M.D.

455

1907.]

which are due to affections of the various centres of lower asso¬
ciation (including hallucination), is obvious, and affords support
to the opinion of the writer (Journ. Ment. Sci ., April, 1906,
p. 268, and Brain , Summer, 1903, pp. 217, 218) that the psycho¬
motor area is also a centre of lower association, and not a
projection sphere.

As might be expected from the above remarks on the general
pathology of “ catatonic ” motor phenomena, the histological
evidence hitherto obtained has been positive and negative in the
hands of different observers. The purely developmental or
sub-evolutional phenomena of the “ Frankenstein ” or
“mechanical model ” nature, being due to a deficient stability
of neuronic groupings owing to insufficient practice in the co¬
ordination and control of the complex physical bases of the
“ skilled ” movements evolved, have necessarily no morbid
histological features capable of detection by the methods at the
disposal of the neuro-histologist; and hence the entire absence
of gross morbid appearances, in the psycho-motor area of cases
which exhibited during life marked cataleptoid phenomena, is
only to be expected. On the other hand, well-marked morbid
appearances in the cortex cerebri—especially obvious in the Betz
cells—of cases possessing considerable dementia, and, at the
same time, exhibiting special stereotyped motor remainders of
former “ skilled ” movements, are naturally found in association
with general prefrontal and frontal cortical dissolution; but,
with our present knowledge, at any rate, it is impossible to
isolate relatively normal physical cell-groupings for such motor
remainders amongst the complex galaxy of normal, and partially
or completely disorganised, cell-elements in the psycho-motor
area. It is, however, likely that the histological study of cases,
selected according to the general type of the motor phenomena
exhibited by them, may, even by the employment of the neuro-
histological methods at present at our disposal, lead to fruitful
results in the near future.

The present sub-class, like the last, includes both presumably
“ normal ” individuals and degenerates. In the male sex the
percentage of high-grade aments is 30*4, in the female, 39*0,
and in the whole sub-class, 34*1. This last is much lower than
the corresponding percentage of 51*6 in the “ hebephrenic ”
sub-class, and considerably lower than the percentage of 44*6
in the total class of premature dementia. Such a result is

3 2

LIII.

456

AMENTIA AND DEMENTIA,

[July,

a priori to be expected, as more extensive dissolution naturally
occurs when the breaking-strain of the relatively normal
cerebrum is reached by over-training, than follows the attain¬
ment of the less severe breaking-strain of the cerebrum of the
degenerate. A considerable proportion of high-grade aments,
in fact, break down so readily under the “ stress ” which is the
normal environment of the sane, that they sustain no appre¬
ciable neuronic damage, and convalesce, only again to relapse,
until they finally become permanent and non-demented asylum
inmates.

Of the forty-one cases in the present sub-class sixteen were
workers (eight good, two ordinary, and six poor), eight refused
to work, and seventeen were incapable of useful employment.

The following twelve cases are inserted for illustrative
purposes:

Attitudes and Forced Movements; Stubbornness; Impulsiveness; Rapid
Cerebration ; Mild Premature Dementia ; certified four years and
previously at the age of 15.

Case 596.—W. E. W—, male, single, aet. 25, clerk. Certified since
the age of 21 and previously at the age of 15. Notes taken three
days after admission.

A dull, heavy looking man. Palate high, and narrow in front. He
takes little or no notice of me, but replies to short, sudden, and rapidly-
spoken questions. He knows where he is and where he has come from.
He cannot say when he came but asks me if I have forgotten. He
then guesses several days in succession and all wrongly, and afterwards
talks on to himself in short sentences : “ Why shouldn’t it be? . . •
Is it absurd that . . . ” etc. He has been at his previous asylum

four years and three months. He knows the present month and year
but is four days wrong in the date. He gives his age correctly. He
did gardening at his previous asylum and got cigarettes from home and
tobacco from “ one of the officials, a young fellow there.” It is impos¬
sible to get replies to questions unless he is asked sharply and rapidly,
in which case he replies in kind, as otherwise he mutters to himself and
takes little or no notice. Occasionally after a question he talks on
apparently quite incoherently; the sentences are, however, short and
grammatical, and it is probable that several intermediate ones are
missed out in such a way as to render it impossible to follow the
association of his ideas. He informs me that he passed all the
standards at school. He was then a clerk for seven years, during
which he lived in three different towns. He was only in his last situa¬
tion three months. When he begins to reply to questions the answers
come so rapidly, and his attention so quickly fails, that it is difficult to
cerebrate rapidly enough to understand the replies and state another
question in time to retain his fleeting attention, and render the conver¬
sation consecutive.

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•9° 7-]

BY JOSEPH SHAW BOLTON, M.D.

457

At the time the above notes were taken the patient had exhibited
no definite motor phenomena beyond partial stupor, and a general
tendency to stubbornness when anything was required of him. In a
few days, however, he was noticed to stand for long periods in forced
attitudes, and to be aggressive and at times impulsive. Whilst under
observation such phenomena were of common occurrence, and were
especially noticeable at entertainments, etc. He would suddenly kneel
on the floor with upraised hands, or stand in cataleptoid attitudes,
and keep up these positions for long periods. Similar phenomena
were also at times exhibited whilst at exercise. He was a worker of
ordinary type but was at times untrustworthy, very stubborn, and
aggressive. Mentally he continued quite unchanged, either cerebrating
with extraordinary rapidity, or taking absolutely no notice of any ques¬
tions put to him.

Verbigeration ; Moderate Premature Dementia ; certified twenty-one years.

Case 597.— H. W—, male, single, £et. 42, porter ; certified since the
age of 21. Notes taken four days after admission.

A dull-looking man with bright, prominent eyes. Horizontal wrinkles
on forehead. Palate is V-shaped and shelves forward. Teeth good
but irregular. When asked his name he makes no reply. When his
name is mentioned he replies “ Yes, Yes.” He then looks up, notices
what I am doing, and smiles. Where are you ? “ No, No.” Where
are you from ? “ E—, E—.” What is your name ? “ W—, W—He
thus replies readily to a question, of which shortly before he took no
notice, as soon as he has begun to speak. What is your age ? “ Oh,
Pm sure I don’t know, sure I know.” Are you married? “No, No,
No, No.” Do you know H— ? (his previous asylum) “ Yes, Yes,
Yes, Yes.” Have you any children? “No.” Have you any children ?
“No, No, . . . No, No.” Did you work at H—? “No, No,

No.” Do you smoke? “ No, No.” He occasionally smiles in a silly
manner during the conversation. Did you strike any one at H— ?
“Oh, no! Oh, no!” and laughs. Were you in the padded room ?
“No, No, No, No, No.” Nothing further can be got from him, and, if
he is smiled at, he laughs in a vacuous manner.

Whilst under observation he was dull, stupid, uninterested in his
surroundings, and unemployed, and required prompting, and at times
assistance, before he would attend to himself and his bodily functions.

Partial Stupor; Attitudes; Mild Premature Dementia; certified five
years ; and showed symptoms for at least six years previously.

Case 599.—A. S—, male, single, aet. 39, gardener ; certified since the
age of 34, but showed symptoms for at least six years previously. A
paternal relative insane. Notes taken two days after admission.

Patient sits staring vacantly forwards and upwards, with the head
thrown back, and the muscles of the front of the neck prominent. His
lips are compressed, and at times he nods and slowly closes and opens
his eyes. He is very slow in replying to questions, but gives his sur¬
name and his Christian name. He says that his age is 20. He knows

458

AMENTIA AND DEMENTIA,

[Ju'y.

where he is and where he has come from, and he states that he was in
that asylum for four or five years. When again asked his age he repeats
that he is 20. His limbs can be fixed in cataleptoid positions by
stroking the necessary muscles, but these are not now (voluntarily)
assumed.

Whilst under observation, the patient, as a rule, stood for practically
the whole day long, in the same attitude, and, as far as possible, in the
same places. By judicious and persistent prompting he would at times
perform such simple mechanical acts as carrying coals, etc., and could
similarly be got, and at times more readily, to attend to himself. Such
actions as he performed resembled, in their absence of smoothness and
refinement, those that might be carried out by a mechanical model.
Whilst under observation the patient remained in exactly the same
condition.

High-grade Amentia ; Repetition of Movements ; Simple Habit Tricks ;

Moderate Premature Dementia ; certified eleven years .

Case 600.— C. F— , male, single, set. 39, labourer; certified since
the age of 28. Mother insane. Notes taken three days after admission.

A vacuous-looking man, with a badly-developed lower face, teeth
separated by gaps, and a large, partially bald, cranium. He constantly
talks to himself and carries out habit-tricks, such as holding a piece of
paper in one hand, and alternately turning it over, and moving the other
hand up and down, to and fro, or round and round the piece of paper
at some distance away from it. When asked to write his name he does
so, but it is almost impossible to read what he has written, as he so
exaggerates, and repeats over itself so many times, the beginning and
end of each letter he writes. He also duplicates the “e” in “Charles.”
He writes his age as “35.” Whilst writing “age” he seems quite
unable to leave the “ g ” alone, and after writing the “ 5 ” he proceeds
to cover it over with fine curled lines until the letter is practically
invisible. This was probably owing to his not being prompted to
write anything further, and to his being quite unable to take the pencil
off the paper without being told to do so. As soon as the pencil has
been taken from him he develops a vacuous grin of satisfaction. He
is extremely garrulous. He is “ not a married person, but I have a
brother and sister married.” He speaks inconsequently about asylums,
convalescent homes, and sanatoria, and he asks me if this place is C—
or M— (names of asylums). He thinks he has been away from town
(H—) for about five years. Have you done any work? “With a
piece of iron on a stock ” (probably a farm or garden implement). He
tends in his replies to questions to say the reply and then to spell it
out, and he even at times repeats the spelling. Whatever he says or
performs, he cannot leave alone, but tends to repeat the words or actions
over and over again. During conversation he hardly ever stops twirling
his right hand about or moving it around at different angles. When
asked about hallucinations he replies : “ People come close to me and
give me stones, and I wet them in my mouth and spit them out.”

Whilst under observation the patient was mentally unchanged, and
he was practically useless as a worker.

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BY JOSEPH SHAW BOLTON, M.D.

459

1907.]

Note .—The tendency to repetition of movements, the simple
habit-tricks, and especially the method of writing, which are
exhibited by this patient, are worthy of attention.

Resistive Stupor; Impulsiveness; Mild Premature Dementia ; certified

five years .

Case 603.—A. V—, male, married, aet. 34, brick-maker. Certified
since the age of 29. Notes taken three days after admission.

A blank faced man who sits with his head bent forwards, or tries to
turn away from me, or to get up and go away. As soon as he settles
on his chair he looks downwards with wide open eyes and dilated
pupils, and exhibits an intent expression which resembles that produced
by fear. His attention can only be momentarily attracted, and when
he is intently gazed at he gradually begins to exhibit tremor of the head
and neck as a result of the great rigidity of his muscles. He is
extremely resistive. There is no tendency to a cataleptoid state, but if
the limbs are raised they remain in this position owing to their extreme
rigidity. He either takes no notice of questions or replies quite
suddenly, e.g., “ I sleep very well, sir.” He therefore, at any rate, at
times, hears and understands, and can reply to what is asked of him.
When I tell him that I have done with him he gets up and^goes at
once.

Whilst under observation the patient continued unchanged mentally
He was at times violent and impulsive and he was totally unemployed.

Note .—This case, in many respects, presents a great re¬
semblance to Case 596.

Partial Stupor; Moderate Premature Dementia; certified two years t
and previously at the ages of 25 and 23 years.

Case 604.—P. T. M—, male, single, jet. 28, private in the army.
Certified since the age of 26 years, and previously at the ages of 25 and
23 years. Notes taken four days after admission.

A sleepy man who looks up when told to do so, and who makes
grimaces when asked to put out his tongue. He gives his name and
states that his age is 24. He speaks in a whisper. At times he smiles
in awacuous manner, moving the left side of the face more than the
right He is very slow in replying to the simplest questions, and nearly
all the information he supplies is either inaccurate or inapposite.
When, for example, he is asked if he knows anyone here, he remarks
“Plenty to do.” He sits all day in one position and does not
voluntarily move, even for meals. He does nothing for himself,
frequently masturbates, and is wet and dirty in his habits. His bodily
health is satisfactory.

Whilst under observation he gradually recovered from his stupor, and
though very dull, phlegmatic, and uninterested in his surroundings,
became a useful worker.

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460 AMENTIA AND DEMENTIA, [July,

Verbigeration; Echo/alia; Moderate Premature Dementia ; certified six
years and previously at the age of 21.

Case 605.—G. P. P—, male, single, set. 30, grocer’s assistant Certi¬
fied since the age of 24 and suffered from a previous attack at the age
of 21. Aunt insane. Notes taken two days after admission.

A vacant-looking man who stares about him, occasionally smiles in
an insipid manner, and fidgets with his hands. When asked his name
he replies “ P—, P—.” Christian name ? “ Christian G— P—

Where are you ? “ Where am I ? ” He reads the name of the asylum

when shown it. He came here “ 3—4—5 years ago,” and still seems
to think that he is in his previous asylum, though he points to and
speaks the name of the present one. How old are you? “How old
am I ? 27—28, yes.” He says that he can work, in reply to a

question. At his previous asylum he worked in the garden ? Did you
get tobacco ? “ Tobacco. Yes, little pieces.” Often ? “ Why, three

times a week, yes.” Do you hear people talking to you ? “ Yes, talk

at night. Yes, they talk you know. Yes.” He owns that he has been
a troublesome patient, and uses such expressions as “ Giving way,”
“Breaking out,” “Smash,” “Windows and such things,” “Yes, Yes.”
During examination he has a piece of bread in his left hand, and he
persists in holding it whilst he dresses.

Whilst under observation the patient showed no signs of mental
change and was dull, listless, apathetic, and quite unemployed.

Semi-voluntary Cataleptoid State ; Some Premature Detnentia ; certified
nineteen years atidpreviously in an asylum .

Case 623.—C. R—, female, single, aet. 44, of no occupation.
Certified since the age of 25, and had previously been in an asylum.
Notes taken on the day after admission.

A woman with a dry skin, a mask-like face, and many fine,
horizontal wrinkles on her forehead. She holds her hands, which are
cold and blue, in more or less constrained positions. She grins in a
silly manner at times. She sits up, puts out her tongue, and does
generally as she is told. She otherwise sits quite still except for a
more or less constant slow movement of the eyes, and an occasional
smile. There is partial cataleptoid rigidity of the limbs. This is by
no means marked, as occasionally, whilst I am moving her limbs about,
a few (involuntary) movements of the extremities occur. Further,
the limbs gradually fall to the bed under the influence of gravity,
though if so placed as to be least subject to this force, e.g., in the
vertical position, or so curved as to be best supported by the resistance
of tendons and ligaments, they remain for a considerable time
practically immobile. Again, when one limb has been fixed, it tends
to undergo relaxation when that on the other side is placed in a similar
position. It is probable, therefore, that in at least many instances the
cataleptoid condition is semi-voluntary. The patient takes no notice
of questions, and except for an occasional smile, which at times appears
to exhibit a certain degree of slyness, takes no interest in her
surroundings.

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1907.] BY JOSEPH SHAW BOLTON, M.D. 46 1

Whilst under observation patient continued unchanged. She was
totally unemployed, but would feed and dress herself.

Verbigeration; Attitudes; Moderate Premature Dementia ; certified
thirty-one years .

Case 628.—F. S—, female, single, aet. 51, occupation unknown;
certified since the age of 20. Notes taken two days after admission.

A vacant-looking but restless woman, who mutters to herself and
plays with her hands. She frequently strikes attitudes. She often makes
such remarks as “ Yes,” “ Yes, is it ? ” “ Yes, is it ?” “ Say it,” “ Yes, is
it? . . . it is,” “What is it, no?” “Yes,” “See,” “To see,” etc.

When spoken to she becomes more restless, but she makes no replies
beyond such as have just been stated. She often sits for long periods
with her head bent forwards.

Four months later her condition was as follows: She is dull in
appearance, and at times looks around her. She replies to questions
by means of a few partially-intelligible words which are spoken smartly
and in jerks— e.g. y “ Yes, yes, three years,” to a question as to where
she is. Who is that? (a nurse) “Yes, yes, that is.” What is your
name ? “ I call.” It is very difficult to catch what she says. She
accepts such names as “Mary,” “Susan,” etc., although they are not
correct. On one occasion, when asked why she did not reply, she said
“because I wouldn’t.” She frequently strikes attitudes. She sits in
one chair all the day long. She is noisy at times but does not swear.
She never works. She occasionally undresses herself. She never
reads or writes. She can find her way about the ward, but she never
goes alone. She never asks to go to the lavatory, but she goes when
the others do. In the mornings she partially dresses herself. She has
once or twice been wet in her habits.

High-grade Amentia ; Stupor; Salivation ; Moderate Premature
Dementia; certified four years.

Case 632. —G. K—, female, single, aet. 26, domestic servant.
Certified at the age of 22. Notes taken two days after admission.

A dull-looking woman of vacuous appearance. Some asymmetry of
the face, the right eyebrow being higher than the left. Forehead very
peaked, /.<?., each side falling rapidly away from the metopic suture.
She sits with her hands doubled up, the thumb lying inside the flexed
fingers, and takes no notice of her surroundings. She states her name
in a childish whisper, and, when asked to write it, does so slowly and
laboriously and in copy-book style, the details resembling those
already referred to and described in previous cases as characteristic
of patients who have learnt to write properly and have afterwards
developed premature dementia. She rarely says more than one or two
words in reply to questions, and usually merely whispers a “ yes.” She
is very slow in replying to questions, and the responses are, as a rule,
quite incorrect. She salivates a good deal. She feeds herself with a
spoon and partially dresses herself. She is clean in her habits and
follows the other patients to the lavatory.

462 AMENTIA AND DEMENTIA, [July,

Whilst under observation the patient remained unchanged; she was
dull, apathetic, semi-stuporose, and entirely unemployed.

High-grade Amentia; Attitudes; Explanatory Delusion; Some
Premature Dementia; certified six years.

Case 635.—A. L. M—, female, single, aet. 33, servant. Certified
since the age of 27. Notes taken on the day after admission.

A morose-looking woman with a small moustache and beard, ears
without lobules, and the general appearance, except for complexion, of
a Red Indian. She states her name, speaking with a lisp, and gives her
age as 36. She knows that she came here yesterday, where she has
come from, and that she was in that asylum for six years and seven
months. She informs me, in reply to a question, that she cleaned the
bath-room whilst there, but she adds that it was not she herself who
worked but a machine which walks about as her, because she would not
do “county work.” “This machine goes and walks about and does
things I don’t want to do.” She has had the machine in her all her life.
When asked about hallucinations she denies them, but she states that
“men come about and pretend I am a person I am not.” She
knows the day correctly, and states that the month is “September
or October” (October). She does not know the date or the year. She
is spiteful, and has already several times spit and scratched. She is un¬
tidy as regards her hair. She is clean in her habits.

Four months later the patient continued unchanged. She usually
sat still all day, or stood looking out of the window, and always in
more or less forced attitudes, which she was constantly striking. She
spit about a good deal and often rubbed it on her dress. She did no
work, and though she dressed herself she neither did her hair nor made
her bed. She was clean in her habits.

Note. —The simple explanatory delusion exhibited by this
patient is worthy of attention.

Habit Tricks; Attitudes; Forced Movements; Moderate Premature
Dementia ; certified nine years, and previously at the age of 20.

Case 636.—J. S—, female, single, set. 40, housekeeper; certified since
the age of 31, and previously at the age of 20. Paternal grandfather
insane. Eldest brother, and also paternal uncle, committed suicide.
Notes taken two days after admission.

Hair very thin (from a habit of pulling it out) Teeth very irregular.
Palate high, narrow, especially in front, and shelves forwards. Lobules
of ears deficient. No cracks on abdomen. Breasts very atrophous.
Marked corns on right knee (from a habit of kneeling).

A dull, childish-looking woman, who sits quietly and pays little
attention to questions. She sniffs almost continuously, and plays with
and picks her fingers. What is your name? “Sally, Polly, Tommy.
Jip,” and laughs. She then, when the question is repeated, replies
“Jane” (incorrect). “That’s cherry tree they put in, your name, and
turpentine and beeswax” (possibly objects she has recently noticed,
as the gardens are being planted and the floors are being polished).

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1907]

BY JOSEPH SHAW BOLTON, M.D.

463

She then mutters away to herself about “ Polly Paine,” “ Lucy Mercer,”
etc. (names unknown). She cannot dress herself. She stays wherever
she is placed. When she walks she keeps stopping and kneeling down
on the right knee.

Some three or four months later her condition was substantially
unchanged, being as follows : She picks away at her finger nails and takes
no notice of me. If I try to attract her attention she says, “ Don’t do
that,” and goes on picking away as if absorbed in her occupation. At
times she looks up and smiles in a shy manner.

She is very quiet but mutters to herself at times. She kneels down
before she does anything— e.g., on getting up in the mornings she kneels
down and then stands naked for about half an hour. She does nothing
for herself except as regards partial dressing, not even attempting to
wash herself or do her hair. She is at times wet and dirty in her habits.
If put in a certain place she, as a rule, stays there till she is moved, but
at rare intervals she darts suddenly to the opposite side of the room.
She often performs such actions as carrying out rolling movements with
her fingers, or lying flat on her back on the floor for a minute and then
getting up and kneeling on her right knee. She is stubborn over her
food, which has to be more or less forced into her mouth.

Class (d).

Sub-class (3). Premature Devientia—approximately “ Paranoid."

This sub-class contains seven cases, of which two are males
and five are females. In spite of the small number of included
cases, the writer is of the opinion, for reasons which are given
below, that a “ paranoid ” sub-class of premature dementia is
desirable for descriptive purposes, as he is convinced that the
delusional cases now under consideration should not be in¬
cluded under either the “ hebephrenic ” sub-class, or under the
class of “ paranoia or insanity with systematised delusions,”
which is described under “Amentia” in Part II (Journ. Ment .
Sci. t January, 1906, pp. 14—28).

With reference to the former the differences are obvious, and
as he is here dealing, not with the precursory symptomatology
of, but with developed examples of, premature dementia, a few
words on this point will suffice. Cases belonging to the present
sub-class exhibit relatively little confusion, and resemble
ordinary examples of delusional insanity in the existence at
their onset of a distinct and, at any rate, semi-systematised, per¬
secutory stage in which hallucinations occupy a prominent
place, and in their relatively slow progress; whereas, in the
“hebephrenic” type of premature dementia, mental confusion,

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464

AMENTIA AND DEMENTIA,

[July,

with hallucination as one of its symptoms, is the prominent
feature, and more or less rapidly ends in a mild or moderate
grade of dementia. In the case of hebephrenia also, if perse¬
cutory ideas arise in consequence of persistent hallucinations,
they are multiple and unsystematised, and the patient, at the
most, develops an explanatory delusion.

With regard to paranoia, on the other hand, the differences
are less obvious, and the psychiatric description of these is
somewhat difficult to give with clearness. The ordinary state¬
ment that paranoid cases are primarily dementias with a less
systematised set of delusions is inadequate, as it is possible to
reply that the earlier age of onset, and the consequent existence
of a less stable and experienced cerebrum, result in the deve¬
lopment of an abbreviated and less systematised set of delusions
and in a more rapid course to dementia, and that, therefore,
such cases are really examples of true premature paranoia.

The latter was at one time the opinion of the writer, but
further experience convinced him that it was necessary to limit
the term “ paranoia ” to a special type of case with systema¬
tised delusions, which possesses its sane prototype, as does
amongst others another and simpler, but correlated, type of
high-grade amentia, the insane “crank” ( Journ . Ment. Sci. f
January, 1906, pp. 14—28). Such cases exhibit anomalous

psychic processes which are presumably of developmental
origin, and mild dementia ensues only with the onset of cere¬
bral involution. The remainder of the cases commonly classed
under “ paranoia ” exhibit complex phenomena of association
which arise under the influence of local disorders of lower asso¬
ciation. These phenomena are probably indicative of neuronic
dissolution in the particular centres of lower association which
serve as their physical basis, and such cases frequently develop
considerable dementia. Two such examples are described and
discussed in an earlier section of this paper [Journ. Ment. Sci
July, 1906, pp. 481—486). In paranoia, in the view of

the writer, the centre of higher association is the primary
region at fault, in that it is unable to exercise its normal
functions of co-ordination of, and of corrective and selective
control over, the centres of lower association. In the delusional
cases, which he excludes from the group of true paranoia,
various local disabilities exist in one or more of the centres of
lower association, and these lead either to unharmonious action

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1907.] BY JOSErH SHAW BOLTON, M.D. 465

of these centres in relation to one another, or to more generally
aberrant psychic processes, involving also the centre of higher
association. The former condition is developmental, and the
latter is evidence of local cerebral dissolution which slowly
becomes widespread; and for the moment, for the sake of
clearness, they may be spoken of as developmental and dissolutive
paranoia respectively.

The cases contained in the present sub-class are of a similar
type to the latter, and may be termed, for the moment, examples
of premature dissolutive paranoia . Such cases occur at all ages
and might conveniently be classed as examples of “ paranoid
dementia.’’ The writer, however, prefers, owing to the fact
that all grades of delusion exist in cases of dementia, from the
unsystematised to the semi-systematised, or even the systema¬
tised, not to make use of any such general symptomatological
division, although during the description of premature dementia
he has found a sub-class of the kind convenient. His excuse
for making an exception in the present instance lies in the fact
that, of all the classes of primarily neuronic dementia, the
amount of dementia is the greatest in the premature variety,
in which, therefore, such a symptomatological division is both
possible and convenient for descriptive purposes, although,
from the general psychiatric aspect, it is undesirable. In other
words—to render his position quite clear—whilst in premature
dementia the few “ paranoid ” cases stand out sharply from the
(usually more demented) “hebephrenic” and “catatonic”
types, in the other varieties of primarily neuronic dementia no
such “ paranoid ” group is evident unless all cases exhibiting
unsystematised, semi-systematised, or even systematised delu¬
sions were included in this, to the exclusion of every other
symptomatological characteristic. Under such circumstances,
as so many further possible sources of delusion exist, owing to
the more extensive mental content of the adult individual, a
reductio ad absurdum would necessarily result.

The writer therefore limits the term “paranoia” to cases
possessing anomalies of the higher psychic processes which are
of developmental origin, and includes dissolutive delusional
cases, with the above restriction of convenience, under the
more general divisions of primarily neuronic dementia.

That this reservation is one of convenience only is clearly
shown by the following case, which exhibits a symptomatology

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466 AMENTIA AND DEMENTIA, [July,

comprising motor phenomena— c.g. t the striking of attitudes,
semi-voluntary cataleptoid states, verbigeration, and character¬
istic handwriting ; stereotyped “ paranoid ” phenomena— t.g.,
hallucinations and delusions of persecution and grandeur; and
with these a moderate grade of dementia. The interest attached
to this case is still further increased by the fact that a brother
of the patient, now dead, had exhibited a similar complex
symptomatology.

J. J. M— (Rainhill Asylum), male, married, aet. 41, iron-
moulder, certified since the age of 32. Brother died in this
asylum (see notes below); father and also other brothers
intemperate.

Six months before admission patient suffered from influenza,
and three weeks before admission he developed mental sym¬
ptoms, which chiefly consisted of hallucinations of hearing.

On admission he was quiet, coherent, and rational, and his
memory was fairly good. He was able to give a good account
of himself. He stated that his wife had committed adultery,
and that people could easily read his thoughts by means of
some machine.

For some months he continued quiet and unobtrusive, and
was somewhat depressed. He was much occupied with his
hallucinations, but worked fairly well. He then became
grandiose, stating that he owned millions of pounds, and that
the Prince of Wales and others were trying to kill him by means
of machines in order to obtain this money.

A few months later he became restless, excited, dangerous,
and threatening, and was noisy and talkative, and much troubled
by hallucinations of hearing and delusions concerning electricity.

Four years after admission he was still in a similar condition,
and he suffered severely from hallucinations of hearing, the
voices appearing to come from the ceiling and from under the
floor. He stated that he was in the asylum as “J. J. M—
but that this man was tortured and killed two years ago, and
that he had assumed his form and name. He therefore gave
his age as two years.

He then for some time showed little mental change, but
gradually came to speak of the voices as “ crack-pots/’

He continued in this condition for some three or four years,
and then gradually developed characteristic motor phenomena
and a fixed delusion of grandeur.

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1907.] BY JOSEPH SHAW BOLTON, M.D. 467

He has now been in the asylum nearly ten years, and his
present mental condition, in brief, is as follows :

He is a dull, listless man with a broad nose and a high
and shelving palate. He is clean in his habits and a
ward worker. He is at times noisy, and he is occasionally
annoyed by what he calls the “ crack-pots.” He often stands
motionless for long periods with his eyes closed, his mouth
open, and his hands outstretched. He exhibits semi-voluntary
cataleptoid phenomena. If, e.g., one of his arms is raised, it
remains where placed; if, then, the second arm is also raised,
both arms remain for a long time rigid and motionless; if during
this period the patient is suddenly told to open his mouth, he
does so, and his arms at once fall down to the sides.

He replies readily to questions. He rejects his proper name,
and states that his name is “ King George,” and when asked to
write his name he slowly and laboriously indites “ king George,”
carefully finishing off the letters and then returning to dot the
“i” after he has finished. The style of hand-writing is in every
way characteristic of that frequently referred to as occurring
in premature dementia. When asked which “ King George ” he
professes to be, he replies, “ Not King George III; my name
is King George only to you, sir.” Age ? “ Unknown Zetland
years of age I been dead ” {cf. a delusion referred to already).
“I came with a man named M—” (his own name). “ I’m
turned five years in this building, sir. Altogether here going
for ten years. He came from W— on 7th or 8th October, ten
years ago” (correct duration within two months). He knows
the day and the exact date within a day, i.t ., “ 26th or 27th
February, 1907, 1907 year to you, sir ” (really 25th). When
again asked his age he replies, “ Unknown Zetland, Unknown
Zetland, Unknown Zetland, if you know what ‘Z* means.
Unknown Zetland. I have to go by 4 Z * to you sir. I have no
father and no mother to you, sir.” It will be noted that he
ends many of his phrases with “ to you, sir,” and also verbi-
gerates.

The brother of this patient exhibited a very similar sympto¬
matology, which is, briefly, as follows:

He was nine years older than his brother, and was admitted
at the age of twenty-nine years. He was married, and was a
file-cutter. When admitted to Rainhill Asylum he was excited,
and suffered from hallucinations of hearing concerning women

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468

AMENTIA ANI) DEMENTIA,

[July,

and spirits, and from hypochondriacal delusions concerning his
heart and stomach. He then became noisy, abusive, threaten¬
ing, and violent, and suffered from marked auditory hallucina¬
tions and visceral delusions.

Two years later he often conversed with himself in an excited
manner and suffered from hallucinations, he had numerous
delusions regarding his present position, and he considered
himself a supernatural being.

Shortly afterwards he began to develop cataleptoid
phenomena, often remaining on his knees for hours in a
partially dressed condition.

Five years after admission he stated that he had been in the
asylum 20,000 years, that he was sixteen years of age, and that
“ spinks ” were around him ( cf . the “crack-pots” of his
brother).

Seven years after admission he became dull and slovenly, and
ceased to speak, work, or amuse himself. He also became dirty
in his habits. Concurrently with this change in his mental
condition, and probably as the cause of it, he developed tuber¬
culous pleurisy, and he died of phthisis six months afterwards.

The remarkable resemblance between these two cases is too
obvious to need further reference. The writer, however, as he
made no personal observations on the latter, purposes to con¬
fine his attention to the former in the following remarks.

Such a case, though certified at the age of thirty-two years,
would fall equally under the “ catatonic ” and “ paranoid ” sub¬
classes of premature dementia, in that it exhibits on the one
hand, developmental and dissolutive motor phenomena, and on
the other, complex dissolutive psychic products of paranoid
type. The former of these have a physical psycho-motor basis,
which justifies a symptomatological “ catatonic ” sub-class; the
latter, except perhaps as regards the hallucinatory phenomena
of lower association, have no such relatively simple physical
basis, and therefore the formation of a “ paranoid ” sub-class,
except as regards convenience, possesses no present patho¬
logical justification. Such a paranoid symptom-complex, in
fact, occurring in a case which exhibits the typical character¬
istics of the “ catatonic ” sub-class of premature dementia, is,
in the opinion of the writer, ample evidence that the “para¬
noid ” state, in contra-distinction to “ developmental paranoia/'
is simply indicative of a cerebral dissolution which involves both

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BY JOSEPH SHAW BOLTON, M.D.

469

1907 .]

the individual neurones of the higher centre of association, and
of several centres of lower association, and also, as a conse¬
quence, in a most intricate manner, the various intra-centric
neuronic complexes.

He therefore holds that the “ paranoid ” state is a variable
symptom-complex indicative of widespread, though not neces¬
sarily advanced, cortical dissolution, and that it is consequently
undesirable to employ the term generally, either for gross
symptomatological purposes, or to denote a psychiatric sub¬
division possessing a histo-pathological basis.

The small number of cases in the sub-class at present under
consideration renders it impossible to draw conclusions of value
with regard to degeneracy and dementia respectively. It may,
however, be stated that three of the seven cases are high-grade
aments, which is about the average occurring in the total class
of premature dementia; and that two of the seven cases exhibit
a moderate grade of dementia, which is much below the average
occurring in the whole class.

Of the seven cases, four were workers (two good and two
ordinary’), one refused to work, and two were incapable of useful
work.

The following five cases are appended for the purposes of
illustration.

High-grade Amentia; Grandeur; Suspicion; Systematised Persecutory
Delusions; Hallucinations of Hearing ; Mild Premature Dementia ;
certified eleven years .

Case 637.— A. A. S —, male, single, ret. 31, painter. Certified
since the age of 20. Father insane. Notes taken on the day after
admission.

Palate very high, very narrow, and shelves markedly forwards. Incisor
teeth very prominent. Mouth open. Chronic disseminated tuber¬
culosis of both lungs.

A thin, bright-eyed young man with a bad cough, who speaks with a
slight lisp. He gives his name, and the year in which he was born,
(presumably correct). He knows where he is, and says that he has
never been in this neighbourhood before. He gives the correct day
and date. He states the exact date on which he was first taken to an
asylum, and states that he was there “just under 21 years.” He
presumably here refers approximately to his age when admitted. He
gives the exact date on which he was transferred to the asylum from
which he was admitted here. He was an “artist decorator” and
served the whole of his apprenticeship, afterwards “jobbing about.”
“I pleased myself and suited the exhuberance of my own verbosity in
going to C—(his first asylum)—this remark being given in reply to a

470

AMENTIA AND DEMENTIA,

[July,

question as to the cause of his detention. He replies that he hears
voices, but “ I was all right, I was all right. I was keeping my eye
open.” He thinks it was a male voice, and he very seldom hears
women’s voices. He then states that “ Electricity is life. As Dr. —,
passed through the ward, he said ‘Is that the line?’ and I said ‘not
yet ’ and then he came parallel, and we seemed to go by train, didn’t
we? . . . But it’s such a lot, its no use talking, except giving an idea

of what we are talking about.” He thinks the voices “ are all to my
good,” also “ my brain is touched and played on by electricity.” Who
does it ? “ That’s a matter of the combination, one thing or another.
Doctors must get well and so a patient must get worse ” . . “ I was
much afflicted the first two months at C —. I had the battery put on.”

Whilst under observation patient improved in health and became a
moderately useful worker. Further conversations resembled that given
above, and merely confirmed the conclusion, which had already been
acquired, that the patient had previously elaborated a systematised
group of delusions of a persecutory nature, but that his abbreviated
modes of thought and expression, consequent on the development of
stereotypism and mild dementia, rendered it impossible to obtain a
complete account of their exact nature and mode of development He
was suspicious, conceited, and grandiose, and had a habit of showing
very obviously that it was not worth while troubling, and might even be
risky, to give detailed descriptions of his experiences, which could not
be comprehended and might readily be misunderstood by his inter¬
locutor.

High-grade Amentia ; Delusion of Grandeur ; Moderate Premature
Dementia ; certified seven years .

Case 638. —G. P. T— , male, single, aet. 29, of no occupation.
Certified since the age of 22. Notes taken two days after admission.

A fatuous-looking young man with a small upper lip. He gives his
correct surname, and when asked his Christian name he remarks,
“ Whatever you like to call me.” He does not know where he is or
what is his age, but, hearing a piano, he remarks, “ It’s a good-toned
piano, that is.” Can you play ? “ Oh, yes.” He states that he was

born in P— workhouse and used to scrub floors there. He tells me
that his father and mother were Mr. and Mrs. M—. He is extremely
dull, silly, and fatuous, and the information he supplies is quite untrust¬
worthy. For example, he previously did not know his age, but when
asked later he replies “ 22.” He says that he went to school, so I ask
him to write his name, which he has previously stated correctly. He
takes the pencil in his hand readily, but slowly, and, after licking it, he
painfully and tediously writes as follows :—

He informs me that this is really his name, that it is a “ Christian
name,” and that he has to keep writing it so as not to forget it.

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1907-]

BY JOSEPH SHAW BOLTON, M.D.

471

Whilst under observation he remained dull, fatuous, and listless, and
could not be persuaded to do any work, though he would attend to his
own wants. When requested, he would write his name as above.

Note .—The case is an unusual one, and owing to the amount
of dementia present it was not possible to determine the
method by which the patient had arrived at his fixed idea,
which, curiously enough, he could only be got to express in
writing. The writing is similar to that already several times
mentioned as characteristic of premature dementia. The
general behaviour of the patient, as already stated, was that of
a moderate dement, and not that of an imbecile, though the
patient was obviously a degenerate. The case, after considera¬
tion, has therefore been placed in its present position, as an
example of the delusional type of premature dementia in a
patient of originally defective intelligence. The writer has
been influenced to adopt this view owing to having seen more
than one case of similar type, and, notably, a patient of origin¬
ally defective intelligence who thought that he was heir to the
throne and son of the late Queen. This patient was firmly
convinced of the truth of his delusion, although he could give
the names of his father and mother, and was able to inform
me that they had both been dead some years. (The late Queen
was then alive.) When confronted with this discrepancy he
was not in the least disconcerted, but talked fluently and in-
consequently about his “ family likeness to the Georges,” etc.

Delusions of Grandeur; Mild Premature Dementia; certifiedfive years.

Case 639.—A. E. R—, female, married, set. 30, charwoman.
Certified since the age of 25, and showed symptoms since the age of
24. Notes taken on the day after admission.

The teeth are very irregular. The palate is very high, narrows
remarkably anteriorly, and then rapidly shelves forwards. The ears
have no lobules. The finger nails are bitten into the quicks. There
are no skin cracks on the abdomen, and the breasts are nulliparous.

A lively-looking woman with a very smooth forehead and bright eyes.
She informs me that her name is Mrs. L—, and that she became
Mrs. L— whilst at G— (the asylum from which she has been trans¬
ferred). Mr. L— is a lawyer at H— (her native town), and she used
to know him when she was a girl at school. She thinks that he died
six months ago. She was married by telephone in his hospital at H—
two and a half years ago. Mr. R— (her present husband) died 10 or
12 years ago, and two days after his death she was married to the Czar
of Russia because she was an adulteress. She was then the Czarina of
St. Petersburg. When asked about the asylums in which she has

Eli I. 33

472

AMENTIA AND DEMENTIA,

[Ju'y.

resided she informs me that she lived “ 3^ years next November at
G—, might be longer.” She went there from C—, in which she had
lived three and a half years. (She has only been certified five years.)
When leaving home “I was to go to Windsor Castle to go to the
palace at Constantinople and if not there to St. Petersburg or Germany
but they sent me to C— instead.” She knows the present day and the
day on which she came here, but she guesses the month as “June or
July” (August), and she does not know the present year. She then
becomes garrulous, and amongst her remarks a question as to whether
she has had any children elicits the following: “ I have three living
children as I know of but they are in Zululand doing well. Two little
boys with golden hair and one little girl. I had a boy and a girl
before but they had fits. One was a sailor and one was a soldier,” etc.
No clear persecutory stage prior to her present condition of grandeur
could be elicited.

Whilst under observation the patient remained mentally unchanged,
and she was a willing and useful worker.

Delusions of Persecution; Hallucinations of Hearing; Premature
Dementia ; certified seven years.

Case 641. —M. E. G—, female, single, set. 31, servant. Certified
since the age of 24. Notes taken three days after admission.

A somewhat depressed woman, who says she is rather unsettled
owing to coming here, but has nothing to complain about. She gives
her name and her age correctly. She says that to-day is Wednesday
(Thursday), and that she has been here a few days and came on
Monday (correct). She knows the month but not the date. She
complains that she received no wages except an occasional penny, and
money from her friends, whilst at C— (the asylum from which she has
been transferred). She states that she was there for seven years. She
acknowledges that she suffers from auditory hallucinations, but “ I
refuse to attend to them.” They are “in my head, but I will not
attend or they would run away with me. It is very hard to have this
trouble but I try to bear it.” “ They repeat my thoughts and seem to
know them. They connect with me in some way and are not to be
seen only heard. They would paralyse me if I would allow them the
power. There are two or three of them, and it sounds like a man or
woman. If I think of a thing I hear the words back.” As an example,
she tells me that if she thinks of my name she hears it repeated by them
in her head. She left her home at H—, as she was ill owing to this
persecution. “ I suppose it is someone I have done harm to, but it is
anyway a very unnatural sound. I have been well brought up and I
feel that it is hard on me.” She finally, when asked about work,
informs me that she can wash up, cook meals, or do anything, and she
says that she is willing to do so.

Six months later her general condition was substantially unchanged,
being as follows : She is dull and phlegmatic, and smiles in a fatuous
manner when addressed. She knows the day, the date, and the date on
which she came here. Voices? “I hear them but I don’t listen to

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BY JOSEPH SHAW BOLTON, M.D.

473

1907.]

them.” When? “Any fime." “I answer myself . . . thoughts.”

She is more secretive regarding her experiences than she was six
months ago. She works in the ward kitchen, and works well at times,
but as a rule she is very slow. She would like to attend to the kitchen
by herself, but she is too slow. She is also slow over eating her food.
It is always necessary to look after her in order to see that her work is
properly performed. She talks to herself, and if she thinks she is alone
she speaks quite loudly. She, as a rule, ceases when she is observed.
She is very fond of hoarding rubbish. She reads newspapers and
books and writes letters. She talks fairly sensibly on ordinary subjects,
and would be a useful worker if she had more initiative.

Note .—This patient resembles in every essential respect
certain cases which exhibit complex psychic products, due,
probably, to local disorders of the regions concerned with lower
association, and allied to, and usually considered one of the
types of, paranoia. Two of these cases are described and
discussed by the writer in an earlier section of this paper
(Journ. Ment. Set ., July, 1906, pp. 481-486). The present
case commenced at an earlier age, namely, twenty-four,
whereas the others had well passed the third and fourth decades
respectively. The patient has developed considerable dementia,
and this disability, her sex, and her lesser intelligence and
education, are probably conjointly responsible for the absence
in her case of a grandiose stage, for this stage in such slowly-
developing cases occurs late, and is arrived at by a process of
more or less elaborate reasoning. The present case thus
rightly falls, in the view of the writer, into the 44 delusional”
or “ paranoid ” sub-class of premature dementia.

High-grade Amentia ; Delusions of Grandeur; Hallucinations of

Hearing \ Moderate Premature Dementia ; certified eighteen years.

Case 643.—M. A. S—, female, single, set. 41, domestic servant.
Certified since the age of 23. Notes taken two days after admission.

An excited woman, with numerous stigmata of degeneracy, who
talks extremely rapidly and almost without cessation. She was sleepless
all last night, and refused her breakfast this morning. She at once
informs me, when I ask her her name, 44 1 thought I was a boy some
years ago and if I had anything to do with a girl I don't know what
they would say.” She tells me that her age was 44 31 on 30th
September.” She knows when she came and the day and the date, and
states, 44 1 have come from a house where there is a girl named
C— P—” (correct). She then rapidly and almost unintelligibly
gabbles on about Queen Victoria, the Government, the Prince of
Wales, etc. She speaks so rapidly, and it is so difficult to retain her
attention, that it is nearly impossible to obtain any further information

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474

AMENTIA AND DEMENTIA.

• ."f 1
- j ,

[July,

from her. She left home in 1876 (incorrect). She hears voices, but
“not much. They talk about throwing chamber-pots.” She then
talks of Holy Communion, etc., and speaks so rapidly and so in¬
distinctly that a satisfactory specimen of her conversation cannot be
obtained, although each phrase seems to follow the previous one
in a coherent, if inconsequent, sequence.

Six months later her condition showed no substantial change, and
was as follows: She talks continuously, and appears to be telling her
history, but, though the individual phrases are correct, the whole is a
most unintelligible conglomeration, which, however, sounds sensible.
At times she gives quite sensible replies to questions, and then runs on
again. She knows the day, but not the month, apparently from non¬
attention. She breaks away too frequently to allow of any satisfactory
history being obtained from her. She says that her illness began at the
age of 16, and that she is an actress and is to marry the Prince of
Wales. She often mutters to herself or shouts to voices, and at times
apparently to the Prince of Wales. She is often threatening in manner,
but she never strikes. She reads, but never writes letters. She sews
and rubs and dusts and makes beds, etc., at times, but becomes noisy
when asked to work, and says she is told not to do it as she is a person
of importance and keeps servants here. She never works unless asked
to do so, and then only under protest. She is clean in her habits, but
is very fond of picking up food with her fingers.

Note ,—In the description of this case, owing to her rapid
speech, it was impossible to reproduce the evidence, which was
constantly being exhibited, that she was not a mere degenerate,
but had lived outside and had seen a good deal of life before
her incarceration. She had obviously suffered a certain amount
of mental deterioration, and the frequent glimpses of a grandiose
condition which she exhibited, together with the absence of
the dulness and apathy of the simple case of premature
dementia, have led to her inclusion in the present sub-class.

(*) The writer is, of course, perfectly aware that “ Frankenstein ” was the maker
of the monster and not the monster itself. As, however, Mrs. Shelley omitted to
supply the latter with a name, he sees no reason why it should not be granted the
modern privilege accorded to motor cars, etc., and therefore christens Frankenstein s
creation after its maker. This explanation is inserted lest the writer’s name
should be added to the list of those who, for the greater part of a century, have
been pilloried for the perpetration of the “ Frankenstein blunder/*

(To be continued,)

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I907.] THE CLINICAL MEASUREMENT OF FATIGUE. 475

The Clinical Measurement of Fatigue . Part I .—The

Measurement of Mental Fatigue . By WILHELM Specht,

of Tubingen University. (From Prof. Kraepelin’s Psycho¬
logical Laboratory in the Heidelberg Lunatic Asylum.)
With twenty-four figures in the text. Authorised Trans¬
lation from the German, revised by Thomas Johnstone
M.D.Edin., M.R.C.P.Lond.

(Continued from p. 570, Vo/. LII.)

The Measurement of Fatigue in Traumatic Neuroses .

We have already pointed to the great practical importance
of the measurement of fatigue in traumatic neuroses. It is
particularly important for our purpose because, as we have
already observed, exaggerated fatigue is always present in
this disease, and so it gives the best opportunity of testing
the general applicability of our method to the clinical measure¬
ment of fatigue.

Many years ago Gross ( ] ) and Roder ( 2 ) measured fatigue in
traumatic neuroses by the method of continuous addition.
They made use of periods of work lasting half an hour, half
an hour’s addition without any pause being done daily for
several consecutive days. Gross calculated the amount of
fatigue from the diminution of the work done in the second
quarter of an hour, stated as a percentage of the work of the
first quarter of an hour, and also from a comparison of the first
quarter of an hour of the second day with the second quarter
of an hour of the first day. By comparing the work values of
his patients with the corresponding work values of a large
number of healthy subjects, Gross discovered that his patients’
liability to fatigue considerably exceeded the “ limits of health,”
and also that the absolute amount of work performed by them
was far below the normal values. These results were after¬
wards confirmed by Roder, who applied the same method to a
larger number of patients.

Gross himself was conscious of the error inherent in his
method of calculating the amount of fatigue. Yet it cannot
be denied that the method has a certain utility, especially if
the amount of work done in each separate section of five
minutes is recorded. In cases where the liability to fatigue is

476 THE CLINICAL MEASUREMENT OF FATIGUE, [July,

extraordinarily great, it will make itself known in a continuous
decrease in the work performed. We recognised the significance
of such a course of work when discussing the experiments made
by Oehrn and Weygandt. On the other hand, we are fully
persuaded that experiments with a pause form the only means
by which anything like a satisfactory measurement of fatigue is
possible.

The patients we employed in our experiments were kept
under observation for a considerable time, partly in the Insane
Hospital and partly in the Medical Hospital of Heidelberg, and
were found to be suffering from traumatic neuroses, free from
all complications. The following brief accounts are taken partly
from the hospital notes made on these patients and partly from
my own observation:

P—, C) 64, belt-maker and clerk to the Guardians of

the Poor. Formerly perfectly healthy. In 1897 was in a
railway collision. Slight external injuries. Great fright, much
excited, fainted. Has been changed ever since. Very forgetful,
depression, monotonous train of thought, hasty temper, very
loquacious. Reduced capacity for work at his business. Highly
exaggerated liability to fatigue. Examined by Gross in 1898;
the same disturbances. Practically unchanged in 1903.

B—, aet. 56, grinder. Luetic infection in 1867; always
healthy in other respects. Accident, 1891, open wound on
forehead. Not unconscious. Wound healed well. Subse¬
quently neuralgic pains radiating from the scar, especially on
physical exertion. Almost entire incapacity for work in conse¬
quence of this. Change of character since that time. Irritable
to the point of fits of wild rage, sullen, mentally indolent, weak
of will. Increased liability to fatigue. Numerous hysterical
symptoms. Practically no improvement in capacity for work
so far.

Pf—, aet. 42, whitewasher. Formerly healthy. Fell on his
head in 1900, unconscious for a short time. Open wound,
soundly healed. Able to work in a few days. Changed ever
since. Felt tired, was irritable, and apathetic, grew worse a
year later. Giddy feeling, hysterical attacks. Left off working,
was very quiet, lived “as if in a dream.” Difficulty in compre¬
hension, timidity, increased liability to fatigue, great reduction
of mental and physical capacity for work. Practically no im¬
provement since.

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1907 ]

BY WILHELM SPECHT.

477

J—, set. 48, carter. Insane heredity, formerly healthy.
Struck by lightning and thrown to the ground in 1902, not
unconscious; paralysed on right side. Quick recovery from
paralysis; very timorous since then ; afraid of thunderstorms.
Quiet, shy disposition, feeling of incapacity, hypochondriacal
direction of thoughts. Capacity for work at occupation
reduced, increased liability to fatigue.

T—, mason, aet. 49. Lungs at one time transitorily affected
healthy in other respects. A series of accidents since 1886
some resulting in considerable external injuries; neveruncon¬
scious; capacity for work only temporarily impaired; last
accident in 1901; broke some bones in the face; not uncon¬
scious. Numerous nervous troubles since then; depressed and
tearful mood, irritable, timorous, taking no interest in those
around him, quite devoid of will-power; capacity for work
completely lost; increased liability to fatigue; hysterical
symptoms.

M—, vintager, set. 48. Formerly healthy. Ill health since
1899. Fall in a cellar on his left side in 1900. No external
injuries; severe dyspnoea, attacks of pain since then in the
region of the heart, with giddiness, breathlessness, and a
“ feeling of annihilation.” Depressed, irritable, tearful. Hypo¬
chondriacal loss of will-power; incapacity for any mental or
physical occupation ; increased liability to fatigue. Hysterical
tachypnoea up to 52 respirations a minute. Numerous other
hysterical stigmata.

Fig. 18.

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478 THE CLINICAL MEASUREMENT OF FATIGUE, [July,

Work-curves of Patients.

Subject P—.—In its general course, curve a much resembles
that of Subject 17, who was so very liable to fatigue. The rate
of work decreases continuously from the first minute to the
pause. But while in Subject 17 there were obvious signs of
impulse in the first and fifth minutes, it is hardly possible to
discover in P— any influence of an exertion of the will in the
amount of work done. Only from the third to the fourth
minute does the curve show a less abrupt fall. Even here
the subject is unable to increase his performance of work by
the exertion of his will. After the pause the rate of work is
higher at first than at any previous time. As the course of the
curve seems to show that the work of the sixth minute was not
affected by impulse, we may assume that the fatigue so far
disappeared during the pause, that the persistent effect of
practice prevailed at first over the effect of the fatigue remain¬
ing. From the comparatively high starting-point after the
pause the curve falls very abruptly, and by the eighth minute
the rate of work is lower than at any time before the pause.
Thus the pause has at first had a purely favourable influence
on the course of the work through its restorative effect, but
the restorative effect itself has been extremely fugitive.

Curve b falls abruptly from the first to the fifth minute
without changing its general course. It rises a little in the
sixth minute, then falls again and follows a more horizontal
course until the tenth minute. Curve a also shows a change
of direction, which takes place at the eighth minute. It is
probable that the work done in these last sections of the course
was partly influenced by impulse, but we cannot attribute the
more horizontal course of both curves in the last few minutes,
especially the course of curve b from the sixth minute onwards,
exclusively to this cause. We knew that the exertion of the
will can only be kept up for quite a short time, and that it
seldom lasts for more than a minute, but the more horizontal
course of curve b continues for several minutes. We must
rather explain the course of this curve, which changes its
direction from the fifth minute onwards, by supposing that the
fatigue of the subject increased very quickly at the beginning
of the work, but reached a point in the fifth minute beyond
which it increased only slowly.

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BY WILHELM SPECHT.

479

Co-efficient of practice = 235 - 257 = + in per cent.
Additions in I 5' - Additions in II 5' (with pause)

= 1083 - 1007 = — 7-1 per cent.
Additions in I 5' - Additions in II 5' (no pause)

= mo - 913 = — 17*9 per cent.

Difference = io*8 per cent.
5' - 6' (with pause) = 192 ^ 257 = + 33^8 per cent.

5' - 6 ' (no pause) = 191 - 192 = + 0*5 per cent.

Difference = -f 33*3 per cent.
Co-efficient of fatigue = — 25*8 per cent.

Total additions = 2193.

2' io' = — 24*1 per cent.

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Subject B—.—Both curves resemble those of Subject P—
in their general course, but the difference in the absolute per¬
formance of work must be noticed. Curve a sinks continuously
from the first minute until the pause, and there are no signs of
impulse. In the first minute after the pause the rate of work
is higher than at any previous time. Here, too, the persistent
effect of practice prevails over the effect of the fatigue remain¬
ing. But by the second minute after the pause the values have
fallen again considerably. The influence of impulse in the
sixth minute is excluded, if we consider the fact that in the
whole course of both curves, with the exception of the very
slight rise in the eighth minute of curve b , there are no signs
of an effort of the will to be found. As in Subject P—, the
amount of work done after the pause is far less than that of

4S0 THE CLINICAL MEASUREMENT OF FATIGUE, [July,

the work done before it, as the result of great fatigue. Here,
too, the pause has at first had a good effect on the work,
through its restorative action, but the subject has not recovered
from his fatigue sufficiently for the persistent effect of practice,
even though reinforced by fresh practice acquired during the
second half of the experiment, to prevail over the effect of
fatigue. With the exception of the trifling rise in the eighth
minute, curve b never alters its direction, a fact pointing to
great susceptibility to fatigue in the subject. It is remarkable
that this curve starts from a rather lower point than curve a.
As the experiments in which the work is done without a pause
come a day later than the experiments with a pause, we should
have expected them to have a higher starting-point, as the
result of the advance of practice, as is the case with all the
other subjects. We must suppose that this subject had little
capacity for retaining practice.

Co-efficient of practice = 179 ^ 193 = 4* 7*8 per cent.

Additions in I 5 ^ Additions in II 5' (with pause)

= 852 821 = — 37 per cent.

Additions in I 5' ^ Additions in II 5' (no pause)

= 831 ^ 709 = — 147 per cent .

Difference = iro per cent.

5' - 6' (with pause) = 158 - 193 = 4- 22*1 per cent.

5' - 6' (no pause) = 153 - 148 = — 3*3 per cent.

Difference = 25*4 per cent.

Co-efficient of fatigue = — 20*8 per cent.

Total additions = 1683.

2' - 10' = — 24 per cent.

Fig. 20.

Subject Pf—.—The absolute performance of work is extra¬
ordinarily small. Curve a shows fluctuations which must be

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1907 ]

BY WILHELM SPECHT.

,|8l

interpreted as signs of impulse. The subject said himself:
“ I tried again and again to add together more figures.” It is
hard to tell how far the difference between the performances of
the first and second minutes was affected by a greater exertion
of the will in the first minute. In curve b there are no signs
of impulse in the first minute. It is possible that the subject
set to work in a different way, according to whether the experi¬
ment was to be made with or without a pause, and that the
prospect of a speedy ending led him to a greater exertion of his
strength. The work was certainly influenced by impulse in the
last minute before the pause. On the other hand, the uniform
downward direction of curve a from the sixth to the eighth
minute does not favour the supposition that the subject worked
with a special effort of the will after the pause.

Co-efficient of practice = 103 - 121 = + 17*4 per cent.

Additions in I 5' Additions in II 5' (with pause)

= 528 - 529 = -f o’i per cent .

Additions in I 5' ^ Addition in II 5' (no pause)

= 584 ^ 491 = — i6*o per cent .

Difference = 16*1 per cent.

5' ^ 6' (with pause) = 102 - 121 = 4- 18*6 per cent, (too small)

3' ^ 6' (no pause) = 116 113= — 2-9 per cent.

Difference = 21*5 percent.

Co-efficient of fatigue = — 28*1 per cent.

Total additions = 1112.

2' ~ io' = 124 - 90 = — 27*3 per cent.

Fig. 21.

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Subject J—.—We have only an eight-day series with Sub¬
ject J—. As the increase of practice gradually diminishes in
the course of the experiments, and is, therefore, greater on the
first than on any subsequent day, we must remember, in dealing
with the average values, that they may be more influenced by
the effect of practice than those obtained from a twelve-day
series of experiments.

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482 THE CLINICAL MEASUREMENT OF FATIGUE, [July,

If we calculate the reduction of work done in the second five
minutes of the individual days without a pause as a percentage
of the work done in the first five minutes, we arrive at the
amount 6 # 8 per cent . less on the second day, I3’5 per cent less on
the fourth day, 127 per cent, on the sixth day, and 19*1 per cent
on the eighth day. From this we see that the diminution of
work in the second part of the experiment has, on the whole,
increased from day to day. This deterioration is to be explained
by the circumstances that the fresh gain of practice diminishes
with the increase of the amount already gained, and that the
effect of fatigue is thus more able to make itself felt. If the
experiments had been continued for twelve days, the effect of
fatigue would presumably have been still more evident.

Both curves show a very horizontal course on the whole, the
highest and lowest performances of work in the individual minutes
differing only by fifteen additions. But we must bear in mind
that the absolute performance is extraordinarily small, and that
the smaller the number of figures added up in a minute the
smaller will be the absolute amount of the fluctuations. It is
only from this point of view that we can judge the fluctuations
of the curve correctly. Curve a falls from the first to the
second minute. We must not suppose the fall to be an expres¬
sion of fatigue; it is more likely that the work-value of the first
minute and also that of the fourth minute are affected by an
effort of the will. There are no signs of impulse to be found in
the fifth and sixth minutes either on the days with or without
a pause.

The total performance of the first five minutes of all eight
days amounts to 542 additions. It appears from the list of
experiments that the performance of the first five minutes was
about the same from the sixth to the eighth day. Seventy-one
additions were made on the sixth day and seventy-four on the
eighth day. The better to compare the absolute performance
of this patient with that of the other subjects of experiment, it
will be well to add to the performance of the first eight days
the amount of work that would presumably have been done in
the four days that are missing. Assuming that the subject
would have made an average of seventy-four additions in the
first five minutes of eSch day, the total performance for twelve
days would have amounted to about 840 additions.

Co efficient of practice = 53 ^ 59 = + 11*3 pc * cent .

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4^3

1907.] BV WILHELM SPECHT.

Additions in I 5' Additions in II 5' (with pause)

= 271 - 276 = r8o per cent.
Additions in I 5' ^ Additions in II 5' (no pause)

= 271 ^ 235 = — 13*3 per cent.

Difference = 15*1 per cent.
5' - 6' (with pause) = 49 ^ 59 = + 20*4 per cent.

5' 6' (no pause) = 50 - 47 = — 6*o per cent.

Difference = 26*4 per cent.

Co-efficient of fatigue = — 21*9 per cent.

2' - 10 = 54 - 46 = — 14*9 per cent.

Fig. 22.

Z 3 4 S’ 4 > 7*9 /o /2J4S6? 99/0

Subject T—.—The absolute performance is even less than
that of the patient J—, amounting to an average of only twelve
additions in a minute. The curves take a horizontal direction.
The fall from the first to the second minute in both curves,
and again the fall immediately after the pause, make a strong
contrast with this horizontal course. How are these falls to
be explained ? In the first place, they might depend on impulse
at the beginning of the work. In that case the patient must
have begun work with a great exertion of will, for the reduction
of work in the second minute amounts to 19*3 per cent, of the
work done in the first minute. Now, the patient’s whole mental
behaviour during the experiment was in contradiction to the idea
that his work could be influenced by a strong effort of the will.
He was very slow and clumsy in his movements, apathetic,
languid, and devoid of all initiative. Again, if the patient had
begun his work with a great exertion of his will, we should have
expected that other obvious signs of impulse would be found,
but there are none to be seen. The sinking of the curves might
also be a result of fatigue. But if the fatigue had reached so
high a degree in the second minute as to cause a deterioration
in the work to the amount of 19*3 per cent., the curve must at
least have shown a further fall in its general course. This is
not the case, for it is almost horizontal.

484 THE CLINICAL MEASUREMENT OF FATIGUE, [July,

To explain the remarkable course of the curve, we may appeal
to experiments made with this patient on the ergograph. With
the object of measuring the fatigue caused by physical work, the
patient was told to make a series of pulls of 5 kilograms at
regular intervals of one and a half seconds. The first pull
was quite successful, but the second puli raised the weight a
considerably smaller distance than the first, and subsequent
pulls had hardly any effect. The weight, which was raised
about 3*5 cm. by the first pull, only rose about 1 cm. at the
third. But instead of the patient’s showing a still further loss
of strength, all his subsequent pulls had about the same result
as the third, and he made thirty more attempts without the
occurrence of any material change in the height of the lift.
All the encouragement to lift the weight higher given him by
the conductor of the experiment was without effect. A fresh
experiment was made after a pause of thirty minutes, beginning
with a weight of 4 kgm., with almost exactly the same result.
The weight was lifted the full height at the first pull, while
at the second the height of the lift diminished to precisely the
same extent as in the first experiment, and remained at about
the same level afterwards. Eventually we reduced the weight
to 1 kgm., but still with a repetition of the results of the first
experiment.

There can be absolutely no doubt that the nature of the
patient’s work on the ergograph was not determined by
physical fatigue. If the reduction in the lift from 3*5 cm. to
1 cm. during the first three pulls had been due to the effect of
fatigue, that would have implied the exhaustion of the muscles,
and the patient would not have been able to continue his work
as he did. That the work always deteriorated in the same way,
independently of the size of the weight, also shows that the
deterioration was not due to fatigue. We must rather suppose
that we have to deal with a severe disturbance of a mental
nature which affected the patient’s capacity for work. We
might explain this disturbance, to a certain extent, by saying
that, following the sense of exertion which belongs to the first
stroke of work, a hampering sense of incapacity springs up and
destroys, or very greatly impairs, the capacity for work. The
feeling of incapacity may exist from the first, when the work
will be feeble from the very beginning, or it may be increased
by the sense of exertion, and then the performance of work

Digitized by

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BY WILHELM SPECHT.

1907.]

485

will decrease and adapt itself more or less exactly to the degree
of capacity which the patient still feels that he possesses.

In the same way we may explain the patient’s mental work-
curves by a sense of impediment. The poor initial performance
points to the presence of the impediment from the first. But
the sense of impediment is increased by the exertion of adding
up, and the work performed is reduced to the amount of which
the patient still feels capable. As extraordinarily little work is
done, there is no occasion for any great results of fatigue to
make themselves felt; the pauses between the separate additions
are so long that the patient always has time for recovery. On
the other hand, even this small amount of work, if continued
for a considerable time, may produce a degree of fatigue that
will have some effect, especially in a person very liable to
fatigue. The sense of fatigue may at first increase the feeling
of impediment only to a certain degree, in which case the work-
curve will fall at first and then follow a horizontal course for
some time after, or if the fatigue increases continuously, it may
produce a continuous increase in the feeling of impediment,
and in that case the amount of work done will decrease
continuously.

Curve b takes an almost horizontal direction from the second
to the fourth minute, then falls until the sixth minute, and re¬
mains at about the same height from that point to the end. It
is quite possible that the impediment is increased by the sense of
fatigue and that the subject settles to the rate of work of which
he still feels capable. From this point of view we might assume
that the decrease in the rate of work for the second five
minutes of the days without a pause is due to the effect of
fatigue. But it is questionable if the difference between the
two work-values immediately before and after the pause can be
employed to estimate the amount of the fatigue. Curve a is
almost horizontal from the second minute to the pause, and
such a course gives no indication of fatigue. The rise in the
curve after the pause might be explained by supposing that
the feeling of impediment, so far as it had been increased by
the work done in the first minute, disappeared during the
pause, so that the patient went on again with the same rate of
work as at the beginning. We found, in the case of his work
on the ergograph, that the weight was raised considerably
higher by the first pull after the pause than by the last pull

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486 THE CLINICAL MEASUREMENT OF FATIGUE, [July,

before the pause, although this difference in the height of the
lift did not depend on the effect of fatigue.

As the patient’s capacity for work was influenced per¬
manently and in a high degree by the effect of the impediment,
we should, of course, expect the other influences that usually
act on the course of work to make but little impression on the
work done by him, yet we cannot fail to recognise that he has
made some advance in practice during the experiments. While
he made 45 additions in the first minute on the first day, he
made 56 on the twelfth day. The average daily advance in
practice, however, only amounted to o*8 additions.

As the decrease in the rate of work for the second five
minutes on the days without a pause is apparently due to
fatigue, we may use the difference between the work-values of
the two sections of five minutes to help us in estimating the
effect of the fatigue. But here, too, we must remember that
the rate of work was influenced by the effect of the mental im¬
pediment, and that the fatigue was, therefore, felt only in a
slight degree. But for the result of the impediment, the effect
of the fatigue would probably have been very much greater.
For the reasons already given, none of the other work-values
are of any use for the measurement of fatigue.

Co-efficient of practice = 63 - 78 = -f 23*8 per cent.

Additions in I 5' ^ additions in II 5' (with pause)

= 337 337 = ± 0 per cent.

Additions in I 5' - additions in II 5' (no pause)

= 329 - 286 = — 13*1 percent.

Difference = 13*1 percent

5' 6' (with pause) = 65 - 78 = -f 20*0 per cent.

5' ^ 6' (no pause) = 62 ^ 57 = — 9*6 per cent.

Difference = 29*6 per cent.

Co-efficient of fatigue = — 29*0 per cent.

Total additions = 664.

2' - 10' = — 12*5 per cent.

Fig. 23.

2 3 S e 7 8 q fo / 2 . J V S 6 7 9 'O

Subject M—.—A ten-day series of experiments. The work-

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BY WILHELM SPECHT.

487

1907 .]

curves of this patient may be considered parallel to those of the
patient T— in their general character. The features common
to both are the extraordinarily small absolute performance of
work and the horizontal, sinuous course of the curves. But
while in the case of the patient T— the rate of work falls
considerably from the first to the second minute and from
the fifth to the sixth minute, and then remains on the same
level in the experiments with a pause, but gradually sinks
still further in the experiments without a pause, both the
work-curves of the patient M— show that the performance
of work improved continuously, in however slight a degree,
during the experiment. The work-values of the sixth minute
of the experiments with a pause and the first minute of the
experiments without a pause are, however, rather higher than
the corresponding values of the seventh and second minutes.
Whether the fall has the cause that we assumed in the case
of the patient T—, or is due to accidental influences, must
remain uncertain. At any rate, the general direction of these
two curves is upward. The amount of the absolute performance
of work, which is even smaller than in the case of Patient T—,
shows that the patient’s capacity for work is reduced to a
minimum. Here, too, we must assume an impediment of
mental origin as the cause of the reduction. The impediment,
which increases still further during the work in the patient T—,
is greater here at the beginning of the work than in its subse¬
quent course. It does not disappear, but its effect on the course
of the work is weakened by the action of practice in facilitating
the work and possibly by that of momentum. The patient
made an average of about eight additions a minute. With this
small performance of work, fatigue had no effect, or so slight
an effect that it was more than covered by the opposite effect
of practice. The effect of practice also appears in the improve¬
ment in the rate of work from day to day. Thirty-seven addi¬
tions were made in the first five minutes on the first day and
forty-three on the tenth day. The average daily increase of
practice was equivalent to o # 6 additions, or v 6 per cent . of the
performances of the first day.

As both work-curves are free from signs of fatigue, we cannot
determine the amount of its effects, even approximately, from
the work-values of the patient. Neither can we form any idea
of the patient’s capacity for practice. The result of practice

Li II. 34

488 THE CLINICAL MEASUREMENT OF FATIGUE, [July,

can indeed be seen, but here, too, we must assume that it is
hidden to a great extent by the effect of the impediment. In
order to compare the amount of this patient’s absolute perform¬
ance directly with the performance of the other patients, it will
be well to count up the additions which he would presumably
have made on the eleventh and twelfth days. In the first five
minutes of the eighth, ninth, and tenth days he made 43, 40,
and 43 additions. If we assume that he would have made
about 42 additions on the eleventh and twelfth days, we obtain
455 additions as the total performance in the first five minutes
of all twelve days.

In order to present the peculiar course of the work, deter¬
mined as it is by the effect of the impediment, in an arithmetical
statement, we have calculated the patient’s work-values. The
only figures that we can apply to our particular purpose are
those of the total number of additions and of the average daily
advance in practice.

Co-efficient of practice = 35 - 38 = + 87 per cent.

Additions in I 5' - additions in II 5' (with pause)

= 180 - 193 = + 7*2 per cent.

Additions in I 5' - additions in II 5' (no pause)

= 190 - 202 = + 6*3 per cent.

Difference = 0*9 per cent.

5' - 6' (with pause) = 38 - 39 = + 2*6 per cent.

5' - 6' (no pause) = 40 - 39 = — 2*5 per cent.

Difference = 5*1 per cent.

Co-efficient of fatigue = — 1*9 per cent.

2' - 10' = 35 - 41 = 4- 17*1 per cent.

Comparison of the Work-Values of Healthy Subjects and of Patients.

Comparison of the results of our experiments on healthy
subjects showed that the amounts of the work-values of which
we could avail ourselves for the measurement of fatigue were
extraordinarily different in different people. If we should speak
of the “ bounds of health ” in reference to the highest and
lowest work-values of healthy subjects, we might place Subjects
2 and 3 upon the upper boundary and Subjects 12 and 16 on
the lower. ( 4 ) The work-values afforded by Subject 17 differ
but little in amount from those of the healthy subjects most
liable to fatigue. We may conclude from this that the liability

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BY WILHELM SPECHT.

489

1907 .]

of healthy subjects to fatigue varies within wide bounds, and
that it may reach a degree not far removed from the highly-
exaggerated susceptibility to fatigue seen in Subject 17. This
subject felt himself so much affected by his extreme liability to
fatigue as to be incapable of strenuous mental work, even for a
short time. As the liability of Subject 17 to fatigue must be
regarded as morbidly exaggerated, and yet this subject is placed,
with respect to his work-values, at the upper limit of the bounds
of health, it does not seem to be unconditionally necessary that
patients who complain of great susceptibility to fatigue should
be far removed from the upper limit of the bounds of health.
We may rather assume that here, as everywhere else, the
transition from health to disease is not fixed, but that there
are all sorts of gradations between the liability to fatigue of
healthy and morbid subjects.

In Table III we have collected the work-values we obtained
from all the healthy subjects, from Subject 17, with his great
liability to fatigue, and also from the patients; 1 to n are
twelve-day series, 12 to 16 eighteen-day series. In Column j
the figure above the line gives the performance in the first five
minutes of the first day, and the figure below the line gives the
total performance in the first five minutes of all twelve days.
The figures in Column k show the amount of the average daily
acquisition of practice as a percentage of the performance in
the first five minutes of the first day.

In Column a the highest values within the bounds of health
are + 25*4 and + 22*9. Both these values are affected by
impulse and have come out too high. The highest value
uninfluenced by impulse, as far as we can tell, is the + 17*8 of
Subject 3. Subject 17, who is very liable to fatigue, has the figure
20. Hence the figure 33*8, belonging to the patient P—, goes con¬
siderably beyond the limits of health. In Column b the values
are quite irregularly positive or negative. But even if we
neglect the error due to impulse in all the subjects, including
the patient P—, he shows by far the greatest difference in
Column c.

In Group d, the values fluctuate in Subjects 1 to 17 between
— 0*4 and + I2’3. In Subject 2 we found that the reduction in
the performance of work after the pause indicated great liability
to fatigue. Here P— comes far below the worst values of the
healthy subjects, with — 7*1. On the days without a pause

Subject.

490 THE CLINICAL MEASUREMENT OF FATIGUE, [July,

Table III.*

pf.

c d

w* a

. I

*tl

VT) O

= 1 • -C V

y 1 — ~ £

£ ' 1 * 1

. ■»

— =

— cd

» a

— 0

. !

c ^

1 ©3

6 a

e •

0 t

U*..

— o* 1

v 5

0 **-

oi
» 2.

« 0

— c

3 3

0 5

H -0
•0
a

U i

< o-

+ 25-4

- 1*4

26*8 + i*3

- 7 *o

8-3

+ I0'3

-132

-144

IIQ

2366

+ 8- 4 i

+ 22'9

- 2*7

2 5 ' 6 1 — 04

- 89

8-5

+ i ri

-*795

- * 3‘9

201

3**2

+ 4*7

+17-8

+ 3 'i

147 + « 2’3

- 0*5

12*8

+ 178

“* 5*52

- 85

III

2781

4 * 5 **

+ 19 3

+ **5

17*8 + 3’9

- 5 *o

+ 9'3

-*3 4

- 4*3

242

4087

+ 6’3

- o*8

234

+ 6*3

+174

-o -5

17 9 +10-3

II I

+ 12-5

- 11*73

- i *7

4127

+ 165

172 + 5-8

18;

-07

— 6*2

12*0

+ in

“ 1 5 * 5 1 |

-1 1'3

4348

+10*1

+ 13*4

±0

> 3'4 + 3'3

- 41

7*4

+ 97

-125 ,

- 6*3

233

4083

+ 5*5

+ 10*0

-38

138 + 24

- 7*3

+ 5*3

— 1 r8

- 6 6

*77

3545

+ 8-9

+ 90

+ 0'2

8-8 + 56

- 24

+ 90

- 8*8

+ 0*9

213

4039

+ jit 1

1+ 49

-2-6

7*5 + i *9

- 5 *i

7 0

+ 37

- 8-3

- o -5

296

44*2

+ 27

|+ 3*5

+ 2'1

1 '4 + 2-5

- 63

+ 6-8

— I2I |

•

— 2*0

2003

+ 60

1 + 91

“IT 1

io*8 + 3-3

— 1*2

4’5 |

+ 6*2

- 6-8

- 2-6

3*3

5749

+ 7*3

! + i 3'3

“27

160 + 3*4

- 6*5

l + 3 ‘ 4 '

- 6*6

222

4344

♦ 8-0

+ 6-i

±0

9*9 + 7‘8

— 21

9‘9

+ 5 * 1

“ 77

r 30

3488

+ 296

+ 159

i* 7 ’° I + 63

" 47

I 1*0

+ 14*9

-« 7 *o

•

— 2*2

*77

3797

I ♦ 120

+ 100

+15

8 ’ 5 ,+ 0-9

“ 2 '5

3*4

+ 79

- 9‘5

r 17

254

4298

+ y°!

+ 200

1 + 07

1 9‘3 + 2-4

-in

*3 5

+ 79

—166

-13*0

*98

4076

+ 8-4

+ 33 ' 8

+ 05

33‘5 - 7 1

1 — * 7*9

108

+ in

-258

-24* I

169

2*93

| +

1 + 28-4

~ 3‘3

3 i 7 - 37

-147

110

+ 7'8

— 208

-240

129

1683

+ **5

+ 186

-29

,21-5 + o-i

—160

16* 1

4 * 7*4

1-28-,

-27*5

1112

+ 16

+ 20 4

— 60

j^6’4 + r8

' — * 3*3

45 *

' + ii *3

-219

” * 4*9

| _ 55 _

840

1+ 40

■f 200

1 —90

296 + 0

- 1 3 *i

i* 3 ’*

+23-8

— 29 0

-12*5

664

+ *7

+ 26

I ~ 2 ’ 5

5-1;+ 7 2

1+ 67

, o '9

+ 87

- 1*9

+ 17* 1

1 +16

1 454

1 1

Cf. the separate descriptions of the work-curves.

Digitized by Google

1907 ] by WILHELM SPECHT. 491

(Column e) Subject 2’s performance of work has fallen 8*9 per
cent, and Subject I7’s in per cent, below their performance in
the first five minutes. With these compare P—, with his
enormous reduction of 17*9 per cent. In Column /, Subject 17
shows the greatest difference, with 13*5 per cent. P—, with io*8
Per cent., would seem, at first sight, to come within the limits of
health, but we have shown that in this case we cannot judge
of the amount of the fatigue from the amount of the difference.
The difference in the rate of work, according to whether there
has been a pause or not, is comparatively small in the case of
P—, because a considerable amount of fatigue remained even
after the pause. P— did, however, recover to a great extent,
as is shown by the increase in the value of his work in the
sixth minute (Column a), and a large amount of his fatigue
disappeared during the pause, but his recovery was only
momentary. His rate of work was much reduced by the
eighth minute—indeed, it was then below the rate of the fifth
minute. It is because P— recovers far less from his fatigue
during the pause than do the other subjects, and because
the useful effect of the pause is far less in his case than in
theirs, that the absence of the pause has not as bad an effect
on the course of his work as it has on that of subjects whose
fatigue disappears more completely during the pause. Moreover,
as we have already shown, fatigue in his case reaches an extra¬
ordinarily high degree in the first five minutes, and its further
advance takes place only slowly. Subject 17, in spite of his
great liability to fatigue, always recovered so much better than
P— during the pause, that the persistent effect of practice,
reinforced by the practice freshly acquired, prevailed over that
of fatigue. For this reason, the effect of the pause on the
course of work made itself felt in a higher degree in his case
than in that of the patient P—. That P—’s pure capacity for
practice is no less than that of the other subjects is clear from the
fact that in spite of his incomplete .recovery during the pause,
his work-values of the sixth minute are considerably higher than
those of the second, and even of the first. Accordingly, we see
that his co-efficient of practice is of normal amount. It is
possible, indeed, that it may have come out too low, as the work
done in the sixth minute may still have been affected by fatigue.
Even so, the co-efficient of fatigue which we have calculated
for P— with the help of his co-efficient of practice, is very

Digitized by v^.ooQle

492 THE CLINICAL MEASUREMENT OF FATIGUE, [July,

much higher than that of Subject 17, for all his liability to
fatigue. P—*s great susceptibility to fatigue also appears very
clearly in the difference between the work-values of the second
and tenth minutes (Column t).

The absolute performance of the healthy subjects in the first
five minutes of all twelve days varies from 2003 to 5749 additions.
Their average performance is about 4000 additions. P—, with
2193 additions, shows a worse total performance than any of the
healthy subjects but one, but his performance on the first day,
amounting to 169 additions, is high compared with the work of
those healthy subjects who also show a small total performance.
From this we may conclude that P— made but little advance
in practice in the course of the experiments. The average
daily increase of practice, stated as a percentage of the per¬
formance of the first day, varies in the healthy subjects from
27 per cent . to 29*6 per cent., the second greatest increase being
15*1. The extent of these variations is remarkably large, but
it is explained by the facts that in Subjects 14 and 3 the first
day’s performance is unusually small—it is very likely that
accidental influences have been at work here—and that the
total performance of Subject 10 is extraordinarily great.
Subject 10, at the time of the experiments, had for a long
time been in the daily habit of solving arithmetical problems,
and so began them with a high degree of practice; that is why
his daily advance in practice comes out so small. P—, with
his daily advance of 1*4, is far below the average values of the
healthy subjects, a sign that his power of retaining practice
was extraordinarily small.

Here it must be remembered that in P— the persistent effect
of the practice in addition, that he had formerly had, both as
a clerk and during the experiments made on him by Gross,
cannot safely be left out of consideration. On the other hand,
we must consider that he gave up his clerkship in 1897, and
that Gross’s experiments were made in 1898. At any rate,
even if we cannot quite overlook the persistent effect of this
practice, in spite of the length of time that has elapsed, it is
not sufficient, by itself, to explain his small advance in practice.
Even Subject 10, who had practised the solution of arithmetical
problems up to the time when the experiments on him were
begun, shows an average daily acquisition of practice equal to 27
per cent, of his performance at the beginning of the experiment.

Digitized by v^.ooQle

1907.] by WILHELM SPECHT. 493

The course of work shown by the patient B— is very similar
to that of P—, but his work-values are on the whole rather
smaller. They, too, fall quite outside the limits of health.
The difference between the values shown in d and e is, again,
smaller than in Subjects 5, 6, and 17, although the reduction
in B—’s performance of work in the second five minutes on the
days without a pause is considerably greater than the reduction
in that of Subject 17. It would appear from the reduction in
the performance on the days when there was a pause that con¬
siderable fatigue remained after the pause in this patient also.
In spite of incomplete recovery during the pause, 4*8 per cent .
more work was done in the sixth minute than in the first.
Hence the capacity for practice does not seem to have been
much impaired in B—.

Like his other work-values, B —’s co-efficient of fatigue in¬
dicates that his liability to fatigue was rather less than that of
P—. Only in column i do both show the same reduction of
work. The work of the first five minutes of the first day
of experiment is within the limits of health and is greater than
in four of the healthy subjects. The corresponding perform¬
ance for all twelve days, however, is much smaller than that of
Subject 11, who has the worst performance among the healthy
subjects. The proportion between the performance on the
first day and the performance on all twelve days points to only
a small advance in practice. The average daily increase of
practice is, in fact, only 15 per cent . of the performance on the
first day. This shows the patient’s small capacity for retaining
practice.

In the patient Pf— the increase in the work of the sixth
minute over that of the fifth minute on the days without a
pause is smaller than in Subjects 1, 2, 4, and 17, but we were
able to discover from his work-curves that the value of work
in the fifth minute was increased by a final impulse. Conse¬
quently, the difference between the work of the fifth and sixth
minutes does not give a correct picture of the patient’s liability
to fatigue. For the same reason the difference between the
figures in columns a and b is valueless. In the five minutes
after the pause (Column d) the performance improved a little,
though only by o # i per cent, of the performance in the first five
minutes; the effect of practice and the effect of the fatigue
remaining very nearly balanced one another. On the days, how-

Digitized by v^.ooQle

494

THE CLINICAL MEASUREMENT OF FATIGUE, [July,

ever, when the work was done without a pause, it deteriorated
even more than in the case of the patient B—. The dependence
of the effect of the pause upon the degree of fatigue is very well
seen in Pf—, as his performance after the pause was not subject
to the same degree of fatigue as that of the two first patients.
In spite of the fact that the reduction of work in the second
five minutes is smaller than in P—, the difference shown in
Column/ is far greater. From this we may conclude that Pf—
is unusually susceptible to fatigue, but is more capable of
recovery than the two other patients. His co-efficient of
practice has come out extraordinarily high, although we cannot
discover any signs of impulse in the sixth minute. It is, how¬
ever, conceivable that his performance in the second minute
has come out too small because he began the work with an
effort of will and then flagged in the second minute. We can¬
not be sure about this. The high co-efficient of practice has,
of course, affected the co-efficient of fatigue, which may, perhaps,
also have come out too high. Yet the high figures in Columns/
and i also indicate that Pf— is extraordinarily liable to fatigue.
The work of the first five minutes of the first day is about the
same as that of Subject 14, but in that subject the work shows
a great improvement from day to day, and a total performance
of 3488 additions is finally reached, while Pf—’s total per¬
formance is considerably less than that of the patient B—.
His capacity for retaining practice is very little greater than
that of the two other patients.

The work-values of Patient J— are derived from an eight-day.
series of experiments. We have already pointed out that the
effect of practice has a greater preponderance over that of
fatigue in the first few days of an experiment than in the last.
Consequently, the effect of fatigue is not so clear in the case of
the patient J— as it would be in a twelve-day series. In spite
of this, J— has higher figures in almost all the columns even
than Subject 17. His performance of work on the first day
and the total performance, which we have calculated for twelve
days, are remarkably small. Both these values are considerably
smaller than those of the patient Pf—. On the other hand, his
average daily acquisition of practice is greater than that of any
other patient or of Subject 10. Here too, however, we must
remember that J— only worked for eight days, and that the
improvement of his work by practice therefore shows up better

Digitized by v^.ooQle

BY WILHELM SPECHT.

495

I90;.]

than that of the other subjects. At the same time, his acquisi¬
tion of practice is less than that of any healthy subject, if we
exclude Subject 10 for the reasons previously explained.

We have already expressed our opinion as to the impossibility
of using the work-values of the patients M— and T— for the
measurement of fatigue. We are not justified in inferring from
these values the amount of the fatigue, because the course of
work was principally determined by influences constituting an
impediment. Only in the case of T— can we find signs of
fatigue in the course of the work. Here the work deteriorates
in the second five minutes, on the days without a pause, to the
extent of 13*1 per cent, of the work of the first five minutes.
This shows that T— was very liable to fatigue. On the other
hand, we may regard it as certain that his real liability to
fatigue was considerably greater than is shown by the course
of his work, because the effect of the fatigue was concealed by
that of the impediment. His absolute performance on the first
day was even smaller than that of the patient J—. In the
course of the twelve days of experiments it improved very little
—only two additions a day.

Signs of fatigue are entirely absent from the course of work
in the case of the patient M—. There were such long pauses
between the separate additions that fatigue could have no effect
upon the amount of work done. But while in T— the effect of
the impediment increased as the result of the sense of effort, we
can see from the work-curves of the patient M—that his rate of
work improved a little under the helpful influence of practice
and possibly also of momentum. This explains why he did
more work in the second five minutes than in the first (Column e)
even on the days without a pause. We can also point to a very
small advance in practice during the whole series of experiments.

The patient’s total performance amounts to 454 additions;

that is to say that M— made an average of ^54 _ y.^

tions a minute. Considering that the worst performance of

the healthy subjects, that of a simple workman, amounted to

2003 . . 5749

;—— = 33 additions a minute, and the best to w c =
12 x 5 12 x 5

95 additions a minute, we can easily see that M—’s capacity for

work was as good as annihilated.

Briefly to sum up the results of those last experiments, we

496 THE CLINICAL MEASUREMENT OF FATIGUE, [July,

have discovered, in the first place, that the patients P—, B—,
Pf—, and J— are highly susceptible to fatigue. We had
found that the liability to fatigue of Subject 17 only slightly
exceeded the ordinary bounds of health, but nevertheless we
had reason to suppose that it was morbidly exaggerated. Of
the patients, J— comes nearest to Subject 17 in his work-
values, yet there is a greater difference in their degree of sus¬
ceptibility to fatigue between J— and Subject 17 than between
Subject 17 and the most easily fatigued of the healthy subjects.
We must also consider that J—’s work-values were taken from
an eight-day series of experiments. The work-values of the
other patients differ so much in their amount from those of
healthy subjects, and even from those of Subject 17, that we
are justified in assuming their liability to fatigue to be far
greater even than that of the very susceptible Subject 17. With
this extreme liability to fatigue is associated a diminished power
of recovery. In all the healthy subjects, except in the single
case of Subject 2, we have found that even great fatigue was so
far recovered from during the pause, that the effect of practice
could completely prevail over the remaining effect of fatigue.
In contrast to this, the power of recovery of the patients P—
and B— is extremely defective. In Pf— and J— the restora¬
tive effect of the pause was rather more favourable, but even in
their case there was reason to assume that a great deal of the
fatigue remained after the pause.

While the patients’ pure capacity for practice does not seem
to have been much reduced, it appears that their performance
of work improved only very little from day to day. Their
power of retaining practice must therefore be extremely small.
Only in J— was the daily increase of practice rather greater,
and even in his case it was less than in the case of those of the
healthy subjects who showed least power of retention, if we
neglect Subject 10, with whom no comparison can be made.
Finally, comparison of the absolute amounts of work performed
showed that the difference between the work of the first and
second five minutes without a pause was always very much
reduced in the patients.

In the case of the patients T— and M—, we were not able
to estimate the liability to fatigue with any accuracy. The
reduction of T—*s rate of work in the second five minutes
(Column e) gave us grounds for supposing that he was very

Digitized by v^.ooQle

BY WILHELM SPECHT.

497

1907 .]

easily fatigued. The true extent of his liability to fatigue may,
however, have been far greater than appeared. In both patients
the effects of fatigue were concealed by the effects of impedi¬
ment. The absolute performance of T— and M— was so
small, that we may conclude that their power of work was
almost entirely lost.

The Detection of Intentional Simulation .

In dealing with our patients, we were able to exclude the
possibility of intentional simulation or exaggeration of the
disturbances of which they complained, because their clinical
observation precluded all doubt as to the real existence of
their illnesses. But even had this unfailing source of informa¬
tion not been available, there are other considerations which
make it improbable that the patients tried to cheat in their
experimental work. Complicated as are the influences which
determine the direction of the work-curve, we have always been
convinced that there are certain invariable laws regulating the
course of work and the mutual relations of the figures obtained
by the comparison of the work-values. We were never able to
discover that our patients’ continuous work had been done in a
way which contradicted the results of our other experiments,
or that the comparative values obtained from them were
different in their mutual relations from the values obtained
from healthy subjects.

To set the applicability of our method to patients suffering
from the results of accidents absolutely beyond the reach of
objection, we must be able to give a satisfactory answer to the
question whether it is not possible for a malingerer simulating
great fatigue to observe these invariable laws which govern the
course of work so accurately as to escape detection.

To decide this question, which is one of extraordinary prac¬
tical importance, we have had some experiments carried out in
the wilftil simulation of abnormal fatigue. Three of the four
subjects of experiment were familiar with the behaviour of the
work-curves, while the fourth, who was a young lady, entered
on the experiments quite unprepared and without any previous
knowledge of the course of work. Each series consisted of six
daily experiments. For three of the subjects the arrangements
were exactly the same as we have employed elsewhere, but in

498 THE CLINICAL MEASUREMENT OF FATIGUE, [July,

two series of experiments, which I made myself, I altered the
conditions to a certain extent. The arithmetic books are
printed with ten vertical columns of equal length on each
page, each column containing thirty-six figures. As each
minute’s work is marked off by a stroke of the pencil, it is
not very difficult to compare the work of the separate minutes,
as the experiment goes on, so as to form an approximate idea
of the number of figures one has added up in a minute, and to
add the number, more or less, which one has pre-determined
in the following minute. If one knew exactly how the course
of work must change from minute to minute to reproduce the
changes which take place in the case of patients suffering with
abnormal liability to fatigue, it is conceivable that the simula¬
tion might be successfully carried out by this means. In order
to deprive myself of this means of comparison I struck out a
piece of different length in each column. As I had expected,
this made it impossible to measure the amounts of work done
in each minute, even approximately, with the eye or to com¬
pare them with one another.

Table IV.

II U

With

No , Ad

Sab*

pause.

pause, j via

jects.

I $ M.

1 5 M.

1 M.

6 M.

1 M.

5 M.

a M. in pi

II 5 M.

5 M.

a M.

7 M.

6 M.

10 M. tici

- 7*1

- 179

-23*3

- 7 ’i

- 132

- 63

+ 4*8

“ 24*5

+ 33’8

+ 0*5

- 24*1 +1

- 37

- 147

- 162

- 57

* 137

- 2*8

+ 3’2

- 196

+ 28*4

- 3*3

- 24-0! * 1

Pf.

+ 01

- 16*o

- 18*2

- 10*7

- 10*0

! +2 * 9 (

+ o*8

- 23*2

+ l8*6 1

- 2*9

j- 27‘5 +1

+ i *8

-i 3'3

- 13*2

- 6*2

±0

+ 4*2 !

+ 17

- l 6 *I

+ 20*4

- 6*o

| — M '9 + ■!

Dr. B.

- 3*5

- 24 6

-384

- 131

-147

+ 3*3

- 2*6

- 3 i*i

+ 75 *i

“ 32*9

1 - 46 9 “ 1

Dr. St.

- 8-3

- 1 o*4

" 33*6

- 24 9

-255

- 16

- 7*11

-25*3

+ 38*8

+ 13 * 1 i

1-22*8: - J

Frl. S.

-265

- 37'6

- 50*4

-24-9

-25*5

- 3 *o

-25*4

- 5*6

+ 52*5

- 5*61

1-52*0 -i

Dr. j a

- 9*2

- 180

-28*3

- 115

- 130

- 1*2

- 6*3

- 28* 1

+ 34’5

+ 3*5

-255

sp.U

-14*2

-243

- 27*4

-260

+ 9-1

+ 3*2

- 23* 1

-38*2

+ 597

+ 8*4

- 3*5 : - *

Table IV shows the results of the experiments, together with
the corresponding work-values of the four patients P—, B—,
Pf—, and J—. Columns i, 2, 9, 10, 11, and 12 correspond to
Columns d , e , a, b , i, and k in Table III.

We will first consider the work-values of the subject Dr. B—.
In Column 1 the amount by which the work of the second five

Digitized by v^.ooQle

1907.] BY WILHELM SPECHT. 499

minutes, on the days with a pause, differs from that of the first
five minutes, is stated as a percentage of the work of the first
five minutes. In this column Dr. B— shows the value of
- 3*5 per cent., about the same diminution of work as is found
in the case of the patient B—. But while the greatest reduction
among the patients on the days without a pause was only 17*9
per cent., Dr. B— shows a reduction of 24*6 per cent. The
difference between the work-values of the patients and Dr. B—
becomes still more striking when we consider their work-values
in Columns 3,9,10, and n. No further comment is necessary;
the figures themselves show, beyond all question, that Dr. B—
has greatly overacted his part. In the other columns also, e.g.
in Columns 4 and 8, which show the difference between the
work-values of the first and second minutes on all twelve days
and the difference between those of the first and sixth minutes
on the days without a pause, he has considerably higher figures
than the patients, but the differences are not so pronounced
here as in Columns 9,10, and 11. While the work of the sixth
minute on the days without a pause is only 6 per cent, less than
the work of the fifth minute (Column 10) in the patient J—,
Dr. B— shows a reduction about five times as great. The
deception is also completely exposed by the fact that the rate
of work does not improve from day to day, but grows worse
(Column 12). The advance in practice in a genuine case is
certainly small, but it can never be a negative quantity.

Dr. St— has not, on the whole, overacted his part to the
same extent as Dr. B—, but this makes the want of proportion
between the separate comparative values all the more striking.
Considering that his work in the second five minutes, on the
days with a pause, is 8*3 per cent, worse than the work of the
first five minutes, the diminution in the second five minutes,
on the days without a pause, is far too small. We should have
expected to find a considerably higher figure in Column 2, while
the reduction of work we see in Columns 3, 4, 5, and 9 is
remarkably great. The disproportion between the comparative
values is even more obvious in Column 10. In this column,
in which the difference between the work of the fifth and sixth
minutes, on the days without a pause, is calculated as a per¬
centage of the work of the fifth minute, we should have ex¬
pected the preponderance of the effect of fatigue over that of
practice to result in a reduction of work in the sixth minute, or

♦i . --.‘V .. \ T

Digitized by CjOO^Ic -

500 THE CLINICAL MEASUREMENT OF FATIGUE, [July,

if the patient worked with impulse here, to allow, at the very
most, a trifling increase. The increase of 13T per cent, can
only be explained as a falsification of the results. Finally,
the work grows less from day to day in the case of this subject
also, and even in a higher degree than in that of Dr. B—.

Dr. B— and Dr. St— were both acquainted with the laws
regulating the course of work. The next subject, Frafllein S—,
had no such knowledge. The results of her experiments are
therefore, for obvious reasons, of special interest for the detection
of wilful simulation. It may be added that she was a lady of
unusual intelligence, and had carefully considered her plan of
simulation beforehand.

The results of her experiments bear throughout the mark of
the most extreme exaggeration, and there are also remarkable
contradictions in the mutual relations of the comparative values.
That the subject was very far from being able to observe the
invariable laws which regulate the whole course of work is
made particularly clear by the way in which the work varies
from day to day. The work of the first five minutes on the six
consecutive days amounts to 125, 95, 85, 82, 66, and 65 addi¬
tions—that is, it deteriorates progressively from day to day by
an average of 8*8 per cent, of the work done on the first day.
The subject has entirely omitted to take account of the factor
of practice in her work.

In the following figure (Fig. 24) we have tried to give a graphic
representation of the gain or loss of practice simulated in wilful
deception and its disagreement with the invariable relations
found in patients and in healthy subjects.

The days of experiments 1 to 6 are marked on the horizontal
line, and the daily increase of practice stated as a percentage of
the work of the first day, is shown on the vertical line. If the
point of intersection of the vertical and horizontal lines is con¬
nected with the co-ordinate points a straight line is obtained,
representing a linear function, the angle of which is determined
by the gain or loss of practice. In this way we have repre¬
sented the advance in practice, or the reverse, of Subject 2,
with an average daily gain of 47 per cent, of the work of the
first day, of the patient P— with a gain of i - 4 per cent., and of
Dr. B— and Fratilein S— with a loss of 1*4 per cent, and 8*8 per
cent, respectively. As P— shows the least advance in practice
of all the patients, and Subject 2 the least of all the healthy

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1907.] BY WILHELM SPECHT. SOI

subjects, excluding Subject 10 for the reasons previously given,
the curves of the other patients would fall between the curve of
Subject 2 and that of the patient P—, and the curves of all the
healthy subjects between that of Subject 2 and the vertical. In
other words, they would rise considerably above the horizontal
line. The curves of the subjects who have simulated abnormal
fatigue fall, on the contrary, below the horizontal, thus depart¬
ing from the necessary and invariable course of the curves.
Thus the deception becomes obvious.

It is sufficiently proved by the experiments we have described

that not even an accurate knowledge of the nature and effect
of the various influences governing the course of work can
enable anyone to simulate abnormal fatigue without betraying
his intention by extreme exaggeration and gross disproportions
between the comparative values. If the attempt is to succeed
at all, the subject must not only have an exact idea of the way in
which the amount of work done changes from minute to minute
in the special case of patients suffering from increased liability
to fatigue, but must also be able to make the exact number
of additions that he intended every minute. I knew myself,
from my study of their curves, how the work that my patients
did varied in every separate minute. I was therefore in a position

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502

THE CLINICAL MEASUREMENT OF FATIGUE, [July,

to calculate exactly, before the experiment, how many additions
I must make in every minute in order to'produce changes in the
course of the work corresponding in all their details with those
which occurred in the work done by my patients. The prin¬
cipal difficulty was this: I had in the first place to count the
additions I made as I went on, and secondly, to estimate the
time when the minute would come to an end. The first con¬
dition was particularly hard to satisfy, for, as I have explained,

I had made it impossible to tell the number of additions I had
made from the length of the columns. I therefore had recourse
to marking the seconds by a regular movement, practised before¬
hand, of one of the fingers of my left hand, which was imper¬
ceptible to the person conducting the experiment, and tried to
make the additions in time with this movement. As I had
expected, I succeeded fairly well, after long practice, in marking
the seconds correctly. It was more difficult to count the move¬
ments and make the additions simultaneously, but this, too, I
practised for a considerable time.

It appears from the results set down in Table IV (Dr. Sp—,a)
that my work-values corresponded fairly well with those of the
patients, and that the advance in practice, in particular, was
pretty well imitated. On the other hand, a closer inspection
shows a disproportion between the comparative values. It
seems unnecessary to point out that the employment of so
complicated a method would hardly occur to any malingerer.
Still, I thought it worth my while to take into account the
possibility even of so elaborate an attempt at simulation.

I also made a second series of experiments to see what form
the course of work would take when the subject was not able,
as I had been, to compare the work of the separate minutes,
and the use of my complicated method was impossible.

The work-value in the very first column (Dr. Sp—, b) shows
that I exaggerated considerably, and the same conclusion must
be drawn from the values in Columns 2, 3, and 4. Besides this,
there is a gross contradiction between the values in Columns 3
and 4. If the reduction of work amounted to 26 per cent . between
the first and second minutes, it must have been very much
greater by the fifth minute. The falsification evident here also
appears in the values of the following columns. In Column 5
we find a great reduction of work between the fifth and sixth
minutes in the case of all the first three patients, and only in

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19°7-]

BY WILHELM SPECHT.

503

that of J— are the values equal. I ought to have had a minus
quantity here, since the work should have decreased from the
sixth to the seventh minute as the result of great liability to
fatigue.

The last three work-values also are evidently falsified. In
Column io P— shows the trifling increase of 0*5 per cent., and
that only because he worked with an effort of will in the sixth
minute. The impulse could only produce a very small
improvement in his work, because the effects of fatigue had
already gained too great an influence over the course of the
work. I, who seemed, according to my other work-values, to
be even more susceptible to fatigue than P—, ought to have
been able to make very little improvement, or none at all, in
ray values, even if I worked with impulse in the sixth minute.
Finally, the slight reduction in my work from the second to
the tenth minute is a gross contradiction of my other work-
values, and the minus quantity in Column 12 is opposed to
the principles which determine the growth of practice.

It is clearly and incontrovertibly proved by the results of
these five sets of experiments that we are able to detect inten¬
tional simulation by our method. Even those subjects who are
fully acquainted with the laws that regulate the course of work
are betrayed at once by their extreme exaggeration of the sus¬
ceptibility they would simulate, and by a disproportion between
the comparative values.

There is still a possible mode of simulation which we must
consider to complete our discussion of the subject. We have
seen in the case of our patients P— and M— that the
absolute amount of work they did was extraordinarily small,
and that the number of additions hardly varied from minute
to minute or from day to day. Although it is altogether
improbable that anyone about whom there was a question of
simulation would know the details of such a course of work as
was performed by these two patients, the possibility cannot
be excluded with absolute certainty. In such a case, it is con¬
ceivable that the malingerer might try to make his work
resemble theirs—that is, to make about eight additions in every
minute. The attempt would not be difficult to carry out in
itself. But it must be observed, in the first place, that even
the work of these two patients followed certain laws in its
course, as is shown more especially by their regular advance in

Lin. 35

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504

THE CLINICAL MEASUREMENT OF FATIGUE, [July,

practice. Secondly, and here is the difficulty, such a course of
work as we met with in patients T— and M— is only possible
when the work comes under the influence of a very severe
impediment. Where an impediment of this kind is actually
present, the general clinical picture is such as to leave no
room for doubt about the reality of the morbid disturbances.
From this it follows that, in the case supposed, there would
not be the slightest difficulty in detecting the imposition.

Recapitulation .

The object of this work has been to discover a method by
which it might be possible to measure fatigue clinically. The
method itself is based on the results obtained by Kraepelin from
his preliminary investigation of the influences determining the
course of work. The accurate comprehension of the composi¬
tion of the work-curve is an indispensable preparation for the
use of the method of continuous work for the purpose of measur¬
ing fatigue. Our method has, therefore, been developed in close
dependence on the work of Kraepelin and his pupils. To measure
fatigue in our patients we had first to obtain comparative values
from healthy subjects. With this object we carried out experi¬
ments, lasting for twelve or eighteen days, on a considerable
number of healthy people. By this means we discovered that
the amount of liability to fatigue existing in healthy people is
very variable, and that the liability may reach an extraordinarily
high degree even within the bounds of health. We have tested
the usefulness of the method in the clinical measurement of
fatigue by applying it to patients in whom greatly increased
liability to fatigue is a regular symptom. Our comparison of
the work-values of healthy subjects and of patients has brought
to light the fact that the patient’s liability to fatigue is consider¬
ably greater than that of the most susceptible healthy subjects.
We were able to present the difference in a series of arithmetical
statements. From all this we may draw the conclusion that
the method has made good its claims, and, therefore, may be
applied to the object of clinically measuring fatigue.

For determining the amount of the effects of fatigue we had
a number of comparative values at our disposal in each indi¬
vidual case. The difference between the work-values of the
fifth and sixth minutes, on the days with a pause, and the

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1907.]

BY WILHELM SPECHT.

SOS

difference between the differences in the work of the first and
second five minutes, on the days with and without a pause, were
particularly useful for our purpose. We had expected that these
two comparative values would correspond to one another. In
many cases they did not, but we were able to show from the
work-curves that the amount of the values of the fifth and sixth
minutes was affected by impulse in many people. We were also
convinced that the amount of the effects of fatigue could not be
discovered from the difference between the work on the days
with and without a pause in the case of people whose work
showed a diminution in the second five minutes, even on the
days when there was a pause. The reason for this was that, in
such people, great remains of fatigue persisted after the pause,
and its useful effect was, therefore, unable to make itself felt to
the same extent as if there were more complete recovery from
fatigue. These two facts explained the apparent contradiction
between the comparative values in an absolutely satisfactory
way.

The fact that the amount of the difference between the
differences in the work of the two periods of five minutes,
on the days with and without a pause, cannot be employed
in such a case to determine the amount of the fatigue does
not particularly increase the difficulty of measurement. The
great decrease in the work of the second five minutes, on the
days both with and without a pause, points at once to great
liability to fatigue. The error arising from impulse, which
more or less affects the work-values of the fifth and sixth
minutes, on the days with a pause, may also be neglected, as
a rule. But where the separate comparative values are out of
proportion to one another it will be as well to consider the
possibility that the values of the fifth and sixth minutes may
be influenced by impulse, and this can best be done by reference
to the work-curve. Examination of the work-curve affords the
best means of judging if the work has been affected by impulse.

Of the other comparative values we have employed for deter¬
mining the amount of fatigue, the co-efficient of fatigue, as we
have calculated it, is perhaps the least reliable. It is true that
we found certain points of agreement to exist between it and
the other comparative values, and that it was always greater in
the patients than in the healthy subjects; but as it could only give
an approximate and very inexact idea of the true amount of the

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506 the clinical measurement of fatigue. [July,

effects of fatigue, while the other comparative values have proved
to be sufficient without it, one might give up calculating it. On
the other hand, the value which we calculated from the difference
between the work-values of the second and tenth minutes, on
the days without a pause, has proved to be extremely useful.

The results we have obtained from our experiments are
derived from series of twelve, or occasionally of eighteen, days.
We continued the experiments for this length of time because,
on first testing the method, it was important to obtain the
most reliable average values possible and the least affected by
accidental influences. Very probably shorter experiments,
continued for a few days only, will be sufficient to determine
the amount of the effects of fatigue in a perfectly reliable way.

The measurement of fatigue in traumatic neuroses in par¬
ticular has shown that the patients* liability to fatigue is greatly
increased, that they have very little power of recovery, and
that their capacity for work is much reduced. Their capacity
for practice does not seem to be much impaired, but the traces
of practice disappear extraordinarily quickly, their power of
retaining practice being very small.

In the case of two patients it was impossible to determine
their liability to fatigue in arithmetical terms, but we were able
to discover that their work was affected by a severe psychogenic
impediment, which had practically destroyed their capacity for
work.

Finally, the method has to the fullest extent made good its
claim to be a means of detecting intentional simulation. We
were able to prove with certainty that it was impossible, even
with an accurate knowledge of the laws which govern the course
of work, intentionally to alter one’s way of working for the
purpose of malingering so as to observe these laws without any
contradictions. Intentional simulation is at once betrayed by
its extreme exaggeration of the morbid disturbances it imitates
and by the disproportions between the comparative values.

(*) Kraepelin’s Psych. Arb., vol. ii, p. 577.—(*) Munchener med. Wockenschrift,
1898, No. 49.—( 3 ) Cf. Gross, Ibid . P— is the same patient in whom Gross
measured fatigue.—( 4 ) Cf. Table III.

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1907.]

DEMENTIA PARALYTICA IN BRAZIL.

507

A Contribution to the Study of Dementia Paralytica in
Brazil. By Juliano Moreira, M.D., Medical Director
of the National Hospital for the Insane, Rio de Janeiro,
and Antonio Penafiel, M.D., Ex-assistant (*).

Brazil, with its vast area, comprising a fifth of the western
continent, its various climates, and its population of 21,000,000,
formed of several ethnical groups, offers an admirable field for
the study of the comparative racial pathology of the insanities.

We have the so-called “ white races,” represented by the
Portuguese, Spanish, Italian, German, Swiss, English, French,
Belgian, Hungarian, Polish, Russian, Scandinavian, Dutch,
Danish, Greek, and Syrian immigrants and their pure de¬
scendants. China contributes the “ yellow man ” and Africa
the negro. These, with the aboriginal Indian and the numerous
mestizos of various races, complete an enumeration serving to
show the composite character of the Brazilian population.

Did space permit, it would be interesting to study the
manner in which the various ethnical groups have intermingled
to form what may ultimately become the definite Brazilian type.

Though a new country, Brazil already affords abundant
opportunities for the study of the various neuropathies.
Statistics have proved the rapid increase of psychoses, and the
Government has been obliged to make more extended provision
for the care of the insane.

The causes of this increase must be sought for in the rapid
intellectual development of our time, the steadily increasing
competition, the fears of political, financial and commercial
crises, and the overcrowding of our great towns, all tending to
intensify the keenness of the struggle for existence of modern
life.

The immense advances in intellectual and political life have
not been accomplished without a great expenditure of mental
energy—an expenditure which must be continued if we are to
keep what has already been acquired.

We do not, however, in the present paper, intend to review
the various forms of insanity occurring in Brazil. We desire
merely to present some statistics of general paralysis in this
country, adding certain observations suggested by the facts

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508 dementia paralytica in brazil, [July,

gathered therefrom, in the hope that such a task may add
something to the knowledge of that very interesting disease as
it occurs in our own country.

The statistics of our asylums do not show any alarming
increase in the occurrence of the disease, but these statistics are
less trustworthy than those derived from European sources, and
that for two important reasons—firstly, our people, especially
those of the better classes, usually keep an afflicted relative at
home as long as his condition permits them to do so, and
secondly, the disease in most instances still passes unrecognised
by the general practitioner, at least, in the early stage, or when
it assumes an atypical form, the syndrome too often being
diagnosed as neurasthenia, hypochondriasis, or cerebral syphilis.

The statistics of the Hospicio nacional de Alienados de Rio
show during the period from 1889 to 1904 an admission of
9609 insane, 5878 being males and 3731 females. Of the
total number admitted 266 were general paralytics, giving a
percentage of 276. On comparing this with the percentages
given by the following statistics obtained from other countries
a marked difference is to be noted.

In Russia, Dr. B. Greidenberg, of the Kharkow Ziemskoi
Hospital, gives 8*8 per cent . for the years 1890 to 1901. But
Dr. Idanow, from the statistics of several asylums, reports a
percentage of 18*18.

In 3916 cases admitted to the Psychiatric Clinic of the
University of Moscow from 1887 to 1901, Professor S.
Soukhanoff and P. Gannouchkine found 17*42 per cent

In Germany, YVeygandt gives the percentage as from 10 to
15 ; Siolli found 26 per cent.

In Hamburg, Kaes found 14 per cent . in 10,148 insane
patients.

In Austria, Meynert found in 8546 cases 34*6 per cent.

In Belgium, in 7656 cases admitted at Gheel, Peters reports
16*6 per cent.

In Italy, Roscioli found 10 5 per cent. In Genoa, Giovanni
de Paoli found 31*5 per cent .

Professor Bianchi, in 555 cases admitted to the Provincial
Manicomio of Naples from 1891 to 1893, reports 137 A r
cent. Dr. Lojacona reports at the Manicomio de Palermo a
percentage of 10 7 5.

In Denmark, the statistics of the Saint Hans Asylums pub-

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1907 ] BY JULIANO MOREIRA AND ANTONIO PENAFIEL. 509

lished by Rohvvell and Jehersen, show in twenty years a per¬
centage of 17*31. But, following these, Jacobson gives statistics
of the same asylum for a period of seven years, showing 23 per
cent, general paretics.

In England, Dr. Thurnam gives the percentage as 24*33.
Dr. Oscar Woods gives 12*5 per cent, for England, 4 per cent.
for Scotland, and only 1*1 per cent, for Ireland.

In France, Dr. Plants gives 17 per cent . Dr. Laurent puts
the percentage in the public asylums of that country at 18. In
Paris it is much higher, Charenton Asylums showing 46 per
cent, amongst the male insane and 5 per cent, in the women’s
division. In the private asylums it varies between 35 and 44 4
per cent.

In Switzerland, Dr. Camuset, Saint Alban’s Asylum, Laz&re,
found in 200 admissions, during a period of ten years, a per¬
centage of 5.

In Greece, Dr. Yamiris, Dromocaitis Private Asylum, Athens,
observed 19*89 per cent, in 1136 patients, from 1887 to 1902.
Dr. Scarpas reports 9*7 per cent, in the Corfu Asylums.

In Portugal, Professor Bombarda, Rilhafolles, Lisbon, in
2782 admissions from 1892 to 1902 found io*i per cent.

In the United States of North America, statistics collected
from various sources since 1849 by Dr. O. G. Wagner show
that there has been a gradual increase from 1*5 per cent, to 12
per cent, on all admissions. Data from the Manhattan State
Hospital East show a percentage of 8*75.

The infrequency of general paralysis in tropical countries
has been asserted more than once. Van Brero writes:

Dementia paralytica ist eine Irrseinsform, welche in tropischen
Landern wenig beobachtet wird.” In Java, among 230 patients
he found only two general paralytics. Manning, in New South
Wales, writes: “ I have never seen or heard of a general
paralytic.”

Law, in the Georgetown Reports for 1887, says : “ As regards
general paralysis of the insane it is undoubtedly very rare in
the colony, and was, in fact, till recent years unknown.”

Barnes, in 1891, says : “ General paralysis has been repeatedly
declared to be non-existent ; but it does exist, and is not un¬
common.”

Friedrichsen, quoted by Jeanselme, saw no cases of general
paralysis in Zanzibar—a hot climate—but it is interesting to

510 DEMENTIA PARALYTICA IN BRAZIL, [July,

note that Ehlers says that in Iceland—a cold climate—the
syndrome is unknown.

Nevertheless, we do not consider that climate influences the
frequency of the occurrence of the disease. Its incidence is, in our
opinion, regulated by those factors of modern civilisation which
intensify the stress of life. Excessive mental and emotional
strain, alcoholism, sexual excesses, etc., weaken the resisting
power of the nervous system and render it liable to be affected
in a special manner by the toxins of syphilis and other etio¬
logical factors, which are the direct cause of pathological changes.

The percentage amongst the Brazilian patients and that of
the foreigners admitted to the National Hospital in 1889 to 1904
were about equal.

Of the 1091 patients admitted to Dr. Eiras* private hospital
in Rio from 1889 to 1903,4*3 per cent were general paralytics.

In 1889 Professor Teixeira Brandao reported to the Brazilian
Congress of Medicine of Rio de Janeiro that of 670 patients
observed from 1883 to 1888 in Rio and Nicteroy asylums,
only 1 *6 per cent\ were affected with general paralysis. At the
same congress Dr. Eiras reported a percentage of 6*22 in 610
admissions to his private hospital ; but here it is important to
note that at that time nearly all the well-to-do patients of the
other states were removed to the private hospitals in Rio.

State of 5 . Paulo .—In the public asylum of this State,
Dr. Franco da Rocha found in ten years—1894 to 1904—
among 1057 Brazilian patients a percentage of 3*87 general
paretics, and among 626 foreigners admitted during the same
period the percentage was 8*3.

State of Rio Grande do Sul —In St. Peter’s Asylum, from
1884 to 1904, Drs. Dias de Castro and Tristao Torres found
in 2252 admissions a percentage of 1*46 paretics, vis. y 27
Brazilians, 3 Portuguese, 1 Italian, 1 German, and 1 African.

Race and general paralysis .—The relation of race to insanity
has been studied by some authors, but the data are too incom¬
plete and imperfect for positive generalisations. No information
of value on this point can be gleaned from statistics owing to
the loose definition of the ethnical groups contentedly accepted
by the North American and Brazilian physician. As an illustra¬
tion we may quote Babcock as saying: “ The term * coloured
insane’ is here applied to all persons of African descent, to full-
blooded negroes as well as to half-breeds.” In Brazil our

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I907.] BY JULIANO MOREIRA AND ANTONIO PENAFIEL. 5 I I

colleagues are satisfied with the imperfect classification : white,
mulatto, negro.

Our statistics show that there is no race immunity from the
various forms of insanity.

Some years ago it was thought that the negro was exempt
from the disease under discussion. Dr. Roberts, of the Eastern
North Carolina Insane Asylum, in 1883 had never met with
general paralysis among his coloured patients, nor had
Dr. Powell, of Georgia, in 1886 ever seen a case in a
“full-blooded negro/* But the investigations of Kiernan,
Berkley, and others show that the negro does not enjoy an
immunity.

We ourselves have observed the disease in members of all
the ethnical groups inhabiting Brazil, with the exception of
the pure aborigine and the directly-imported African negro.
The disease frequently assumed the apathetic form, and there
was nothing in the symptomatology peculiar to the various
groups. Such differences as did exist were individual, and
due to the degree of civilisation and education attained by
the patient.

The exalted type was seen by one of the writers in the case
of a mulatto, the offspring of a European and a negress. He
had been an intelligent army physician, and by his own merits
had obtained a good practice in an important capital in the
Union. In the course of his illness he showed the grandiose
delusions so commonly observed in the disease in Europe.

Another interesting case was that of a mulatto, a captain of
an engineer corps, who became governor of an important
state in Brazil. Here also the disease showed all the
exuberant symptomatology of the classical type.

Owing to the deficient classification of the ethnical groups by
means of the colour of the skin we have on the statistics of our
hospital among 148 Brazilian men, 99 whites, 36 mestizos, 10
blacks, and 3 unclassified ; among 9 Brazilian women, 3 whites,
4 mestizos, and 2 blacks !

Table III shows the nationalities of the foreign patients on
the statistics of the hospital.

Influence of sex .—In various European countries the pro¬
portion of female general paretics to males varies considerably.
Saunder in 1870 gives the highest proportion, viz ., 5 to 7 !
Krafft-Ebing, Schule, and Sioli give 1 to 7, Greidenberg 1 to

512

DEMENTIA PARALYTICA IN BRAZIL,

[July,

6, Stark i to 5, Mickle, Siemerling, Keilner, Roscioli 1 to 4,
Peters, Kaes, Thurnam, Giovanni de Paoli, and Bianchi 1 to 3,
Jacobson 1 to 3 6, Weygandt 1 to 3*5, Meynert and Idanow
1 to 3‘4, Planes 1 to 2*4.

In the National Hospital for the Insane at Rio there is a
proportion of 1 female to 18 males in a total of 266 general
paretics. Of the females, 9 are Brazilian and 5 foreigners.
In Dr. Eiras’ Hospital the proportion is 3 women to 82 males.
Dr. da Rocha, at the S. Paulo Hospital, found 3 female paretics
to 90 males among a total of 1753 insane observed from 1894
to 1904.

Our statistics show that general paresis in females is much
less common here than in other countries, the difference
perhaps being due to the fact that our women have not yet
entered into competition with the male sex in the affairs of
business and public life.

The clinical history of the female general paretic in Brazil
introduces no new features. Compared with that of the male
sex it runs a slower, more even, and less explosive course.
The maniacal outbreaks are not so expansive, the delusions of
grandeur not so pronounced, the periodical exacerbations and
remissions are not so frequent nor so well marked as in the
male. A form of quiet dementia is the prevailing type.

Age .—The great majority of cases occur between thirty-five
and forty-five years of age.

The following table is from the statistics of the Hospicio
Nacional de Alienados.

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1907.] BY JULIANO MOREIRA AND ANTONIO PENAFIEL. 5*3

From 20 to 30 years ... 6 cases.

>, 31 » 40 „ • • * 18 »

» 4 1 » 5° » • • • 1 S »»

n S 1 » 60 „ • • • 8 1 *

Early cases of the adult form of general paralysis occur also
in Brazil. We have met with cases in which the disease has
come on at twenty-three and at twenty-four years of age.

Franco da Rocha, of S. Paulo, has also observed general
paralysis in several patients of twenty-five years of age.

The youngest subject of general paralysis admitted to the
Hospicio Nacional of Rio de Janeiro was twenty years of age.

Juvenile General Paralysis .

Prior to 1877 general paralysis of the insane was believed
to be only a disease of adult age. In that year Dr. Clouston
described, in the Journal oj Mental Science , a case of the
disease in a boy, set. 16, and he pointed out that, clinically
and pathologically, the disease that affected his patient in no
way differed essentially from the adult form. He designated
it “ developmental general paralysis,” and it was looked upon by
him as an extremely rare disturbance. Since his article cases
have been published in Germany, Austria, France, etc., and as
the knowledge of this morbid condition has become more
common, so the number of cases has increased. Especial
attention has been drawn to the early form of paretic dementia
by Krafft-Ebing, Karplus, Alzheimer, Gudden, Regis, Haushalter,
Mott, and others.

In 1895 Alzheimer, in a very valuable monograph, was able
to collect only thirty-seven published cases, to which he added
three cases of his own, with careful microscopical examinations
of the nervous tissues. In 1898 Dr. Thiry collected and
analysed sixty-nine published cases, which include all those of
Alzheimer with three cases from the clinic of Haushalter, which
he has observed. Dr. Frederick Walker Mott, the distinguished
director of the pathological laboratory of the London County
Asylums, has recently published notes of twenty-two cases of
juvenile general paralysis occurring in the London County
Asylums during three years. The number of cases recorded
increases every year, and, although the disturbance is rare, it
will be seen from the foregoing remarks that it occurs much

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514 DEMENTIA PARALYTICA IN BRAZIL, [July,

oftener than was hitherto supposed. Here in Brazil we have
only an account of two cases—one by Professor Teixeira
Brandao, the other by one of the writers. No doubt a great
many cases would not be recognised, especially in the early
stages of the disease, because of the difficulties in diagnosis,
which are more or less considerable.

The following case was diagnosed “ a case of imbecility,” by
two medical men, not alienists :

M—, white, single, needle-woman, act. 18.

History .—No insanity in the family (?). Very little history
could be obtained. Her mother was nervous and excitable.
Father nervous and syphilitic.

Personal history .—Patient was a full-time child and her
birth was uncomplicated and natural. Her health was good
until eight years old. Her eyes were always healthy, but the
milk-teeth were very bad. Mentally she was always deficient.
She was sent to school when six years old, but was removed
because her education was considered hopeless.

At twelve years she had her first fit when playing in the
garden. She suddenly became unconscious, and lay for two
hours with her face pale, lips blue, and her eyes open. From
this time she gradually got worse, becoming day by day more
weak-minded. From time to time occurred a fit of a similar
character to the first. She became very spiteful, biting those
who came in contact with her.

Condition when seen , September , 1902.—Patient has an
imbecile, childish expression, and speaks in a childish manner
and in a very nasal tone. Her speech is hesitant, tremulous,
and syllabic. Attention difficult to obtain. Appeared to
understand very simple questions, but was unable to frame a
reply. She can stand and walk, but her gait is very unsteady,
and she walks with a wide base, hardly raising her legs.

The central incisors are peg-shaped and notched, and there
are linear erosions of the enamel.

The tongue is protruded by a succession of inco-ordinate,
irregular jerks, and there is marked fibrillary tremors both
in it and in the muscles of the face.

The pupils are dilated, unequal, irregular, and do not react
to light, and but sluggishly on convergence.

The knee-jerks absent. Plantar reflex present. Tremor in
the extended fingers. Taste and smell are good, and there is

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1907.] by JULIANO MOREIRA AND ANTONIO PENAFIEL. 5 I 5

apparently no loss of the sensations of touch or pain. Although
eighteen years of age there is very little hair on the pubes.
Her hands and feet are somewhat blue and very cold. Her
appetite is exaggerated. She has lost control over her
bladder and bowels.

Professions and Occupations .

It is easy to see how certain professions favour the occurrence
of several forms of insanity more than others, but with regard
to general paresis the influence of occupation is not evident.
It has been said that it is a disease of the higher educated
classes as distinguished from the labourer or wage-earner, but this
is not strictly true, for here in Brazil it affects all classes, with¬
out regard to social or financial position or education, and this
fact is becoming more evident as the disease becomes more
frequent. The statistics of the Hospicio Nacional and of
Dr. Eiras* Hospital show that in Rio de Janeiro all classes and
professions are represented among the paretics. In Brazil, if
any pursuit is especially more liable to the incidence of this
disease, it appears to be the commercial (vide Table IV).

Of the.266 paretics in the Hospicio Nacional there are 80
(excluding 1 female) whose occupations are unknown, the pre¬
sumption being that they are of a low class.

It is to be remarked that about half of our patients are
illiterate. The women were all of an inferior class and all
without education.

Of the paretics at the S. Pedro Hospital, Rio Grande do Sul,
the occupations are as follows :

Rural pursuits. . 9 Mason . . 1

Merchants . . 3 Carpenter . 1

Soldiers . . .2 Tailor . . 1

Public functionary . 1 Shoemaker . 1

Clergyman . . 1 Unknown . 12

The following is from Dr. Moreira’s private practice:
Merchants . . 8 Physicians . 2

Engineers . 3 Army Physician 1

Military engineer 1 Lawyers . . 2

Statesmen . . 3 Army officer . 1

Marine officers . 2 Capitalist . . 1

Master mariner 1

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5 16 DEMENTIA PARALYTICA IN BRAZIL, [July,

Civil state .—Of the 266 general paretics at the National
Hospital of Rio, 113 are married, 102 single, 22 widowed, and
29 unknown.

In Dr. Eiras* Hospital there are 32 married, 14 single, and
1 widowed.

Kraepelin, Defendorf, and other authors say that the disease
is more frequent among the unmarried, but our statistics do
not support that statement. One of the writers of this article
(Dr. Moreira) has met with only two cases amongst the
unmarried in his private practice.

Duration of the disease .—The following table shows the
time of residence of the patients in the National Hospital from

admission till death.

I to 10 days ..... 7

10 „ 29 „. 8

1 month . . . . 35

2 months. ... . . 36

3 27

4 .17

5 24

6 „ . . . . . 11

7 5

3 .7

9 .3

10 5

11 .5

1 year to 1 year and a half . . 16

1 „ and a half to 2 years 17

2 years to 3 years .... 6

Total 231

Of the 3 5 others, 13 are still in the hospital; the remaining
22 had remissions that permitted them to return to their
families. Relatively the onset of the paralysis was later in the
women than in the men.

That 190 cases died within a year of their admission shows
the rapid course which typical general paralysis runs now and
then here in Brazil. However, several of the patients were
admitted in a fairly advanced stage. The question arises how

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1907.] BY JULIANO MOREIRA AND ANTONIO PENAFIEL. 5 I ?

long the patients are affected prior to admission. Dementia
paralytica, in our experience, here in Brazil, usually leads to
death in the course of a few years.

Now and then it may last for six or eight years, or some¬
times perhaps even longer, but the end generally comes in four
or five years, and often very much sooner.

Among the cases occurring in the private practice of one of
the writers (Dr. Moreira), only one patient lived more than five
years. On the other hand, we have seen eight paralytics die a
few weeks after the occurrence of the second stage, either from
exhaustion attending intense agitation or from a simple pro¬
gressive decline in the vital metabolism, the end being preceded
by a series of apoplectiform seizures.

With regard to the mental state of the general paralytic in
Brazil, we have classified 200 cases drawn from hospital and
private practice, as follows :

Those with grandiose delusions or excess of euphoria at any
stage of the syndrome, 96 cases, or 48 per cent . Those who
exhibited simply a progressive dementia, 72, or 36 per cent .
Those who were depressed and never had any excess of
euphoria, 32, or 16 per cent . Several cases were not grandiose
on admission, some were even depressed and afterwards became
grandiose. All these are included in the first category. Suicidal
tendencies were by no means rare.

The physical signs of these 200 cases were investigated with
regard to oculomotor abnormalities, slurring of speech, and state
of knee-jerks on admission, the results being as follows :

Pupils unequal -95

„ equal . . . .98

„ not recorded ... 7

„ fixed to light (one or both) . 63

„ sluggish . . -98

„ normal . . 3 5

„ not recorded ... 4

Slurring of speech .175

Speech clear . . .23

Not recorded .... 2

Knee-jerks normal .12

„ absent . -55

„ increased ... 90

„ diminished ... 39

„ not recorded . 4

Digit!?

5 I 8 DEMENTIA PARALYTICA IN BRAZIL, [July,

With regard to etiology, one of the writers, while not sub¬
scribing to the dictum “ no syphilis, no general paralysis,"
believes in the preponderating influence of syphilis as an etio¬
logical factor of the syndrome. In 60 cases observed by him
30 per cent . had had syphilis ; in 50 per cent . syphilis was
probable ; in the remaining 20 per cent . there were no signs of
the disease to be found.

Other factors reported in the antecedents of the patients are
alcoholic and sexual excesses, head injury, mental shock, and
insolation.

Mental strain, excessive work under trying circumstances,
and painful emotions are reported among the causes of the
syndrome, which arises in most instances from cumulative
factors prolonged through a series of years.

Table I.— Showing the number of admissions of each sex to the
Hospicio Nacional de Alienados de Rio de Janeiro
(1889—1904).

Years.

Brazilians.

Foreigners.

Total.

M. |

1889

1890

l8l

139

«23 1

498 j

1891

IIO

..8

302

1892

162

149

219

610

1893

185

141

126 j

5 «°

1894

267

215

160 ;

706

1895

276

197

175

706

1896

232

148

208

665

1897

241

239

201 i

742

1898 1

278

267

I 171 '

785

1899

1 241

217

173 !

7>4

1900

229

216

122 i

615

19OI

253

195

1 I44 1

641

1902

247

199

1 >43

643

19 °3 1

275

249

156

7*7

1904

265

194

152 1

662

Totals .

3475

2847

j 2403 ;

884

9609 i

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I907-] BY JULIANO MOREIRA AND ANTONIO PENAFIEL. 519

Table II .—Showing the Nationality of the Foreigners admitted
to the Hospicio Nacional de Alienados de Rio de Janeiro
(1889—1904).

Nationality.

1889 to 1892.

1893 to 1896.

1897 to 1900.

1901 to 1904.

Portuguese

118

309

358

106

339

Italian

Spanish

4 i

100

French

9 1

German

Austrian

English

—

| Russian

—

Polish

—

African

Turkish and Syrian .
Dutch

| Danish

Belgian

—

' Swiss

—

1 Swedish

—

1 Greek

—

1 Roumanian

—

Chinese

—

1 North American

l 2

—

1 Argentinian

—

Uruguaian

•

—

1 Paraguaian

1 _

—

Chili, Peru, Ecuador

j _

—

Cuban

1 _

—

Unknown .

253

102

139

1 ~~

! 472

175

669

j 257

667

261

595

191

LIII.

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Table III. — Nationality of the General Paralytics in the Hospicio Nacional de Alienados de Rio

de Janeiro .

520

DEMENTIA PARALYTICA IN BRAZIL,

[July,

VO 00 Tf tr. o « -

4 !
o

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i i

ul |

i i

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i i

2 1

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1 ** N 1

i l

x |

1 1

i i

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1 1

i i

1 1

_ i

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1 1

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8 1

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1 I 1 1 1

1 2

■*

1 1

r 1

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1 2

i o

c*o

- 1

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1 1 1

i i

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i i

1 2

! 10

“1

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i i

1 fc*

’ 1

i i

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1 2

i «

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1 1

1 ^

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i "i

i i

l“s_.

1 " 1

i i

1 ^

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1 2

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l“l

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1 1

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1 2

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6u < O W CO U D

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1907 ] BY JULIANO MOREIRA AND ANTONIO PENAFIEL. 521

Table IV .—Professions and Occupations of the General Para¬
lytics at the National Hospital for Insane, Rio, and at Dr.
Eiras' Hospital, Rio.

Professions and occupations.

National Hospital
for the Insane, Rio,
1889 to 1904.

Dr. Eiras' Hospital,
Rio, 1889 to 1903.

i Physician.

Apothecary.

Dentist.

—

Advocate.

Notary .......

■

Engineer.

Surveyor.

—

Architect.

—

Draughtsman.

—

Photographer.

Mechanician.

Machinist .......

—

Painters, etc.

Printer .......

—

Workman.

—

Carpenter.

Cook.

—

Coachman, loader, streetworker, paver

Stower .......

—

Fisherman.

—

1 Boatman.

—

1 Mason.

—

Barber .......

—

Tailor.

— '

Soldier.

—

Army officer.

Marine officer.

—

Sailor .......

—

Policeman.

—

Functionary.

, Merchant’s clerk.

—

Bookkeeper .

Merchant .......

Capitalist . . %

Schoolmaster.

—

Clergyman.

Diplomatist.

Player.

—

; Clown.

—

Farmer.

Planter.

Attendant.

—

Total.

172

i 86

(*) The Editors much regret that, owing to lack of space and to other circum¬
stances, the publication of this article has been so long delayed.

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522 LIABILITY OF INSANE TO TUBERCULAR INFECTION, [July,

The Liability of the Insane to Tubercular Infection as
demonstrated by an Examination of the Tuberculo -
opsonic Index. By C. J. Siiaw, M.B., Ch.B., Assistant
Medical Officer Perth District Asylum, Murthly. Awarded
the Bronze Medal of the Medico-Psychological Association.

Introduction.

DEATH-RATE statistics of persons dying in large institutions
are often inexact, as their accuracy depends to a very large
extent on the personal factor of their compiler. Unfortunately,
the statistics of the death-rate from tubercular disease, particu¬
larly phthisis, occurring in asylums leave no room for doubt
that the insane, as a class, are particularly liable to contract
tubercular disease. The English Lunacy Commissioners in
their report for 1902 say: “The proclivity of the insane,
whether confined in asylums or not, to tubercular disease,
especially pulmonary, has long been recognised.” In all
asylums, according to Clouston, who was amongst the first to
draw attention to the fact, consumption is between three and
four times more common than in the general population at the
same ages.

There is, however, great difference of opinion as to whether
this high tubercular death-rate is due to the fact that the insane
are herded together in asylums, or whether the insane, as a
class, have an abnormally low resistive power to the invasion
of the tubercle bacillus. Clouston says that four-fifths of the
insane dying of phthisis contract the disease after admission to
asylums. Another observer has stated that not more than 7*5
per cent, of cases admitted into asylums are phthisical, and in
10 per cent, a family tendency exists. In English asylums
about 1 5*5 per cent . of deaths are officially assigned to phthisis,
and in at least 20 per cent . signs of tubercular deposit in the
lungs may be traced. The average duration of residence of
those dying from this cause in Scottish asylums is 3*66 years.
It is therefore probable that in many cases phthisis is con¬
tracted after admission to the asylum.

Clouston further states that out of ninety-seven cases of
general paralysis who died, twenty - seven were phthisical.
Mickle has stated that of all the general paralytics examined

Digitized by C^ooQle

1907.] BY C. J. SHAW, M.B. 523

post-mortem , 26 per cent, exhibited caseation or cavities, 12 per
cent, arrested phthisis, and 65 per cent, pleuritic adhesions. In
the last report of the General Board of Commissioners in
Lunacy for Scotland, the percentage of deaths from phthisis in
all Scottish asylums is given as 14*6. The percentage of deaths
due to general paralysis for the same year was 14 8. If one
takes into consideration the fact that many cases of general
paralysis really die of tubercular disease, although returned as
dying of general paralysis, the death-rate from tubercle must be
higher than that above stated.

As during recent years, with improved hygienic conditions in
asylums, the death-rate from phthisis has diminished among the
insane, it is possible that at one time confinement in an asylum
did act as a factor in swelling the tubercular death-rate. On
the other hand, it cannot be denied that many cases of phthisis
admitted into asylums make most excellent recoveries, and the
environments of the modern asylum do not suggest that tubercle
should be an endemic disease. In this asylum, among patients
drawn largely from a rural population, of the last hundred
deaths, seventeen were due to tubercular disease. Quite a
number of phthisical patients are admitted, however, who are
ultimately discharged recovered with no apparent signs of
active tubercular disease.

It is reasonable to suppose that, if the insane contract
phthisis through residence in asylums, the resistive power of
those who have been long resident should be considerably
below that of those more recently admitted, always provided
that the patients so examined show no symptoms of active
tubercular disease. On the other hand, if the insane, as a
class, be more liable to phthisis than the sane, their average
resistive power should be below that of the sane healthy
population.

The recent researches of Wright and others on the opsonic
power of human blood-serum to the tubercle bacillus and other
organisms have opened up a field of inquiry which, although at
present little explored, has already, they contend, yielded
certain results, in so far that it is now possible to calculate the
resistive power of the individual, not only to tubercle but also
to other organisms. As Wright found that in cases of
staphylococcal and tubercular infection with an entire absence
of clinical symptoms there was a diminished phagocytic power

524 LIABILITY OF INSANE TO TUBERCULAR INFECTION, [July,

to those organisms as compared with that of healthy individuals,
and as this power could be increased by injections of the
corresponding vaccine, he concluded that the lowered phagocytic
power permitted infection to occur, and that the resistance to
infection by any organism could be estimated by calculating
the opsonic power of the blood-serum. The results of observa¬
tions recorded by Bulloch and others agree with those obtained
by Wright and support his conclusion.

It occurred to me that in the study of the opsonic index of
the insane resident in the asylum we have a means of deter¬
mining the question as to whether the insane contract tubercle
as a result of residence in asylums or as a result of a lowered
resistive power to infection by the tubercle bacillus. With
this object in view I made observations on the opsonic index
of six members of the staff, who were, so far as could be ascer¬
tained, absolutely free from tubercular disease. I also made
observations on thirty cases of persons suffering from various
forms of mental disease, commencing with those most recently
admitted, and extending my observations to those who had
resided in the asylum for so long a period as eleven years. All
these cases were, at the time of observation, free from active
tubercular disease, but five showed evidences of having, at some
time, suffered from tubercular infection. One of them had
cicatrices in the neck. Four had flattening of the chest, with
diminished movement, some dulness on percussion, and increased
vocal fremitus with prolonged expiration. Two of these were
cases of general paralysis. During their period of residence
none of the thirty cases observed had ever required medical
treatment for any serious ailment.

The opsonic index of the blood-serum was determined for
five consecutive days, and the average index of each case
calculated for that period. In all cases the serum was com¬
pared with my own, which was taken as unity. To ascertain
if any further information could be gained from the opsonic
indices, I injected the control cases and the insane patients
with Koch’s new tuberculin T. R. Four of the control cases,
and twelve of the insane persons received an injection of
mgr. T. R., while two control and eighteen cases were injected
with mgr. T. R. The opsonic indices were then observed
for a further period and the results tabulated.

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1 907 .]

BY C. J. SHAW, M.B.

525

Technique employed.

Before reliable results can be obtained in estimating the
opsonic power of the blood, considerable experience in the
technique of the operation is necessary. I had been engaged
at this work for three months before I considered my results
sufficiently accurate for definite conclusions to be drawn from
them. I have continuous records of many cases for so long as
three weeks, but as I had records of only five consecutive
observations in all cases prior to injection with tuberculin,
I give the results for that period only.

The blood examined was taken at the same hour daily, and
therefore as nearly as possible under the same conditions as to
exercise and the digestive processes. Any change which
these conditions may cause in the opsonic power of the blood,
and which might lead to error in the results obtained, was
thereby reduced. The blood, in all cases, was taken from the
lobe of the ear, which was purified before being punctured
The first drop of blood was removed, and a sufficient quantity
for the number of observations being made was drawn into a
straight glass pipette with capillary ends. The pipette was
not quite filled, and, to prevent heating the serum, the vacant
end of the pipette was sealed in a flame. After centrifuging,
the serum separated from the corpuscles. The unsealed end
of the pipette was then broken off and the serum exposed.
My own serum, which was the control observed in every case,
was drawn from my finger. My leucocytes were also used
during the observations. Blood was dropped directly from my
finger, which was deeply punctured and bled freely, into a
solution of 1 per cent, citrate of soda in *8 5 per cent . chloride
of sodium solution. Two parts of this solution were put into a
small tube set in a piece of cork, and the blood run into it, the
whole being thoroughly mixed during the process. With a less
dilution the blood tended to clot. This mixture was then
centrifuged. The supernatent fluid was pipetted off and the
corpuscles again washed with a solution of *85 per cent, sodium
chloride. After centrifuging, this solution was drawn off with
a pipette, and the corpuscles left in the tube. These were
gently stirred and the leucocytes fairly distributed.

A suspension of tubercle bacilli was made in a 1 in 1000
sodium chloride solution. With a stronger solution this

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526 LIABILITY OF INSANE TO TUBERCULAR INFECTION, [July,

organism tends to clump, and the results are then less accurate
than with a more uniform suspension. The amount of tubercle
powder necessary was moistened with the solution and pounded
in an agate mortar. More solution was added, and when the
suspension was complete the whole was filtered into a small
sterilised test-tube. The suspension was renewed at very
frequent intervals, though the contrast staining employed pre¬
vented any error of enumeration which might have resulted
from the presence of contaminating organisms in the solution.
The suspensions were made as nearly as possible of the same
strength throughout, but as the same control serum was used
in all cases, and the index calculated by the result obtained in
the control case, no error resulted from a slight variation in the
strength of the suspensions used from day to day.

Having obtained the blood-serum, leucocytes, and organismal
suspension, equal quantities of these three were measured in a
capillary tube, and thoroughly mixed in the cell of a hanging
drop-slide. The mixture was then drawn into a capillary tube,
the end of which was sealed in a flame, and the whole incubated
for fifteen minutes at a temperature of 37 0 C. The end of the
capillary tube was then snipped off, and the contents blown
upon a slide. As uniform a film as possible was made, so that
the leucocytes and the organisms not ingested were fairly dis¬
tributed and not clumped at the edges of the film. Enumera¬
tion is prolonged by so doing, but the result obtained is more
accurate, as it can at once be seen whether the organism is
actually inside, or only lying on the top of the leucocyte. The
slides were dried in the air and stained with Ziehl-Neelsen
carbol-fuchsin stain by the usual method, decolourised with a
20 per cent, sulphuric acid solution, and counter-stained with a
saturated watery solution of methylene blue.

The microscope used for enumeration was fitted with an oil-
immersion lens and a movable stage. The cedar oil was applied
directly to the film, no cover-glass being used. The centre
of the slide was always the part examined, so that clumping
of the leucocytes or organisms might not affect the results
obtained.

To estimate the opsonic index the number of organisms
ingested by a definite number of leucocytes was first calculated
in the control film. The number so obtained was taken as
representing unity for the series of observations made that day.

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' 907 -]

BY C. J. SHAW, M.U.

527

By the comparison of the number of tubercle bacilli ingested by
the same number of leucocytes in the film of any case under
observation, with the number found in the control film, the
index of that case for that particular day was obtained. For
example, if in the control film 80 leucocytes ingested 160
tubercle bacilli, while in the film of a case under examination
80 leucocytes only ingested 140 organisms, the tuberculo-
opsonic index of that case for that observation would be *87.
Only polymorphonuclear leucocytes were examined. The
number of organisms ingested was enumerated in never less
than fifty of these cells, and in the majority of the observations
made eighty cells were examined. The same number of
leucocytes was examined in each film on any one day. The
same organismal suspension and my own leucocytes were used
for each series of observations, the only variable factor being
the blood-serum in each film, so that the relative opsonic power
of each serum was ascertained. The opsonic power of the con¬
trol serum was very constant, the number of organisms ingested
showing little variation from day to day when the same
organismal suspension was used. As the same methods of
procedure were employed throughout these observations, the
amount of spontaneous phagocytosis which might occur could
not affect the results arrived at.

Opsonic Indices to the Tubercle Bacillus in the Control Cases
prior to Injection with Tuberculin .

In six control cases the tuberculo-opsonic index was estimated
for five consecutive days before injection. The average index
obtained by these observations was 1*07, the average for each
case being *98, *97, i'32, ro6, roi, ri 1, the variation there¬
fore being between *97 and 1*3 2.

Urwick found the average tuberculo-opsonic index in twenty
healthy persons to be roo6, while Bulloch found the average
index of eighty-four healthy persons to be *96, the variation
ranging from *8 to 1*2. Lawson and Stewart obtained an
average tuberculo-opsonic index of one in twenty-five healthy
persons, with a variation between *9 and 1*2. In none of
these records, however, is any indication given as to how often
each case was examined before the average index was calcu¬
lated. As I have found a considerable daily variation in the

528 LIABILITY OF INSANE TO TUBERCULAR INFECTION, [July,

opsonic indices of healthy persons, in my opinion a single
observation cannot be relied upon to give a correct indication
of the opsonic power of an individual. There is no indication
given in these records either of the time when the observations
were made. As it has been shown that in tubercular patients
at least there is an increase in opsonic power after exercise,
the observations ought to be made at the same hour daily, and
as nearly as possible under the same conditions. Urwick
states that there is little variation in the opsonic index of the
same persons from day to day. I found a considerable varia¬
tion in the indices registered in the control cases from day
to day. One of them fell as low as *65 on one occasion.
In cases of acute tubercular disease fluctuations in the
opsonic index occur, some of the patients having indices
which pass from subnormal to above normal on occasions,
while others have a persistently high index. In none
of the control cases examined was there any evidence of active
or latent tubercular disease, but the control who showed on one
occasion the low index of ’65 had a tubercular family history.

I found, however, that the average opsonic index of my con¬
trol cases differed very little from week to week, and I have
therefore based my results upon these averages. Considered
in this manner the results of my observations on the control
cases are very similar to those obtained by Lawson and Stewart
in healthy country subjects.

The Tukerculo-opsonic Indices obtained in the Insane Cases
prior to Injection with Tuberculin .

The thirty insane patients examined for five consecutive
days gave an average index of *88. The variation was between
65 and 1*23. This result is below the indices obtained by
Lawson and Stewart, as well as those recorded in the six control
cases examined by myself. The daily variation in the indices
of the insane patients was also greater than in the control
persons, and the fluctuations were more marked, the rise and
fall being abrupt.

The average indices of the five patients with evidences of
old tubercular disease were 1*03, *96, *65, ‘84, *93, giving an
average index of *88, the same as that found for all the thirty
cases.

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HY C. J. SHAW, M.Ii.

529

1907.]

The difference between the index found in the six control
cases—1 x>7—and that found in the insane patients examined
—*88— is very striking. As the insane are admitted by all
to be liable to tubercular infection this observation is strong
evidence in favour of the view expressed by Wright and
previously stated, that the opsonic power of the blood-serum
can be used as a test of the liability to infection by particular
organisms. That being so, it may be concluded that the
insane, as a class, have a lowered resistive power to the
tubercle bacillus as compared with the healthy sane population.

To estimate whether the length of residence in asylums has
any bearing upon the liability of patients to contract tubercular
infection, in the first table the patients examined are classified
according to their length of residence.

Table I. — Table classifying the Insane Patients according to
their Length of Residence in the Asylum .

Length of residence.

Number
of cases.

Average

opsonic

index.

A. Under 6 months.

•«3

B. Over 6 months and under 1 year

C. Over 1 year and under 2 years

•89

D.'Over 2 years and under 3 years .

•92

i E. Over 3 years and under 4 years .

•96

j F. Over 4 years and under 5 years .

•89

| G. Over 6 years.

*95

This table shows that the average opsonic index of the
patients in the classes A and B is lower than that found in any
of the other classes whose length of residence in the asylum
had been greater. That this is not due to the fact that the
number of patients included in these two classes is larger than
that in any of the other classes is proved by the fact that the
average tuberculo-opsonic indices of all the patients of less
than one year’s residence is *82, while the average index for
all the seventeen patients of longer residence is *92. Length
of residence in an asylum is therefore not a factor which of
itself tends to lower the resistive power of the insane to
tubercular infection but rather the reverse, as those patients
who had resided for over one year in the asylum had an average

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530 LIABILITY OF INSANE TO TUBERCULAR INFECTION, [July,

opsonic index of *92 as compared with the index of ’82 in
those of under one year’s residence.

As the chronic insane are believed to be more prone to
tubercular infection than the acute cases, the second table is
drawn up so as to classify the patients according to their
mental state.

Table II.— Table classifying the Insane Patients according to
their Mental State.

Number
of cates.

Average
opsonic
' index.

I A. Cases with acute mental symptoms .

| *87

B. Cases with subacute mental symptoms

•86

C. Chronic cases (secondary dementia).

D. Cases of general paralysis

*79

This table seems to me to point to the fact that the acutely
insane have a much lower resistive power to tubercle than the
chronic demented cases, and it is quite possible that these
become infected with tubercular disease during the period of
onset of the mental disease.

The acute cases were all recent admissions except one—a
case of mania who had been resident for more than three years,
but whose opsonic index was *95. With three exceptions
these patients were adults. In all the demented cases the
illness had commenced during adolescence.

All the general paralytic cases had been resident in the
asylum for less than one year. Two of them showed evidences
of having at some time suffered from tubercular disease, but I
could detect no symptoms of active disease at the time these
observations were made. The average opsonic index of the
remaining two cases was very low, being only 78. General
paralytics are as a class very liable to tubercular infection, and
the low tuberculo-opsonic indices recorded in these four cases
indicate that their liability to tubercular infection is due to
their low resistive power.

Certain forms of mental disease are supposed to predispose

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I907.] BY C. J. SHAW, M.B. 53 I

the patient to tubercular infection, and the type of mental
disease which is believed to be most frequently associated with
tubercular infection is adolescent insanity. The three most
common forms of insanity met with in adolescent subjects are
acute mania, katatonia and hebephrenia.

Table III classifies the acute cases according to their form of
mental disease.

Table III. —Table classifying the Insane Patients with Acute
Mental Symptoms according to their Form of Mental Disease .

Average 1
tuberculo-
opsonic index. !

Form of mental disease.

Number of cases.

A. Adolescent insanity

3 cases (katatonia 1,
hebephrenia 2)

84 i

B. Melancholia

2 cases (adults)

•88 |

C. Mania

>> >1

•91 |

The table shows that the tuberculo-opsonic index of the
acutely insane adolescent patients is lower than that of the
acutely insane adults. It is interesting to compare this index
in the acutely insane adolescent cases with that obtained in
the eleven chronic cases, in all of whom the mental disease had
originated during adolescence. These eleven cases, in spite of
their state of dementia, and in spite of their long residence in
the asylum, had a tuberculo-opsonic index averaging *93. Such
a finding does not suggest that a lengthened asylum residence
predisposes to tubercular infection, but it points to the fact that
the resistive power to tubercle is lowered by the onset of mental
disease. It is also an interesting fact that the tuberculo-opsonic
index in the melancholic cases is only ’88 as against 91 in the
two cases of acute mania, as it is an undeniable fact that adults
suffering from maniacal excitement are much less prone to
contract tubercular infection than adults suffering from
melancholia.

Observations on the Control Cases after Injection with Tuberculin .

To estimate still further if there was any difference between
the sane and insane persons in their reaction to tubercle, I

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532 LIABILITY OF INSANE TO TUBERCULAR INFECTION, [July,

injected the six control cases, all members of the asylum staff,
with Koch’s new tuberculin, which will be subsequently referred
to in this paper as T.R. So far the only record of such injec¬
tions in healthy persons is that recorded by Lawson and Stewart,
who injected four control cases ; the dose of T.R. which they
employed is not stated.

It is now generally believed that if a person be infected by
any of the pathogenic organisms, an injection of a vaccine of
the infecting organism is followed by an immediate fall in the
opsonic power of the blood-serum of the person so injected.
The amount and duration of this fall, commonly spoken of as
the negative phase, depends, according to Wright, on the
amount of the dose of vaccine administered, and if the dose
injected be large enough a temperature reaction and consti¬
tutional symptoms may be produced. The negative phase is
followed by a positive phase, as it is called, when the opsonic
power of the blood-serum is increased. This positive phase
may last a variable time, but ultimately the opsonic power falls
back to the level at which it stood prior to injection.

In estimating the effect of the use of any drug or vaccine, it
is always necessary to take into consideration the idiosyncrasy
of the individual to the particular drug or vaccine used. With
a vaccine injection the idiosyncrasy of the person injected may
be taken to represent the liability to infection by that particular
organism from which the vaccine is made.

So far no exact definition of the term “ negative phase ” has
been made. After months of careful work and by noting the
differences found in the opsonic power of the blood-serum of
healthy persons to various organisms upon several successive
days, I do not consider that a reliable idea of the amount of
fall in the phagocytic power produced by the injection of a
vaccine can be obtained by a single observation of the opsonic
power made before injection, even though daily observations
are made thereafter. In many instances I found, especially in
the insane cases, that a slight rise of the opsonic power occurred
within eighteen hours after the injection of the vaccine, which
was followed by a very pronounced fall. I therefore define a
negative phase as: “ Any fall in the opsonic index to a
particular organism occurring at any time within forty-eight
hours after the injection of the vaccine made from that
organism, the index being below the level noted at the time

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I9O7.] BY C. J. SHANV, M.B. 533

of injection, and also below the level of the average opsonic
index for at least five days preceding the injection.” Any fall,
however slight, occurring within forty-eight hours and falling
below the two levels stated is described as a negative phase in
the following observations :

The Opsonic Indices of the Control Cases after Injection with

T.R.

Four of the control cases were injected with mgr. T.R.
Two of them gave a distinct negative phase. The fall in the
opsonic power was immediate, and lasted in the one case two,
and in the other three days, reaching ’59 and 63 respectively.
The subsequent rise was rapid, reaching 157 in the one and
174 in the other, on the sixth day after injection. The
average index of one of these cases prior to injection was *98
and of the other 1*32. In the remaining two control cases
injected with yjy mgr. T. R. no negative phase followed
injection.

In the healthy persons injected by Lawson and Stewart no
negative phase occurred. As the results I obtained did not
agree with the observations recorded by Lawson and Stewart
I concluded that the dose of T. R. which I had used was too
large. The remaining two control persons were, therefore,
injected with yjy mgr. T.R., and with this dose no negative
phase occurred. The rise in the tuberculo-opsonic power
occurring after injection in these two controls was immediate,
the maximum being reached the day following injection. The
average index of these two control cases prior to injection was
high, being roi and ill, and they rose to 1*25 and 1*38
respectively.

As all the control persons were in good health and free
from tubercular infection it is probable that the large dose of
T.R. used in the first four cases accounts for the occurrence
of the two negative phases recorded. It is necessary, however,
to state that one of the two control cases who presented a
negative phase after injection had a tubercular family history.
No rise of temperature or constitutional symptoms occurred
as the result of injection in any of the cases.

534 liability of insane to tubercular infection, [July,

The Opsonic Indices of the Insane Patients after Injection

with T.R.

Twelve of the insane patients received an injection of yJo
mgr. T.R. Eleven of them, or 91 per cent., gave a negative
phase after injection. Four of the patients who gave a negative
phase had, in the first instance, a slight rise in the tuberculo-
opsonic index. This initial rise was followed by a decided
fall which was complete in all the cases on the third day after
injection. In the insane patients who gave a negative reaction
it was noticed that the fall in the tuberculo-opsonic index was
gradual and prolonged when compared with the same fall in
the two control cases who gave a negative reaction, and in whom
the fall in the curve of the tuberculo-opsonic index was abrupt.
The onset of the positive phase in the insane patients was
gradual and prolonged, the majority taking longer to attain
their maximum than the two control cases who showed a
similar reaction. The insane patients also at the height of
their positive phases failed to reach such a high level of
tuberculo-opsonic power as the two control cases who showed
a negative reaction. In other words the positive reaction to
the injection was much slower and less pronounced in the
insane patients than in the control cases.

In two of the insane patients who presented signs of old
tubercular disease, the negative reaction after injection was
much less marked than in some of the other insane patients
who presented no signs of old tuberculosis.

On comparing the results of the injection of tuberculin upon
the opsonic indices of the acutely insane and chronic cases, I
find that in the acute cases the negative phase produced was
more marked than in the chronic cases and that the succeeding
positive phase was more prolonged. The three most chronic
cases who were injected with -5-^ mgr. T.R. showed a much
less marked and prolonged reaction than the acutely insane.

These observations would seem to indicate that the resistive
power of the patients suffering from acute mental disease was
less than that of the more chronic cases who had to some
extent recovered their power of resisting tubercular infection,
but in whom the mental disease had left irreparable brain
damage. The views recently advanced, that many of the acute
forms of insanity owe their cause to bacterial toxins may

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•907]

BY C. J. SHAW, M.B.

535

explain this difference in reactive power, if it can be proved
that a severe organismal infection by one organism lowers the
resistive power of the human body to other organisms. If this
should be so then the acutely insane have their resistive power
so reduced as to render them liable to any form of infection,
while the chronic cases, who have recovered from the acute
toxaemia, although left with damaged brain cells, have, to some
extent, regained their general resistive power ; at all events
this seems to apply to tubercular infection.

It may also be further deduced from these observations that
prolonged residence in an asylum does not predispose the
patient to tubercular infection, as the acutely insane, all of
whom, with one exception, had been resident for periods under
one year, showed a deficient reactive power when compared
with the chronic cases, many of whom had been many years
resident. This conclusion is also supported by comparing the
opsonic indices of the insane patients as shown in Table I
where, as has already been pointed out, the more recently
admitted cases, who were also the acutely insane, had a lower
tuberculo-opsonic index than the patients who had been longer
resident, and were, therefore, chronic cases of mental disease.

That so large a proportion as 91 per cent, of the insane cases
should show a negative phase after injection with mgr. T.R.
as against 50 per cent, in the control cases seems to indicate
that the resistive power of the insane to tubercular infection is
less than that of sane persons. That such a large proportion
of both the sane and insane should give a negative phase after
injection is probably due to the fact that mgr. T.R. is too
large a dose. In none of the twelve patients injected with this
dose, however, were any constitutional symptoms produced.

Eighteen insane patients were injected with mgr. T.R.
Of these only four showed a negative phase—that is to say,
22*2 per cent., as compared with 91 per cent, of those injected
with mgr. T.R. Only one of these four patients showed
evidences of old tubercular disease, and this was a case of
general paralysis. The average tuberculo-opsonic indices of
these four cases for the five days prior to injection did not lead
one to expect that a negative phase would follow injection.
One of them had an index of 1*07, and the average for the four
cases was ’99.

In the remaining fourteen cases of this series in whom no
Lin. 37

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S36 LIABILITY OF INSANE TO TUBERCULAR INFECTION, [July,

negative phase supervened, the maximum rise of the positive
phase was reached much more slowly than in the two control
cases injected with the same dose. In only two of these cases
was there an immediate rise in the tuberculo-opsonic index on
the day following injection, while in the majority of the cases
four days were required to reach that point.

All the patients injected with mgr. T.R., with the excep¬
tion of four who suffered from general paralysis, were subacute
or chronic cases, and, with only two exceptions, they had been
resident for more than two years in the asylum.

The difference between the reaction in the two control cases
and the four insane patients injected with mgr. T.R. who
showed no negative phase was the slow reaction of the insane
after injection. Both the control cases reached their maximum
on the day following the injection, while the insane patients
took an average of four days to reach the same positive
maximum. There was, however, no difference in the maximum
positive level ultimately reached in both the control and insane
patients.

The result obtained in these two control cases corresponds
with that recorded by Lawson and Stewart in the four healthy
persons they examined.

Wright has stated “ that the result of his observations seem
to suggest that the development of a negative phase following
a dose of T.R., smaller than that which would produce this
result in a healthy person, may prove to be an index of tuber¬
cular infection. Such a conclusion would be in harmony with
our experience in connection with the therapeutic inoculation
of T.R. vaccine (new tuberculin). We find in this connection
that the negative phase supervenes upon a very much smaller
dose, and persists much longer in the case where the patient is
the subject of extensive infection than in the contrary case.”
As the result of the observation made by Lawson and Stewart
upon the four healthy persons whom they injected with tuber¬
culin, they state : “ The appearance of a negative phase after
inoculation with a small quantity of tuberculin (T.R.) should
enable one to distinguish between the blood of a subject of
tubercular invasion and that of a person in sound health.** Of
the six control cases whom I injected with tuberculin, two, as
previously stated, gave a negative reaction. Both these control
cases, as well as the eleven of the non-tubercular insane patients

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1907]

BY C. J. SHAW, M.B.

537

who also gave a negative reaction, were injected with mgr.
T.R. I therefore conclude that this dose is too large for
diagnostic purposes. The results obtained with an injection
of m £ n T.R. were very different. Neither of the control
cases so injected showed a fair in the tuberculo-opsonic power,
while of the eighteen insane patients similarly injected only
four, or 22*2 per cent, presented a negative phase. Of these
four, one presented signs of former tubercular disease. The
other three presented no signs or symptoms of tubercular
infection, but the evidences of early tubercular disease are
admittedly difficult to detect in the insane.

The tuberculo-opsonic indices prior to injection in these four
patients, who showed a negative phase, were much more
irregular than the tuberculo-opsonic indices in the fourteen
cases who gave no negative reaction. The same fact was
noted in the tuberculo-opsonic indices of the control cases and
insane patients injected with mgr. T.R. In those who
gave no negative phase the tuberculo-opsonic indices prior to
injection were very regular, showing little variation from day to
day, while the tuberculo-opsonic indices of those who gave a
negative phase showed considerable daily variation.

Wright has shown that a fresh injection of tuberculin given
during the negative phase, induced by a previous injection,
produces a cumulative effect, that is to say, it still further
emphasises the negative phase. It is, therefore, possible that
in those who are already infected with tubercle an injection
given when the tuberculo-opsonic index was much below or
much above the healthy average might produce very different
results. In the control persons and the insane patients
upon whom I made these observations, however, I could detect
no connection between the level of the tuberculo-opsonic index
on the day of injection and the subsequent presence or absence
of a negative phase. It is, therefore, probable that the amount
of tuberculin administered has a more important bearing on the
production of a negative phase after injection in non-tubercular
persons than the level of the tuberculo-opsonic index at the
time of injection, and, as I have already pointed out, the
amount of variation in the tuberculo-opsonic index prior to
injection has also to be considered in estimating the occurrence
or absence of a negative phase after inoculation.

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538 LIABILITY OF INSANE TO TUBERCULAR INFECTION, [July,

Summary and Conclusions .

(1) That the average tuberculo-opsonic index in persons free
from tubercular disease varied between *97 and 1*32.

(2) That the tuberculo-opsonic index of persons free from
tubercular disease varied considerably from day to day, but
that the weekly average of the tuberculo-opsonic index in the
same persons varied very little from week to week.

(3) That the average tuberculo-opsonic index of thirty insane
persons, all free from symptoms of active tubercular disease, was
•88, the variation being between *65 and 1*23.

(4) That the daily variation in the tuberculo-opsonic indices
of insane persons is much greater than in healthy persons.

(5) The results of these observations lead me to conclude
that the insane, as a class, are more liable to tubercular infection
than the healthy sane population.

(6) That the tuberculo-opsonic indices of the insane, classified
according to their length of residence in the asylum, is ’92 in
those patients who had been in residence for more than one
year, as against *82 in those who had been in residence under a
year. From this I conclude that asylum residence does not
predispose the insane to tubercular infection.

(7) That the tuberculo-opsonic indices of the insane, classified
according to their mental state, viz. t acute, sub-acute, and chronic,
indicate most clearly that the acutely insane with an average
index of *87 are more liable to tubercular infection than the
chronic cases who had an average index of‘93.

(8) That the low tuberculo-opsonic index of cases of general
paralysis, namely, 79, explains the frequent occurrence of tuber¬
cular disease in this class of patient.

(9) That the tuberculo-opsonic index of the acutely insane
patients, classified according to the form of their mental disease,
is lower in cases of adolescent insanity than in adult cases
suffering from mania and melancholia. The tuberculo-opsonic
index of the adolescent cases was ’84 as against ’89 in the
adult cases.

(10) That the tuberculo-opsonic index of cases of melan¬
cholia in adults is *88, as against an index of *91 in adults
suffering from mania.

(11) As the result of Observations 9 and 10, I conclude that
the acutely insane adolescent is more prone to contract tuber-

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1907-1

nv C. J. SHAW, M.B.

539

cular disease than the acutely insane adult, and that adults
suffering from melancholia are more liable to tubercular infec¬
tion than adults suffering from mania.

(12) That an injection of inn*- mgr. T.R. in healthy, sane
persons produced a negative reaction in two out of four cases.
As I have no reason to suppose that these two controls who
gave a negative reaction were tubercular, I believe 3^7 mgr.
T.R. is too large a dose to use for diagnostic purposes.

(13) That out of twelve insane persons injected with 3^
mgr. T.R., eleven showed a negative phase, from which I con¬
clude that the insane, as a class, have a low resistive power to
the tubercle bacillus.

(14) That the reaction after injection in the non-tubercular
insane persons, who showed a negative phase, was more pro¬
longed than in the healthy, sane persons who gave a similar
reaction.

(15) That the negative phase induced by the injection of
si"? mgr. T.R. in the acutely insane cases was more marked
than in the chronic cases, and that the succeeding positive
phase was more delayed. From this observation I conclude
that the acutely insane have a lower resistive power to tuber¬
cular infection than the chronic cases.

(16) That so large a proportion as 91 per cent . of the
insane patients gave a negative reaction after injection with
yfor mgr. T.R. is probably due to the dose being too large for
diagnostic purposes.

(17) Thatout of eighteen insane patients injected with rhr m S r -
T.R. only four, or 2 2‘2 per cent., gave a negative reaction.

(18) That the remaining fourteen cases in this series
injected with rhr mgr. T.R., although they showed no negative
reaction, reacted much more slowly than the two control cases
injected with the same dose.

(19) That although an injection of rihr mgr. T.R. is probably
a sufficiently small dose for diagnostic purposes in the healthy
sane population, it is still too large a dose for diagnostic
purposes in insane persons.

(20) That in estimating the occurrence or absence of a
negative phase after injection with T.R. it is necessary to take
into consideration the variations in the tuberculo-opsonic
indices for at least five days prior to injection.

(21) That in both the sane and the insane persons who gave

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540 LIABILITY OF INSANE TO TUBERCULAR INFECTION. [July,

a negative phase after injection it was noted that the tuberculo-
opsonic indices, prior to injection, show greater daily variation
than in those who gave no negative phase.

(22) That I could discover no connection between the level
of the tuberculo-opsonic index on the day of injection and the
subsequent presence or absence of a negative phase.

Bibliography.

(1) Bulloch, “On the Nature and Action of the Opsonic Substances
in the Blood-serum,” London Hospital Gazette, March, 1905.

(2) Bulloch, “On the Variations of the Opsonic Power in Health and
Disease,” ibid., March, 1905.

(3) Bulloch, “ Inquiry into the Opsonic Content of the Blood-serum
in Healthy Individuals and in Patients affected by Lupus,” Path. Soc.
Trans. , vol. lvi, 1905.

(4) Bulloch, “The Principles Underlying the Treatment of Bacterial
Diseases by the Inoculation of Corresponding Vaccines,” Practitioner ,
November, 1905.

(5) Bulloch, “ The Treatment of Tuberculosis by Tuberculin,” Lancet,
December 2nd, 1905.

(6) Bulloch and Aitken, “ Experiments on the Nature of the Opsonic
Action of the Blood-serum,” Proc . Roy. Soc., 1905, vol. lxx.

(7) Clouston, Ninety-first Annual Report of the Royal Edinburgh
Asylum for the Insane , 1904.

(8) Clouston, The Neuroses of Development.

(9) Clouston, Mental Diseases.

(10) Clouston, fourn. of Ment. Sci., 1863.

(n) Crookshank, “Phthisis Pulmonalis in Asylums,” ibid., October,
1899.

(12) Drapes, “ Phthisis and Insanity,” ibid., October, 1901.

(13) France, “ Abstract of a Paper on the Necessity for Isolating the
Phthisical Insane,” ibid., January, 1900.

(14) General Board of Commissioners in Lunacy for Scotland, Forty -
ninth Annual Report, 1904.

(15) Green, “Notes on the Incidence of Tuberculosis in Asylums,”
Journ. of Ment. Ski., January, 1906/

(16) Jones, “Prognosis in Mental Diseases,” Brit. Med. fourn.,
December 16th, 1905.

(17) Kraepelin, Lectures on Clinical Psychiatry.

(18) Lawson and Stewart, “A Study of some Points in Relation to
the Administration of Tuberculin (T. R.) controlled by Observation of
the Opsonic Index in Pulmonary Tuberculosis,” Lancet, December 9th,
1905.

(19) Macpherson, Mental Affections.

(20) Meakin and Wheeler, “Observations on the Opsonic Index of
Patients undergoing Treatment for Phthisis, with Special Reference to
the Effect of Exercise,” Brit. Med. Journ., November 25th, 1905.

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1907.] THE CARE OF CHILDREN IN ASYLUMS. 541

(21) Menzies, “Some Points Connected with Tuberculosis in
Asylums,” Journ. of Ment. Sci ., July, 1905.

(22) Mickle, On General Paralysis of the Insane.

(23) Savage, Insanity and Allied Neuroses.

(24) Urwick, “ Observations on the Opsonic Power of People suffer¬
ing from Tuberculosis,” Brit\ Med\ fount., July 22nd, 1905.

(25) Wright, “Notes on the Treatment of Furunculosis, Sycosis and
Acne by the Inoculation of a Staphylococcus Vaccine,” Lancet , March
29th, 1902.

(26) Wright, “A Lecture on the Therapeutic Inoculation of Bacterial
Vaccines and their Practical Exploitation in the Treatment of Disease,”
Brit. Med. Journ., May 9th, 1903.

(27) Wright and Douglas, “An Experimental Investigation of the
Role of the Blood Fluids in connection with Phagocytosis,” Proc. Roy.
Soc., 1903, vol. lxxvii.

(28) Wright and Douglas, “ Further Observations on the Rdle of the
Blood Fluids in connection with Phagocytosis,” ibid., 1904, vol.
lxxvii i.

(29) Wright and Douglas, “On the Action exerted upon the Tubercle
Bacillus by Human Blood Fluids, and on the Elaboration of Protective
Elements in the Human Organism in response to Inoculations of a
Tubercle Vaccine,” ibid., 1904, vol. lxxiv.

(30) Wright, “On the General Principles of the Therapeutic Inocula¬
tion of Bacterial Vaccines as applied to the Treatment of Tuberculous
Infection,” Lancet, December 2nd and 9th, 1905.

The Care of Children in County and Borough Asylums.
By Charles H. Fennell, M.D.Oxon., M.R.C.P., Senior
Assistant Medical Officer, East Sussex County Asylum.

The normal English child has thriven apace of recent years,
as the result of a healthy popular tendency to foster his mental
and physical well-being as thoroughly as may be. But there
exists among the poor a race of unfortunates—happily a small
one—whose interests have rarely met with adequate recogni¬
tion. It consists of the imbeciles who find their way into
pauper lunatic asylums—the children legally certifiable as
idiots. They cannot, I admit, pay a dividend in hard cash on
the money sunk in their education, and their appeal for special
attention mainly rests on their helplessness. My aim is to
speak briefly of the measures already taken in their interest
elsewhere, and to describe in a little more detail those adopted
with success at Hellingly. Lastly, I propose to discuss the

542 THE CARE OF CHILDREN IN ASYLUMS, [July,

cost of our scheme, and to attempt to analyse the benefits
derived therefrom.

In order to gain a rough idea of the number of children in
rate-supported asylums, I have taken at random thirty of last
year’s annual reports These dealt with institutions of every
size, from Ipswich with 290 inmates to Prestwich with 2682.
The total number of patients returned as being less than sixteen
years of age was 229, giving an average for each asylum of
about 8. In ten cases there were no children, and only three
asylums had more than 20. Thus in most institutions the
small numbers form a discouragement to any endeavour to
cater specially for them, and it is to this condition that we
must probably ascribe the comparative lack of initiative hitherto
shown.

It results further from their sparseness that as a rule children
must needs be housed in adult wards, structural causes prevent¬
ing their accommodation apart. The best-behaved adults
usually find their way into non-observation wards, which require
only a small staff* and are practically empty while their inmates
are at work in kitchen, laundry, and shops. Hence the children
are drafted on admission into blocks containing a lower grade
of adult patient, and spend their idle days in the society of the
restless senile dement, the epileptic, and the ill-assorted mixture
which peoples the infirmaries. The effect is bad, both on chil¬
dren and on the rest. I do not suggest that the hopeless idiot
of the former class can be much influenced for good or bad by
any surroundings, but with the tractable and plastic child it is
different. Herded with adult lunatics, children are exposed to
the influence of, and rapidly acquire, almost every degrading
vice. I am far from denying that nurses and attendants can
everywhere be found who will unselfishly devote time and
labour to the attempt to instil habits of decency and self-con¬
trol into the imbecile. But such efforts are severely handi¬
capped when the example of ineradicable faults in its elders is
always before a child’s eyes. Too often the personal influence
of the nurse is baffled by the poisonous moral atmosphere
which the patient breathes day and night. The staff of an
adult ward containing two or three children cannot spare any¬
thing like adequate time for the special benefit of the latter.

Again, the interests of the adults concerned—often senile
cases—call for consideration. I think it will be agreed that in

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190/.] BY CHARLES H. FENNELL, M.D. 543

any block, while two or three patients show a kindly interest
in the ward child the feelings of the rest are about equally
divided between indifference and active dislike. Old people in
asylums are often fidgety and exacting. They are apt to
regard the continual presence of children as an intolerable
nuisance, and to especially resent their natural instinct to play
about and make a noise. Hence neither side quite gets justice.
In fact, it may be said that in lunatic asylums children and adults
are incompatibles, and as a general rule react most unfavourably
on one another.

In the interests of the asylum community, then, we must
first segregate the children. Further, segregation is an almost
essential preliminary to any attempt to educate them.

It is obvious that this can be most simply effected by the
grouping of juveniles from various counties and boroughs in a
few asylums where special attention can be given them. This
can either be done by the system of boarding out under contract,
or by the provision of a separate district institution for children.
The latter method, as yet imperfect, claims special mention.

In February, 1905, mainly through the advocacy of a pro¬
minent alienist in Warwickshire, a definite effort was set on foot
to cope with the problem as it affected the Midland counties.
The plan was adopted of inviting the various lunacy authorities
concerned to join in acquiring a house and land suitable for a
district institution, with a view to the reception of the idiot and
imbecile children from the existing Midland asylums. Unfor¬
tunately, after the project had been thoroughly discussed and
many difficulties overcome, it was found impossible to carry it
through. Owing to a technical difficulty in connection with
the lease the Lunacy Commissioners were unable to sanction
the acquisition of a building which was in other respects suitable.

The enforced abandonment of a scheme which, after long
and careful ventilation had appeared distinctly auspicious, was
a disappointing set-back to the interests of the defective class.
That the proposed measures were soundly and practically based
can hardly be doubted, and I think we may assume that future
organisation will be on the same principle of combined action.
It is satisfactory, however, to know that the importance of the
subject was fully impressed on the lunacy authorities of the
Midlands. Those responsible for the Sandwell Hall project
can scarcely feel that a year’s extremely arduous work was

544 THE CARE OF CHILDREN IN ASYLUMS, [July,

entirely wasted when it is realised that the special care of
imbeciles was at least placed on a new footing of recognition.

The alternative arrangement—that of boarding out under
contract in accordance with the provisions of section 269 of the
Lunacy Act, 1890—has been employed both here and at the
Middlesex County Asylum, Wandsworth. At the latter in¬
stitution an annexe for imbeciles, containing 100 beds, was
opened in 1897, and since that year children have been received
and educated from the counties of Surrey, Herts and Norfolk,
and from Sunderland and Derby boroughs.

At Hellingly we have a separate block specially designed
to accommodate ninety imbecile and idiot children. This
fortunately allows for the inevitable steady increase in their
numbers, a condition which has already caused the Middlesex
asylum to exclude out-county patients. At present a certain
number of beds are filled by quiet adults. Structurally the
block is on the lines of the modern “ acute hospital ” rather
than on those of the average villa. It is two-storied, the upper
floor being occupied by dormitories, while the lower contains a
dining gallery with side rooms, two day rooms, a room for the
cripples and a schoolroom ; adjoining it is a playground. The
staff includes six day nurses, with one for night duty.

Systematic education was begun in April, 1905, with the
engagement of a non-resident schoolmistress at an annual
salary of £50, rising £2 io.r. yearly, and emoluments valued
at £13. The lady appointed had had no previous experience
of the feeble-minded, but was well versed in kindergarten detail,
and had been employed for some years at an elementary school.
She has proved a most capable and energetic teacher, taking a
keen interest in her work and adapting her methods skilfully to
the special needs of her charges. The instruction has followed
the usual lines recognised as suitable to imbeciles—cultivation
of the senses and of co-ordinative power, encouragement of
observation, and, finally, more or less definite manual occupa¬
tions of a useful kind, such as needlework and the making of
baskets and rugs. No less important is the physical culture.
In order to organise this arrangements were made for the
schoolmistress to pass through a course of Swedish drill at
Eastbourne, and the system has been found very satisfactory
in its application, slightly modified, to the children. The
exercises now form a part of the regular daily routine, and

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BY CHARLES H. FENNELL, M.D.

*907]

545

their effect on the physique and bearing of the classes has been
pronounced.

With regard to expense, the outlay may be summarised as
follows:

Initial .

Fitting up schoolroom with blackboard,

desks, and slates . . £*5 13 5

Clubs, etc., for drill . . I 10 5

£7 3 10

Upkeep per Year.

Wools and other material for rug making £817 2

Cane for baskets . . . .560

Sundries for various other occupations . 6 6 8
Salary and emoluments of teacher 64 5 o

£84 14 10

This may be regarded as the total cost of teaching the
twenty-seven children on the school list, and I do not think
that any economy could be effected.

I would emphasise the fact that, although the provision of a
special block is in practice found to be a great convenience and
benefit, there is no reason why a course of education similar to
ours should not be efficiently carried out in any asylum with¬
out the need of building alterations. All that is necessary is a
single room of moderate size.

The question naturally arises, what resulting advantages are
to be set off against the expenditure? These may be classed
under three headings :

(1) Value of goods made. This naturally depends on the
market which can be secured. It may be at once admitted
that but little direct return is to be expected from this source.
The mentally deficient can never enter into competition on
equal terms with normal labour. But their energies can be
guided into certain directly profitable grooves, in so far as
needlework, rug and basket making, etc., are concerned, since
the institution can buy such products at the standard price.
The value of goods made in the Hellingly school in twenty-

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546

THE CARE OF CHILDREN IN ASYLUMS, [July,

two months was £12 10 s. 9 d. Those who have studied the
accounts of large imbecile institutions, where the sale of school
products has been developed through many years, will be aware
that the output of our Sussex patients is above the average in
value.

We must clearly recognise that many children need careful
elementary training for months and even years before they can
produce work which will command any rebate.

(2) Education of the child with a view to make him eventu¬
ally useful in the workshops. Here we are dealing with a more
remote but a far more practical return. It has been found at
Darenth that the school course with its attendant handiness,
method, and self-control, has been stamped clearly on such of
the adult workers as have been through it, and that the best
hands in the tailor’s and carpenter’s shops, the most skilful
laundry-women and sempstresses owe very much of their value
to early training in the imbecile schools. Education in child¬
hood discovers and develops special aptitudes in the weak-
minded no less than in the normal subject.

(3) The routine of school life, as might be expected, has an
important function in building up and strengthening such
character as an imbecile may be capable of developing. Here,
again, we attain a tangible result. The child of faulty habits,
the pickle, and the potential hooligan of the refractory wards
are often strikingly amenable to the discipline of the school¬
mistress. Companionship in work, a spirit of mild emulation,
and the realization of progress combine to mould favourably a
disposition not yet entirely ruined by its environment. And
lastly, the infinite gratification to a child who realises that he is
a responsible human being with a value of his own, instead of
a contemptible loafer, may possibly be held to outweigh any
other advantages which I have tried to attribute to our teaching
system.

Discussion

At the Meeting of the South-Eastern Division at Hellingly on April 17th, 1907.

The President (Dr. Robert Jones) stated that the time was long past when the
teaching of the imbecile and weak-minded was looked upon as a useless occupation,
for, as the reader of the paper had stated, by patient teaching of a special kind a
response was elicited which enabled the persons taught to become, if not completely
self-supporting, at any rate in a great measure contributory to their own support.
This was generally recognised with those grades of weak-minded persons whose de¬
ficiency was “ mild," and the legislature had recognised the value of such training

Digitized by CjOOQle

1907.]

BY CHARLES H. FENNELL, M.D.

547

bygivirg local authorities optional powers to provide educational facilities through
the Epileptic and Defectives Act of 1899 and the Blind and Deaf Act of 1903. The
President related his own experience at the Earlswood Asylum, which agreed with
that of Dr. Fennell, and some of those under his care had become completely self-
supporting under special tuition, whereas others had ceased to be a burden upon
their friends or upon the ratepayers. He had noticed the figures in the Blue-book
as to the admission of those of youthful age, and noticed that there was a decided
increase in insanity from this class, and unless these defectives were specially
trained they tended to become the inhabitants of our workhouses, gaols, and
asyiutns. He believed that Dr. Richard Greene, of Berry Wood, was among the
first superintendents of public asylums who had segregated the defectives in county
asylums from those suffering from other forms of insanity, and he asked Dr. Fennell
if he could confirm this statement. The paper was an exceedingly interesting one,
for it placed definite information of a practical character before the Association as
to the financial results of training, and it was satisfactory to find that imbeciles so
trained could by their labours help to bring down the maintenance rate of those
not so employed. He was interested to learn that physical drill had been used for
this class, and he asked Dr. Fennell if this adjunct to treatment had been extended
to other classes of the insane, as at Claybury the assistant-matron and a nurse had
attended Macpherson’s Classes in Sloane Street, and their special experience of
the drill had been applied with excellent results to some of the insane. He was
delighted to see in the asylum—which, through the courtesy of the committee,
they were priviliged to visit to-day—the special accommodation for all varieties of
mental disease prepared through the wise counsels of their treasurer (Dr. H. H.
Newington), who was a member of the committee. It must, he thought, be a great
satisfaction for him to see the specialised departments working with such good
results, and it should be an encouragement for other public bodies to erect suitable
places for this class, which could only deteriorate by the compulsory association
with adult lunatics, whose habits and conduct were often a very bad example for
imitation. He would like to ask Dr. Taylor if the children admitted as defectives
were received as lunatics, or under the provisions of the Idiots Act of 1886. He
felt sure there were many present who were capable from personal experience of
appreciating and discussing Dr. Fennell's paper, who was cordially thanked.

Dr. H. H. Newington referred to the assistance which the Visiting Committee
had received from Dr. Worthington, who kindly allowed a deputation to look over
the special block at the Hants County Asylum, and who had given them many
valuable hints which they had acted upon. The Visiting Committee were very
pleased with the results so far attained. He directed the attention of the meeting
to the special provisions which had been made should an outbreak of fire occur
in the idiot block. The attendants’ rooms had been so arranged as to afford an
exit from the dormitories.

Dr. Worthington, in the course of a few remarks, recorded his indebtedness to
Dr. Greene, of Northampton, for the idea of segregating children in a separate
block.

Dr. Taylor said that there was another point which had not yet been mentioned
in favour of the establishment of a separate block for children with the accompany¬
ing training, and it was that when parents knew that their children were going to
receive instruction they were not so loth to part with them. He had noticed the
difficulty there was in a county asylum of obtaining the services of suitable trades¬
men, and he had hopes that the best workers among the children would gradually
develop into the best tradesmen in the several shops of the asylum.

Dr. H. A. Kidd stated that several children from West Sussex had been
received into the idiot block at Hellingly, and he was pleased to note the very
satisfactory condition in which he found them.

Dr. Fennell replied.

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548

THE NEW HOSPITAL AT AYR ASYLUM,

[July,

The New Hospital at Ayr Asylum .( l )—By C. C. Easter-
liROOK, M.A., M.D., F.K.C.P.Ed., Medical Superintendent,
District Asylum, Ayr, N.B.

The main features of the hospital which has recently been
added to Ayr Asylum are: (i) It is a substantial building, one¬
storeyed, after the cottage hospital type. (2) It has been spe¬
cially designed for the accommodation of those insane patients
who are more appropriately treated in a building of hospital
character, and the design gives effect to certain principles
which, in my opinion, should underlie the construction of a
mental as distinguished from an ordinary hospital, specially
the principle of facility of supervision of the patients by the
staff both day and night, and the principle of the treatment of
active insanity by rest in bed in the open air, isolation, and
other special measures for the alleviation of mental and nervous
disorders. (3) Owing to the way in which the design facilitates
the work of the staff, the hospital is, for the class of patients it
contains, managed with a relatively smaller staff than usual;
and so, while an efficient instrument for its purpose, is dis¬
tinctly economical to administrate. (4) Owing mainly to the
elimination from the design of everything which was considered
superlluous, and notwithstanding the fact that the cottage-hos¬
pital type of structure is relatively expensive to build, the
liospital at Ayr Asylum has cost, for total construction and
fittings, £100 per bed, which is considerably less than the cost
per bed of asylum hospitals hitherto. Efficiency for its purpose,
low cost of original construction, and permanent saving in
future expenditure on upkeep and administration, seem cogent
reasons at this time, when the public press is constantly harp¬
ing on the cost of modern asylums and the ever-increasing
burden of the lunacy of the country, for giving a description of
this latest addition to Ayr Asylum. Before doing so, however,
I shall describe the way in which the hospital scheme was
taken up and carried through by the Ayr Lunacy District
Board, as this undoubtedly had a distinct bearing on the
ultimate cost to the ratepayers of Ayrshire.

History of hospital scheme .—The Ayr District Asylum for the
rate-paid lunacy of the county of Ayr was opened in 1869 with
accommodation for 230 patients—115 of each sex. During the
next thirty years the asylum population doubled itself, and

Digitized by v^ooQle

I907J BY C. C. EASTERBROOK, M.A. 549

considerable additions were made to the accommodation. In
1902, when I was appointed to my present post, the population
exceeded 500, and the overcrowding of the asylum had again
become a pressing question. Further, owing to the large pro¬
portion of senile and debilitated patients admitted during
recent years, to the increasing infirmity of many of the older
residenters, and to the introduction of the modern treatment of
recent and curable insanity by approved hospital methods, the
accommodation for patients requiring treatment in wards of
hospital character was specially deficient. Several of the wards
of the main asylum, which had originally been intended as
day-rooms or parlours, were in use as sick wards, and this had
greatly curtailed the day-room space and produced a consider¬
able disparity between the day and the night accommodation
of the institution. After considering various schemes and con¬
sulting the General Board of Lunacy for Scotland, the District
Board decided that the only satisfactory way of remedying
matters was to provide a properly-equipped separate hospital
for the accommodation of all patients who would be more
appropriately treated in such a building, the removal of these
patients from the main asylum not only relieving its wards of
the class of patients for which they were not suitably con¬
structed, but also making it possible for the deficiency in day-
room space to be rectified, and the proper balance between
the day and night accommodation of the institution generally
to be restored. Having decided on the hospital scheme, the
District Board commissioned me to visit the hospitals of other
Scottish asylums, so far as seemed advisable, for the garnering
of ideas, and I take this further opportunity of thanking the
physicians of the majority of the Scottish asylums which I
visited for their kindly co-operation, courtesy, and hospitality.
Having had several years’ practical and intimate experience of
the special requirements in hospitals for the insane, particu¬
larly at Morningside Asylum, which, with its large annual
admission rate of 450 and more patients, and population of over
900 inmates, has a specially active hospital department, having
thereby come to form definite ideas on the subject of the con¬
struction of a mental hospital, and having gained various hints
from the experience of other physicians with whom I had com¬
pared notes, I considered at this point that it would be more
satisfactory, in the long run, to make an actual plan of the

5 50 THE NEW HOSPITAL AT AYR ASYLUM, [July,

proposed new hospital at Ayr Asylum, showing not only the
accommodation required, but also the most suitable arrangement
of wards, observation bedrooms, verandahs, bath-rooms, and the
like, than to follow the usual method of making out in writing
a specification of the accommodation, and leaving its arrange¬
ment largely to the originality of competing architects, who
could not be expected to realise all the details of internal
disposition which would facilitate in the highest degree the
working of a mental hospital, and who, further, are pardonably
apt to subordinate the principle of utility to that of beauty and
architectural effects. I therefore made a pen-and-ink outline
drawing to scale of the ground-plan of the proposed hospital,
showing the size and position of every ward, bedroom, bath¬
room, kitchen, and the like, and the position of doors, windows,
fireplaces, baths, beds, etc., the actual drawing being reduced
to simplicity by the aid of a large sheet of paper printed in one-
eighth inch squares, each one-eighth of an inch being taken to
represent one foot, and the walls being represented simply by
lines, without allowance on the plan for their thickness. This
plan was submitted to, and approved by, both the District
Board and the General Board, and the District Board there¬
upon accepted it as the specification and plan of the accommo¬
dation of the proposed hospital, and ordered it to be litho¬
graphed, with a view to circulation among intending architects.
The District Board then appointed an architect of eminence
in his profession as assessor, or judge of the plans, selecting
Mr. Sydney Mitchell, of Edinburgh, drew up the rules and
conditions of competition—one of these being to the
effect that the Board did not bind itself to necessarily
adopt the plan placed first by the assessor—and by ad¬
vertisement invited architects to compete for the work.
To each architect who applied there were supplied a copy
of the rules and conditions of competition, and a copy of
the lithographed design as the specification of the accommoda¬
tion and actual plan of the hospital, and it will thus be seen
that the main problem of the competing architects w f as the
treatment of the exterior of the building (which was to be in
keeping with the other asylum buildings) and its disposition on
the selected site, a piece of ground sloping tow f ards the south
and west. Twenty competitive plans (without distinguishing
names, etc.) were sent in, and the assessor in his report to the

Digitized by v^ooQle

BY C. C. EASTERBROOK, M.D.

I90;.]

551

District Board made a short leet of five, and placed three of
these first, second, and third for the three prizes awarded. The
District Board then appointed the measurers for the work, and
instructed them to measure the five plans on the short leet and
to report thereon specially with a view to their estimated cost.
After thoroughly considering these five plans and the assessor’s
and measurers’ reports, the District Board finally selected, as
all round the most suitable, economical and pleasing, the plan
which had gained the third prize, namely, that of Mr. John B.
Wilson, A.R.I.B.A., who was thus appointed architect of the
hospital. His plans having been passed by the General Board,
he prepared the various schedules for the work, advertised for
contractors, and submitted the applications to the District
Board, who made a selection of contractors who should receive
schedules aiid be allowed to tender for the works, the architect
being given power to add other contractors at his discretion in
order to ensure competition where necessary. Owing to
depression in trade at the time competition for the various
contracts was keen, and the District Board with the aid of the
architect in due course selected the list of contractors for the
hospital, and the works were carried through in the usual way.
The process of erection took eighteen months, and the hospital
was finally opened and occupied in September, 1906.

Organisation of asylum .—The addition of the hospital raises
the accommodation of the asylum to 650 beds (for patients)
distributed as follows: main asylum 368 beds, two villas 104
beds, new hospital 154 beds, and isolation hospital 24 beds.
The new hospital serves as (1) reception-house and sanatorium
for all newly admitted patients, (2) sick room and infirmary for
all inmates of the institution who are on the sick list or are
through physical infirmity more or less bedridden or helpless,
and (3) sanatorium for the isolation of patients with pulmonary
tubercle and other infectious diseases. The isolation hospital,
which is situated near the new hospital, and so will conveniently
serve in the future as an overflow hospital if necessary, is
intended for use during infectious outbreaks of more serious
nature or extent than can safely be dealt with in the wards of
the new hospital for the isolation of infectious cases. The two
villas, one for men and one for women, serve as the convalescent
homes of the institution for those convalescent and better-
behaved patients who are both sufficiently able-bodied and

LI II. 38

.. Digitized by

554 the new HOSPITAL AT AYR asylum, [July,

sufficiently trustworthy to be given parole of the grounds by
day, and not to require staff visitation by night. The main
asylum serves as the asylum proper for the supervision, care,
and treatment of patients who are more or less able-bodied
but untrustworthy. All patients admitted to the asylum are
therefore treated in the hospital to begin with, and remain
there until they become suitable for the convalescent villas, or
otherwise for the asylum proper, the aim being to treat all new
patients amid surroundings which, so far as is possible, do not
suggest the asylum environment, and are with certain modifica¬
tions much the same as those of an ordinary hospital and
convalescent home.

Site and general arrangement of hospital .—The hospital is
situated on a piece of high ground to the east and north of the
main asylum. It is itself sheltered from these colder quarters
by a belt of wood and rising ground beyond, and it faces the
south, the ground immediately in front of the building sloping
gently towards the south and west, and being laid out as a
garden and recreation space for the hospital patients. A
reference to the accompanying sketches will show that the
hospital is one-storeyed and built on the same level throughout,
thus avoiding the risks of upper storeys and flights of stairs,
facilitating the access from ward to ward and from the wards
to the garden and grounds, and ensuring the safe removal of
the inmates in the event of fire; all of these being specially
desirable points in the case of a hospital for insane patients of
more or less acute sick and helpless types. The building
extends for a distance of 120 yards from east to west, the main
wards running forwards towards the south, and having corre¬
sponding north wings which form the main entrances to these
wards for every-day traffic, and are joined to one another by a
north covered way open at the sides. Passing from west to
east there are traversed in succession: (1) The men’s annexe
ward for phthisical and infectious cases, comprising a ward for
three beds with kitchen and bath-room, two isolation and
observation rooms, a nurse’s bedroom, and a small south
verandah; (2) the men’s reception ward with north wing,
containing twenty beds in the body of the ward, six observa¬
tion rooms, kitchen and bath-room at the north end, and
parlour space at the south end ; (3) the men’s conservatory’ or
winter garden with large south verandah, used mainly as an

Digitized by v^ooQle

BY C. C. EASTERBROOK, M.D.

sss

1907.]

extension of the reception ward ; (4) the men’s infirmary ward
with north wing, a large double ward with central partition,
containing forty beds in the body of the ward, six observation
rooms, kitchen and bath-room at the north end, and parlour
space at the south end; (5) the assistant matron's quarters
(parlour south, bedroom and bath-room north) at the centre of
the building; (6) the women’s infirmary ward with north
wing, resembling the corresponding men’s ward; (7) the
women’s conservatory or winter garden with large south
verandah, used mainly as an extension of the women’s reception
ward; (8) the women’s reception ward with north wing, re¬
sembling the corresponding men’s ward; and, finally, (9) the
women’s annexe ward for phthisical and infectious cases with
small south verandah, resembling the corresponding men’s
ward. It will thus be seen that the hospital is divided by the
assistant matron’s quarters at the centre into two sym¬
metrical and opposite halves, each half consisting from centre to
east and west of a double infirmary ward, a conservatory with
large verandah, a reception ward, and an annexe ward with
small verandah, and that there are 154 beds for patients—77 for
each sex. All the wards are 14 feet high ; in the two annexe
wards there are allowed per patient for dormitory, day-room,
and dining-room space 150 square feet of floor space, or 2100
cubic feet; in the four reception and infirmary wards there are
allowed per patient 100 square feet of floor space or 1400 cubic
feet; and each observation and isolation bedroom has an average
floor space of 90 square feet and 1260 cubic feet of air space.
Over and above these allowances of air space per patient, which
correspond to the requirements of the General Board, it may
here be mentioned that the two conservatories furnish supple¬
mentary day accommodation not included in the above figures,
and that a main feature of treatment is rest in bed in the open
air of the verandahs, so that the requirements of the General
Board have been liberally interpreted.

A. The Reception Wards .

Each reception ward is shaped like a dagger, the body of
the ward corresponding to the blade and the north wing to the
haft or grip of the handle, and at their junction the kitchen
and bath-room and the observation rooms opening on to short

Digitized by

556 THE NEW HOSPITAL AT AYR ASYLUM, [July,

passages on either side form the cross-piece or guard of the
handle. These lateral passages lead to the conservatory on
one side and the annexe ward on the other, both of which under
ordinary circumstances are managed as part, and by the staff,
of the reception ward.

{a) The body of the reception ward measures 84 feet long by 24
feet wide. The parlour space is at the south or sunny end,
which has a large bay window containing at its centre a folding
door opening outwards to the hospital garden and recreation
ground; on each side is a fireplace, and the parlour furnishings
comprise basket chairs, table, etc. The twenty beds, ten on
each side, occupy the main stretch of the ward, and are
arranged in pairs opposite the butts between the windows,
the butts being sufficiently broad to take two beds with a chair
(Austrian bentwood) between them, the beds thus not projecting
beyond the interior splays of the windows and so not being in
any draught from the latter. Below each window is a heating
and ventilating radiator. Along the centre of the ward opposite
the beds are the dining tables, which, measuring 4 feet by 3
feet, permit of the classification at meal times of those patients
who are not confined to bed. At the north end of the body of
the ward is a specially-constructed ward cabinet containing
separate cupboards for dressings and lotions, medicines, napery
for immediate use, charts, urine glasses, etc.

(b) The kitchen , bath-room and six observation rooms of the
reception ward open off the north end of the body of the
ward. The kitchen opens directly off the ward so that a nurse
engaged therein, as at sick-room cdokery, can still keep
the ward under observation. The kitchen contains a small
range for sick-room cookery and for warming, if necessary, the
chief meals of the patients, which are cooked in the main
kitchen of the asylum, and delivered in a hand-van at the north
wing, into the corridor of which the kitchen also opens by
another door. The kitchen has also a sink with plate-rack and
drip-board (to save the work of drying dishes, etc.), a cup¬
board for other crockery and kitchen stores, and a kitchen
table and chair. The bath-room , with lavatory and water-closet,
also opens directly off the ward, an arrangement which is
perfectly safe sanitarily with good plumber work, and has
similarly the object of securing facility of supervision, so that the
nurse standing at the door of the bath-room can safely observe

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• 907 -]

BY C. C. EASTERBROOK, M.D.

557

the occupants of the ward and the bath-room. The water-
closets, basins, etc., are so placed in the bath-room that they
are easily observable from the ward door, and the water-closets
for privacy have doors which, to allow supervision, are raised
i foot above the floor, and are only 4 feet high. The bath-room
has one bath with free access all round (a point of importance
in connection with the bathing of new patients), two basins, a
slunge for slops, a steeping tank for disinfection of any bed and
personal clothing before it is sent to the asylum laundry, two
water-closets, a stand for urinals, hand-basins, etc., and a fixed
towel-rail and mirror. The bath-room fittings (chiefly by
Twyford), are the latest asylum types for the avoidance of mis¬
use and accidents, so far as this is possible by structural devices.
The bath-room has, in addition to the door opening from the
ward, two other doors, one opening from an undressing room
in the north wing in which newly-admitted patients discard
their clothing, and the other opening into one of the observa¬
tion rooms, which thus also serves the purposes of an examina¬
tion-room for a new patient (with whom it is thus possible for
the physician to have, at the outset, a private and confidential
interview), and of a dressing room on bathing days. The six
observation and isolation rooms open off two short passages next
to the kitchen and bath-room, and have been partially detached
from the body of the ward to keep the latter as quiet as possible,
but, at the same time, are freely accessible to the inspections of
the nurse, who thus does not require to leave her ward for the
purpose, inspection being facilitated structurally by placing
the door of the observation room, in most instances, across one
comer of the room, so that the nurse looking through the door
can see at a glance all parts of the room. One of the observa¬
tion rooms, in the passage leading to the annexe ward, is an
india-rubber padded-room (by Pocock Brothers, of London).
The isolation rooms are also available, if not otherwise required,
as private bedrooms.

(c) The north wing of the reception ward contains an entrance
corridor, opening at one end into the body of the ward between
the bath-room and kitchen, and at the other end to the north
covered way outside. Opening on the two sides of this corridor
are—(1) cloak and boot-room, next to the outside door;
(2) coal-cellar, next to the outside door ; (3) closet for pails,
brushes, and floor-polish ; (4) closet for soiled linen; (5) napery,

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558

THE NEW HOSPITAL AT AYR ASYLUM,

[July,

blanket, and clothing store; (6) charge nurse’s bedroom;
(7) ward kitchen, which also opens, as already described, by
another door, directly into the body of the ward; and (8)
undressing room for newly-admitted patients, which contains
a weighing machine and height standard, and opens by another
door into the ward bath-room, which, again, as already
described, opens by two other doors, into the body of the ward,
and into the nearest observation room which thus senes the
extra purposes of examination room for new patients and of
dressing-room on bathing days.

B. The Conservatories or Winter Gardens and Large Verandah .

These form elegant and useful features of the Hospital, and
are placed between the reception and infirmary wards, and
were originally intended by me for the use of those patients in
both wards who were able to be out of bed, but unable to go
out of doors owing to stress of weather. In practice, however,
owing to the systematic carrying-out of the sanatorium treat¬
ment of all newly-admitted patients by rest in bed in the open
air, the conservatories and their verandahs have been utilised
almost entirely by the inmates of the reception wards, and are
now regarded as part of the reception wards, and any patients
in the infirmary wards who it is considered would be benefited
by a course of bed-treatment in the fresh air are, for the time
being, removed to the reception wards. Each conservatory
opens by east and west doors into the reception and infirmary
ward on either side, and by a folding door into the verandah,
and is a large airy apartment, containing plants and flowers
and basket-chairs, and forming a pleasant convalescent room
for the reception-ward patients when indoors and not confined
to bed, and devoted to such purposes as sewing-room, reading-
room, smoking-room, etc. The verandahs face the south, and
are sheltered from the north cast and west by the adjoining
buildings, and their roofing projects well beyond the foot of the
beds, which are arranged parallel to one another at right angles
to the long axis of the verandah. A southerly gale with rain
and severe wintry weather are the only conditions which
prevent the use of the verandahs for the sanatorium treatment
of active insanity. All newly-admitted patients, unless there
is some special reason to the contrary, are taken to the

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1907 .]

BY C. C. EASTERBROOK, M.D.

559

verandahs on the morning following admission, and given
straight away a course of rest in bed in the fresh air, lasting for
days or weeks, according to circumstances. This system,
combined with isolation if necessary in certain cases, and
attention to individual features in all cases, is in my experi¬
ence the most satisfactory method of alleviating active in¬
sanity, is productive of good therapeutic results, is based on
sound physiology and correct pathology, and effects a minimum
use of hypnotics and sedatives.

C. The Annexe Wards and Small Verandahs,

These form the east and west extremities of the hospital.
Each is an annexe of the reception ward, and under ordinary
conditions is managed as an extension of that ward, and with
the same staff, but if necessary the annexe can be entirely shut
off from the reception ward and worked as an independent
self-contained unit with its own staff. Each annexe has an
entrance corridor opening by a door at one end to the outside
grounds, and by a door at the other end into the reception
ward, namely into one of the passages between the observation
rooms. On the north side of the annexe corridor are a nurse’s
bedroom next to the outside door, and two observation and
isolation rooms, one of which is conveniently used as a room
for a patient who is dying, and who can be quietly visited by
the relatives, and removed after death by the outer door of the
corridor without attracting the attention of the patients. On
the south side of the annexe corridor are two doors; one opening
into the annexe kitchen is close to the outside door, for the
delivery of food when the annexe is used as an independent
unit, and the other, leading into the ward of the annexe, is
opposite the two doors of the observation and isolation rooms,
so that the nurse merely has to cross the corridor to make her
inspections, and can still keep the ward under observation.
The ward of the annexe has a bay window facing south, and
containing at its centre a folding door which opens outwards
into the garden, and leads to a small sheltered verandah for
the open-air treatment of patients suffering from pulmonary
phthisis and other infectious diseases of suitable nature. The
annexe verandahs are half the width of the conservatory
verandahs, and can accommodate four beds placed side by side.

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560 THE NEW HOSPITAL AT AYR ASYLUM, [July,

Both annexe and conservatory verandahs can be inspected
from the windows of the adjoining wards. The ward of the
annexe has its own bath-room (with bath, disinfecting tank,
slunge, and water-closet), and kitchen (with range, sink, rack,
cupboards, etc.), both opening directly off the ward to facilitate
supervision, the kitchen, as before mentioned, also having
a separate door to the corridor. The ward is fitted with
radiators below the windows, and a fireplace between the bath¬
room and kitchen doors, and it contains three beds, and in
addition to the usual furnishings a cabinet similar to that in the
reception ward, but smaller.

D. The Infirmary Wards.

These form an original feature of the hospital. For some
years past at Ayr Asylum the class of patients suitable for
treatment in such wards has been, in the case of both sexes,
usually twice as numerous as the class of patients in the recep¬
tion wards. This would have implied the building of two
infirmary wards for each sex similar in size to the reception
wards—that is, four infirmary wards in all, with four north
wings, four bath-rooms, four kitchens, and probably not less
than sixteen observation rooms (four to each ward). But the
sick and the debilitated, the paralysed and the bed-ridden, the
blind and the halt, the maimed and the helpless, who form the
bulk of the inmates of an asylum sick-room and infirmary, are
as a class quieter and more easy to manage, and require a rela¬
tively smaller nursing staff than the newly admitted, who, as a
class, are physically ill and actively excited, depressed, confused,
resistive, delusional, impulsive, suicidal, homicidal, and the
like, and require not only skilled nursing but also careful super¬
vision for the avoidance of accidents. Therefore I considered
that there would be at least no loss in efficiency, and yet a dis¬
tinct gain in economical construction and administration, if it
were possible to make one large infirmary ward for each sex.
And this is what has been done. Each infirmary ward, like
the reception ward, is dagger-shaped, but the blade of the
dagger is twice as broad, the body of the infirmary ward
measuring 84 feet long by 48 feet wide, and being partially
divided into two halves by a longitudinal partition, which
by its pillars supports the roof, and is pierced at its centre

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I907-] BY C. C. EASTERBROOK, M.D. 561

by an archway through which, as well as at both ends, there
is free passage between both halves of the body of the ward.
The partition is 10 feet high, and is clear both of the floor and
ceiling for cross ventilation ; its upper 6 feet consists of glass
and wood to facilitate supervision, and its lower part consists
of Fram boarding cemented to give a sense of comfort and
privacy to the patients occupying the beds on either side of the
partition. The body of the infirmary ward, each half of which
measures 84 feet by 24 feet, is thus twice the size of the body
of the reception ward. The parlour space of the ward is at
the south end, which has two large bay windows, with folding
doors at the centres opening to the garden, and a fireplace
on each side. The forty beds occupy the main stretch of the
body of the ward, being arranged ten on each side of the
partition, and ten next to the outside walls in pairs opposite the
butts between the windows. Radiators are placed below the
windows and hot pipes below the partition. In addition to the
usual furnishings there is a large cabinet similar to that in the
reception ward and placed at the north end. Opening off the
north end of the body of the ward are (1) the kitchen, which is
similar in size and arrangements to that of the reception ward ;
(2) the bath-room, which is slightly larger than that of the
reception ward and contains two baths, but experience has
shown that one bath would have sufficed, so many of the
inmates of the infirmary ward being bedridden, and therefore
requiring to be sponged and cleansed in bed; and (3) the six
observation and isolation rooms, which are a sufficient propor¬
tion for the quieter class of patients concerned. The short
passages between the observation rooms on either side lead by
east and west doors to the conservatories and to the corridor of
the assistant matron’s quarters at the centre of the hospital.
Between the kitchen and bath-room is the door leading to the
corridor of the north wing of the infirmary ward, which is the
same size as the north wing of the reception ward, and has the
same suite of rooms with the exception of an undressing room,
which was unnecessary, as no patients are admitted directly to
the infirmary wards from the outside community. The extra
space thereby gained has been utilised for the necessarily larger
napery and clothing store, and cloak and boot-room. From
the description it will be seen that the infirmary ward, like the
reception ward, has main doors of entrance and exit placed

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562 THE NEW HOSPITAL AT AYR ASYLUM, [July,

north, south, east, and west. All the doors of the hospital and
its various apartments, with the undernoted exceptions, have
spring locks, and so when closed can only be opened by means
of an official’s key. The exceptions comprise the doors of all
observation and isolation rooms, and the doors leading from
the body of the various wards to their respective entrance
corridors in the north wings and east and west annexes. These
doors have dead locks. It may be added that all the large
folding doors at the south ends of the wards and conservatories
are kept open during the greater part of the day in suitable
weather, affording pleasant views of the hospital garden and
country beyond.

From the description which has been given of the plan of the
hospital, it will be seen that the essential principle aimed at in the
design of every ward has been to facilitate structurally the work of
the nurse . The essential point of distinction in the nursing,
care, and supervision generally of insane patients in hospital
wards, as compared with ordinary patients in hospital wards, is
that the supervision of the former by the nurses must be con¬
stant, ready, and vigilant. This is the only way to prevent
accidents. In the case of a general hospital ward the nurse on
duty can often leave her ward safely for a few minutes to go,
say, to the kitchen, bath-room, napery store, etc. In the case
of a mental hospital ward, however, in w'hich there are always
some untrustworthy patients, the nurse on duty can never safely
leave her ward in this way, but must alw ays remain present and
w'atchful. The ward must, therefore, be so arranged that it is
not necessary for the nurse on duty to leave it, should there be
only one nurse on duty at the time, as during the night, staff
meals, etc. For this reason, in every ward of the hospital the
kitchen and bath-room and observation rooms have been made
directly accessible from the body of the w'ard, the observation
rooms, for the sake of the quietness of the ward, opening on to
short side-passages; and in close proximity has been placed a
specially constructed w'ard cabinet containing napery for imme¬
diate use, dressings, medicines, etc. By grouping the kitchen,
bath-room, observation rooms, and cabinet at the north end of
the ward—thereby appropriately freeing the sunny south end
for the parlour space—and by aggregating the patients who
require most attention and supervision in the beds at the north
end and in the observation rooms, it is obvious that the work

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I907-] BY C. C. EASTERBROOK, M.D. 563

of the nurse has been considerably facilitated, and that mental
hospital wards constructed in the above manner can be effi¬
ciently managed by a relatively small staff.

Administration of hospital .—The hospital, with its 154 beds
(for patients), has a day staff of eighteen, and a night staff of
four, each infirmary ward having a staff of four day nurses and
one night nurse, and each reception ward with the annexe and
conservatory and verandahs having a staff of five day nurses
and one night nurse. During the eight months the hospital
has been in occupation it has been necessary' on only two
occasions, following the admission of an extra number of difficult
female cases, to temporarily strengthen the staff of the women’s
reception ward by the addition of one special night nurse.
Hitherto, owing to the comparatively simple nature of the cases
in the annexe wards, it has not been necessary to work either
of them as a self-contained unit separately from the reception
ward; but if this contingency should arise the annexe ward
would be shut off from the reception ward and staffed with one
day nurse and one night nurse. The four ordinary night nurses
make their headquarters at the north ends of the reception
and infirmary wards. The day charge-nurses of these four
wards have their bedrooms in the corresponding north wings,
and the second charge-nurses of the two reception wards sleep
in the east and west annexes. The assistant-matron’s quarters
are accessible from the infirmary wards, between which they
are situated. The hospital wards are in telephonic communi¬
cation with the main asylum buildings, namely with the medical
officers* quarters and the headquarters of the two chief night
officials, who pay periodic visits to the hospital.

Male nurses v. female nurses .—In the hospital the men’s recep¬
tion ward is staffed with male nurses or attendants, and the
other wards by female nurses, the nursing of insane men by
women being thus confined to the men’s infirmary ward. In
the men’s infirmary ward the nurses, with the assistance of
three or four helping patients, perform all the duties required
of them, except the bathing of those relatively few patients who
are not confined to bed, and who by a simple arrangement
go for their bath on bathing days to the men’s reception ward.
To some extent the inmates of the men’s infirmary ward are
selected; that is to say, any male patient who requires hospital
treatment, but is considered an unsuitable case to be nursed by

564 THE NEW HOSPITAL AT AYR ASYLUM, [July,

women, is sent, not to the infirmary ward, but to the reception
ward ; and if any patient already in the infirmary ward proves
himself unsuitable for female nursing, he is sent to the reception
ward; and conversely, any male patient in the reception ward
who is considered a suitable case to be nursed by women
is sent to the infirmary ward. The class of patient in the
men’s infirmary ward—the more or less quiet and harmless
insane man with bodily infirmity or illness—is in my experience
efficiently nursed and supervised by women. At the same time
there are many insane men who require careful nursing and
supervision, who cannot be suitably or safely nursed by
women, owing to the intensity of their mental symptoms, for
example, severe excitement, vivid hallucinations and delusions,
suicidal and homicidal tendences, etc., these being common
amongst newly-admitted cases; and for this reason the men’s
reception ward has a staff of male nurses or attendants, and of
attendants only. Given the right type of attendants with the
true nursing instinct—and they exist—the work of the reception
ward is performed with efficiency, propriety, and safety, and
with satisfactory therapeutic results. Although the men’s
infirmary ward has a staff of female nurses, who are under the
jurisdiction of the matron and her assistant, the head attendant
keeps in touch with the patients of this ward and supervises
their clothing and the furnishings of the ward. Given head
officials of the right type, administrative difficulties do not
arise. The assistant matron, who is a fully-trained and
certificated hospital nurse, supervises the practical instruction
of the nurses in the men’s infirmary ward and in the women’s
wards, but she is careful not to derogate the authority of the
charge nurses, and her duties do not extend to the men’s
reception ward.

Food and cooking arrangements .—The chief meals for the hos¬
pital are cooked in the main asylum kitchen, and, as in the case
of the villas, are conveyed in closed hand-vans, being delivered
at the north wings and warmed, if necessary, before serving in
the ward kitchens, which are also utilised for any extra sick¬
room cookery. The meals for those patients not confined to
bed are served at the dining tables in the wards, or for variety in
the conservatories or on the garden terrace in suitable weather.
The staff go for their meals to the mess-rooms in the nurses* and
attendants’ homes at the centre of the main asylum buildings.

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1907] BY C. C. EASTERBROOK, M.D. 565

Laundry arrangements .—All bed and personal clothing from
the hospital is washed in the asylum laundry, being previously
disinfected, if necessary, in the ward bath-rooms.

Ventilation .—The system of ventilation is mainly natural—
by windows, doors, and fireplaces—but is aided by extraction
fans placed in ceiling trunks and driven by electricity supplied
from the asylum electric station and boiler-house. Each
window has (a) an upper “ Hopper ” sash hinged below and
opening inwards, where it rests on two cheeks; ( b) two ordinary
sashes moving vertically up and down so as to allow clear
openings to the maximum extent of six inches above and
below; (c) a deep lower sill-rail; and ( d ) below each window is
a ventilator and radiator. The only windows of the building
which have shutters are those of the observation bedrooms.
These shutters consist of two vertically-moving sashes, which
can be locked half way up or right up, and the upper sash is
pierced for ventilation. Each observation room has its own
ceiling ventilator and extraction shaft.

Heating .—The heating is by means of radiators in the wards
and conservatories, and of horizontal pipes protected with Rus¬
sian steel in the observation and isolation rooms, and is effected
by hot water at low pressure on the Reck patent circulator
system, the steam for heating and circulating the water being
supplied from the asylum boiler-house. The special feature of
this Danish system of heating is that the steam, reduced by a
valve to low pressure (a pressure of three pounds to the square
inch suffices as a rule in the case of the hospital) not only heats
but also circulates the water in the system, thereby circulating
the hot water downwards as well as upwards, and moving it
through the pipes and radiators much more quickly than in the
case of the ordinary low-pressure systems, with the result that
there is no difficulty in keeping the wards at a temperature of
6 o° F. even in the depth of winter. Last winter was a specially
severe one, and yet it was never necessary for the radiators,
which are numerous and can each be independently regulated
with a key, to be worked to their full heating capacity, and
consequently no fires were required to warm the wards. The
circulators and main piping of the Reck system are carried in
the roof, thereby avoiding not only the considerable excavation
and building necessary in the making of an underground duct,
but also the presence of much unsightly piping in the wards,

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566 THE NEW HOSPITAL AT AYR ASYLUM, [July,

the chief pipes visible being the small vertical flow and return

pipes for each radiator.

Lighting .—The lighting is by electricity, supplied from the
asylum electric station, and by means of double filament lamps,
each of sixteen candle-power and two candle-power, subdued
light is secured during sleeping hours.

Protection from fire .—As the whole hospital is on the ground
level, and as each main ward has exits to the north, south, east,
and west, and each annexe has exits to the south, east, and west,
there is abundant provision for the safe removal of the patients
in the event of fire. Each ward has its supply of fire-buckets
for first aid, and an internal fire-plug; and surrounding the
hospital is a 4-inch water main, with external fire-plugs at
necessary points. Each ward is provided with an electric fire
alarm, the button of which, when pressed, sets off the siren at
the asylum fire station, and alarm gongs in the sleeping
quarters of the fire brigade.

The water supply and the sewage system are connected to the
corresponding systems of the rest of the asylum, the water
being supplied by the Corporation of Ayr, and the sewage
being dealt with in the asylum septic tank and filter beds.

The materials, fittings, and furnishings of the hospital are sub¬
stantial in character, and sufficient indication of the nature of
the fittings and furnishings has already been given in the fore¬
going description. As to the materials of construction, the
roofs are slated and have red tile ridges. The walls are of
white freestone outside, and of single brick inside, the stone
and brick walling being separated by a 3-inch cavity. The
brickwork is finished internally with Keen’s cement below
(6 feet), and Adamant plaster above, all internal angles and
corners being rounded off to facilitate cleaning, and the painting
of the walls is in duresco. The floors are in selected narrow
maple, stained and polished, as are also the walls and specially
constructed shutters of the observation rooms. The floors of
the bath-rooms, conservatories, and corridors of the north wings
and annexes are in terrazzo. The walls of the conservatories
are in glazed white brick, and the lower walls of the bath¬
rooms and kitchens are tiled.

Cost of hospital .—The cost of the hospital for total con¬
struction and fittings has been £100 per bed, which is consi¬
derably less than the cost per bed of asylum hospitals hitherto.

I907-] BY C. C. EASTERBROOK, M.D. 567

The main explanation of this moderate cost has been the design,
from which, while securing the means of efficient treatment, I
eliminated everything which could be considered superfluous.
Thus, in the first place, given the main kitchen of an asylum, and
the means of distributing the cooked food—a system which is
observed in all large hospitals and has received further develop¬
ment in asylums with separate villas—there is no necessity for the
central kitchen seen in the majority of the hospitals of asylums.
All that is required is the ward kitchen, which, in any case, is
necessary in any properly equipped hospital ward. Again, there
is no necessity for a central dining-room, or for special day-rooms,
or special dormitories in an asylum hospital, apart from the
hospital wards themselves in which insane patients have their
habitat for the time being, like the inmates of ordinary hospital
wards. The mental hospital ward, like the ordinary hospital
ward, serves as dormitory, day-room, and dining-room for its
inmates, and if the requisite space is provided in the ward for
these three purposes, there is no need to double the dining,
sitting, or sleeping accommodation for the identical patients
within the same building. And it is not a difficult matter to
combine in the form of a well-proportioned ward the allowances
of dormitory, dining, and parlour space required for a given
number of patients, and to arrange the ward internally with a
view both to useful working and pleasing appearance. Again,
the addition of a central kitchen and central dining-room, and
of special day-rooms and special dormitories in the hospital of
an asylum, obviously means not only extra original cost of con¬
struction, fittings, and furnishings, but also a corresponding
increase of officials to look after them, and extra accommoda¬
tion for these officials; and all this means a permanent burden
on running expenses in the future for upkeep of fabric, fittings,
and furnishings, and for board and wages of staff. For these
reasons I eliminated from the design of the hospital a central
kitchen and dining-room, and special day-rooms and dormitories,
and decided that the hospital should consist essentially of
wards, each of which, like an ordinary hospital ward, was to
combine the proper dormitory, dining, and parlour space
required for a given number of patients. Again, as regards the
design of the hospital wards themselves, the plan of the two
large double wards with central partition is not only suitable for
the quieter class of insane patients who form such a large
Lin. 39

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568

RECIDIVISM

[July,

proportion of the inmates of the sick-rooms, infirmaries, and
hospitals of asylums, but has obviously effected a considerable
saving as regards the original cost of construction, fittings, and
furnishings, and also the future cost of upkeep and staff
expenses. In confirmation of this latter point it may be men¬
tioned that during the eight months the hospital has been in
occupation, and notwithstanding a reduction of sixpence per
week in the rate of board for the asylum patients during the last
six months of that period, the credit balance under the main¬
tenance account of the institution was increased by £600. The
opening of a large addition to an asylum, as a rule, tells
heavily at first on the maintenance account.

Other factors which have contributed to the moderate cost
per bed of the hospital have been the care bestowed by the
architect on the details of his schedules and the supervision of
the works during erection, the introduction of the system of
heating adopted, the use of the asylum branch railway for the
conveyance of the heavy materials of construction, and, lastly,
keen competition owing to depression of trade at the time of
the placing of the contracts.

(*) Visited by the Scottish Division of the Medico-Psychological Association, on
the 22nd March, 1907.

Recidivism regarded from the Environmental and Psycho-
Pathological Standpoints. By J. F. Sutiierlan d, M.D.,
F.R.S.E., Deputy Commissioner in Lunacy for Scotland.

PART II.

It does not require a Sherlock Holmes to distinguish the bond fide tramp
with tatterdemalion, unkempt locks, gaping boots and grimed skin,
from the bond fide labourer in search of work.

Interchange of Crimes, and of Crimes and Offences , and of
Criminals and Offenders .

With the view of testing to what extent an interchange took
place between the perpetrators of the four major crimes I have
prepared a return of 370 convicts and long-term prisoners in
Scotland, convicted of (i) homicides, assaults, etc.; (2) crime*

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1907-]

BY J. F. SUTHERLAND, M.D.

569

against property with violence ; and (3) without violence ; and
(4) crimes against chastity. The result, an interesting one,
finds expression in the following figures:

No previous
conviction.

2 .

Convicted of
homicides,
assaults, etc.

Convicted of 1
burglary,
housebreak*
ing, etc.

Convicted of
larceny,
thefts, fraud,
etc.

$•

Convicted of
sexual
crimes.

Per cent.

1. Homicides, assaults,

etc.

Nil.

2. Housebreaking,

burglary, etc.

1 18

I '2

685

j 28-5

Nil.

3. Thefts, fraud, reset,
etc.

■ ■ 4‘5

i *5

306

634

Nil.

4. Sexual crimes

53*3

Nil.

— _ ..

_ _ _

It is strikingly noticeable how the three dominant mental
factors in human composition, vis., malice, acquisitiveness, and
lust govern so largely the criminal problem, and the irrepres¬
sible assertiveness of acquisitiveness and avarice, as shown in
columns 3 and 4, and the fact of few or none having “ no
previous convictions.” With homicides it is the reverse ; nearly
one half have had no previous convictions of any kind, and
very few manifest that degree of acquisitiveness of which the
criminal law takes cognizance. With crimes against chastity
(sexual) more than one half had no previous convictions of any
kind, 13 per cent, repeat, and none have shown any inclination
for burglary and theft. The fact of there being such a small
proportion of repeaters suggests that many may have passed into
asylums. A minority of physically and mentally weak ones
in short, degenerates, vary their larcenous propensities with
over-indulgence in alcohol, and not infrequently do their
pilfering in a confused mental state, with the result that the
conception of meum and tuum , never clear, disappears, and they
are taken by the sufferers or by the police flagrante delicto.
How far they are “ free agents ” at any time may be a moot
question. Not so, however, with the perpetrators of house¬
breaking, robbery, etc. After a big haul yielding plunder
such as a whole year of honest labour could not give, they, like
the apostles of haute finance who manage by stratagem to keep

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570

RECIDIVISM

[July,

outside the meshes of the criminal law, indulge the palate to ex¬
cess, although in the execution of their aggressive work they are
sober, cunning, and in the possession of all their faculties, more
often than not very considerable. This is the type of recidivism
at once most vital, noxious, and costly to the commonwealth.

These observations are called for in order, firstly, to understand
and appreciate how far crimes themselves, and how far crimes
and petty offences are interchangeable, and secondly, to correct a
wrong impression given by those penologists who consider that
alcoholic excess is closely identified with all crimes and offences,
indeed, in the opinion of some of them, falling little short of
direct cause and effect. This idea is not shared by the writer
for the reasons already stated, and neither is it by Mr. C. E.
Troup, C.B., of the Home Office. He says : “No clear connec¬
tion could be traced between indictable crimes as a whole and
prosecutions for drunkenness.” ( J )

Prevalence and Significance of Insanity among the Authors of
the different Crimes .

Perhaps in the investigation made and now set forth the
piece de resistance is the conclusion now submitted that for a
proper and effective study of recidivism in any of its forms the
psychological and psycho-pathological method of inquiry, aided
and supported by the great environmental one, is that most
likely to combat the evil, and to prepare the way for more
rational and remedial measures. The following table is both

Indictable crimes in

Appre-

Percentage

Number of !
inbane

Percentage of

Ratio uf

l England for 1903.

hensions.

of each.

before and
after trial.

insane. |

apprehensions

A. Homicides, assaults,

etc.

1656

2'7

1 39

1 I in 30

B. Sexual crimes.

I39I

2'3

16 ;

US j

1 I in 87

C Arson .

213

'35

6 !

1 »n 35

c. 3 Malicious injury to

! 216

| ( property .

•35

3 5

I in 43

D. Housebreaking,

robbery, etc., with

1 violence . J

1 3734

1 65S

><n <

"■s'] 1

1 in 233

E. Theft, reset, fraud,
etc., without vio-

r 58 !

r 7 '

! lcnce .

54.745

1 «Y6\?

42J |

3 °’- J |

1 in 1300

61,955 1
1

100

•39

IOO

1 in 445

Digitized by v^ooQle

190 /.] BY J. F. SUTHERLAND, M.D. 57 1

highly instructive and suggestive on this point as showing the
liability to certifiable insanity, and, by implication, mental
states more or less allied to the certifiable one.

It amounts to this, that of the apprehensions during the
year for homicides and assaults, i in 30 become insane before
or after trial ; for sexual crimes 1 in 87 ; arson (fire-raising)
1 in 35 ; robbery, burglary, house-breaking, with violence, 1 in
233 ; and for larcenies, fraud, reset, etc., without violence, 1 in
1300. Calculating for crimes A, B, and C, on the number and
percentage of insanity found respectively in D and E, viz., 58
persons and 41*7 per cent ., that for homicides and assaults
should be 1*5 persons and not 54, and the percentage V 2 and
not 39. Or reversing it if the insanity ratio in the former
applied to the latter, the latter would not merely produce, as it
does, 58 insane, but 1780, or thirty times as many! Similarly,
if crimes against chastity produced insanity in the same ratio
as crimes against property, it would amount to 1 per cent . and
not 11*5 per cent., and arson I 5 per cent . and not 4*3 per cent .,
or thirty times less. Thus it appears that certifiable insanity
is much more frequently met with amongst those who commit
crimes in which the elements of malice, passion, revenge, and
lust predominate, than among those in which acquisitiveness
and avarice are the governing mental factors. Among the
authors of crimes of blood and violence against the person
are to be found a small number of homicidal maniacs, para¬
noiacs, etc., both with declared and carefully concealed delusions
of persecution, a larger number of a coarse, brutal type who act
from motives of malice, revenge, and jealousy, and a still larger
number of drunkards and intoxicated persons who do violence
while in that state of exaltation and recklessness which is
induced by' the toxic agent. The point to be observed is that
there is relatively little insanity occurring among the plundering
and thieving class which presents the ugliest and most persistent
phase of recidivism in any country, and yet so much of it
among the perpetrators of other crimes with little recidivism
resulting. It has again to be stated that among the petty thiev¬
ing class there are a number of degenerate and weak-minded
persons.

For Scotland the relative prevalence of insanity' is indicated
infra :

572

RECIDIVISM,

[July.

Prisoners

received.

Became

insane.

Ratio of
insane to

Percent¬
age of
commit-

Percent- i
age of

commitments.

raents.

insane.

a. Crimes of violence

1445

I in 72

30 '

B. Sexual crimes

432

1 in 33

c. Malicious mischief

d. Housebreaking, rob¬

652

1 in 10S |

bery, theft, etc. .

7670

I in 274 !

| i

! 75

IO 199

| 67

l in 152 !

100

100 !

Although in the foregoing figures prison receptions take the
place of the apprehensions in the preceding English table, the
percentage of insane is much the same, and the conclusions
reached are almost identical ; that is to say, insanity is much
more rife among the authors of crimes of violence, sexual
crimes, and malicious mischief than among plundering criminals.

If in Scotland insanity was only as prevalent among the
authors of crimes of violence as it is among the plundering
and thieving classes, then among the former, instead of 20, the
number certified would be 5 ; and similarly among the authors
of crimes against chastity it would be 1 *5, and not 13.

The following table has reference to the different types of
insanity, and their relative frequency among prisoners com¬
mitted in Scotland in 1903 for the different crimes and offences

* ;
>» , &

.-*> C

0 V c.

! (1) Crimes of blood and vio-

| Ience ....

| (2) Crimes and offences against

chastity ....

(3) Crimes indicative of avarice

and acquisitiveness

[ (4) Malicious mischief .

I (5) Breach of peace, drunk and

incapable and disorderly

1 7

! 6

(6) Vagrancy and begging

' 5

j (7) Other offences .

1 Total ....

3 °

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•907]

BY J. F. SUTHERLAND, M.D.

573

specified in column i. The insanities were established in
bar of trial, within eight days of reception, after being eight
days in prison, and on the expiry of sentences, as a rule, of
brief duration. The figures convey the same meaning as those
already given. The frequency of general paralysis is notice¬
able, being 8 per cent . of the whole; imbecility, 16*5 per cent . ;
mania, 20 per cent . ; dementia, 25 per cent . ; delusional in¬
sanity, 1 1 per cent .; and alcoholic insanity and delirium
tremens, 7 per cent .

The following figures referable to the occupations of criminals
and petty offenders who were known to be insane within eight
days of reception, after being in prison for eight days, and on
the expiry of sentences as a rule short, bear out what has been
previously stated, more than one half being labourers. And this
proportion is maintained, not merely for the whole, but for
every one of the crimes and petty offences tabulated. The
“ labourer,” in proportion to his numerical strength in the
general population, contributes, it is safe to say, treble as many
of those becoming insane as his class would justify.

L | 'rt

V. \ >

? ^

0 ii

s l

'P.

§ £

2 | x

c .

Others.

Total.

(1) Crimes of blood and vio-

lence . . .

6 I 1

— 1

—

I lo 1

(2) Crimes and offences against

chastity .

6 —

— —

—

I IO

(3) Crimes indicative of avarice

and acquisitiveness

14 4 1

1 1

—

- '

3 25

(4) Malicious mischief

21 — 1

—

— — ,

— 1

— 5 !

(5) Breach of peace and

drunkenness .

19 4

2 4

3 42

(6) Vagrancy and begging

1 9

—

1 —

—

— 10

| (7) Other offences .

3 —

— 1

1 7

Total

1 59 9

4 7

l ~4

9 109

Geographical Distribution and Loci of Recidivism .

Without exception recidivism of every' description is in the
main in every countiy a product of urban life. It is rarely met

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\ 907 -]

BY J. F. SUTHERLAND, M.D.

575

with in rural districts. The felon who robs a country mansion
is a city dweller, and the loci in towns and cities of the recidivist
are the slum, insanitary, overcrowded, wretched abodes in which
the decencies of life are known to be impossible. And under
present economic conditions it is bound to increase as it is
doing, in consequence of the trend of modern life which is
bringing about, in every country, a depopulation of rural districts
and a corresponding increase in the poorest and most squalid
districts of cities and towns. Apart from the changing economic
conditions and the ways of industry, there can be no question that
intemperance in alcohol in any country has much to do with
slum areas and the submerged tenth who are content to dwell
in them and inhale their noxious moral and material atmo¬
sphere. It is safe to say that it would scarcely be possible for
a saint to live in them and not be contaminated. The contagion
is virulent and paralysing.

The distribution per 10,000 of population in Scotland (33
counties and 4 cities) of crimes of violence, crimes against
property, malicious mischief, and sexual crimes by persons pro¬
ceeded against in the Justiciary Courts and in Summary
Courts is shown by the accompanying table, illustrated by the
shaded map. I am not aware that the geographical distribu¬
tion in Scotland of crimes has been attempted before : it has, I
am aware, been done in regard to certain petty offences, such
as inebriety and disorder.

It is convenient, having regard to the wide range from 4 to
95 per 10,000 which prevails, to have six shadings, the two
darkest representing the chief haunts of the criminal recidivist.

61 to 95 per 10,000

III. 41 to 50 :

Glasgow City

• 95

Haddington

• 44

Lanarkshire

• 70

Dumfries .

Linlithgowshire.

• 78

Dumbarton

• 49

51 to 6 0 :

Peebles

• 41

Edinburgh City.

. 60

IV. 31 to 40 :

Aberdeen City .

. 60

Midlothian

• 40

Dundee City

• 59

Elgin

• 35

Ayr .

. 60

Kinross

• 34

Stirling

• 58

V. 2 1 to 30 :

Renfrew

• 58

Aberdeenshire .

. 26

Fife .

• 55

Forfar

. 21

Clackmannan

• 53

Argyll

• 24

Digitized by

576

RECIDIVISM,

[July,

Inverness .

• 27

Ross

• '7

Caithness .

. 22

Banff

• '9

Kincardine

. 21

Berwick

. 18

Roxburgh

. 30

Kirkcudbright

. 20

Selkirk

. 28

Nairn

. 20

Wigtown .

. 25

Sutherland

Bute

. 24

Orkney

. 5

VI. $ to 20 :

Shetland .

• 5

Perth

. 14

Any one in

the least familiar with Scotland will be able

to sec

at a glance that its criminality

is mainly confined to the four

cities and to the smallest but most populous area of the six
groups, in the midlands, that embracing Lanarkshire, Linlithgow¬
shire, Renfrew, Ayr, and Fife. There is no mistaking the posi¬
tion of Glasgow and Lanarkshire with its million and a quarter of
population, or nearly one fourth of all Scotland. Some of the
counties in Group II owe their unfortunate positions in the list
to the presence of provincial towns like Greenock, Paisley, Ayr,
Kilmarnock, Kirkcaldy, and Dumfermline. In Groups I and II
the populations are for the most part mining and industrial.
Practically north of the Forth and Clyde, save the cities of
Dundee and Aberdeen, the Highlands and Islands, and North-
Eastern District, comprising the fishing, crofting, and agricultural
counties, the amount of crime is small, and likewise in the
pastoral border counties save Dumfries, touching almost the
vanishing point in the county of Sutherland, the Orkney and
Shetland Isles, the Western Isles, and Outer Hebrides.

Between the “criminal” map of Scotland and the “lunacy”
map( 2 )there is no similarity, but between it and t he “ inebriety ”( S ;
one there is. It does not follow, however, for this that there is
any intimate connection between the two in the areas in which
both are found for reasons already adduced.

International Statistics.

The writer is not in agreement with Dr. E. Mischler, of
Vienna, when he remarks that, “ it may even be said that in
consequence of differences of legislation, the difficulties of an
international system of statistics are to a certain extent impos¬
sible ” ; rather he is of opinion that as the criminal laws of
every country are based on Roman jurisprudence, and in the

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190/.]

BY J. F. SUTHERLAND, M.D.

577

main features alike, and as the Greek Kalends would arrive
before the laws of every country could even be approximately
assimilated, something should meantime be done practically by
legislators and statisticians to bring about a better classification
of crimes and offences and their penalties, and a better compila¬
tion and tabulation of information as to sex, age, civil condition,
housing, wages, education, occupation, frequency of conviction,
heredity, mental and physical condition, etc., not merely for
the whole but for the various types of crime and petty
delinquency. Without these details statistics are not of much
use either for national or international purposes. It is surely
not beyond the wit of students of psychology and criminology
to devise a scheme for presentation to Ministers of Home Affairs
and of Justice which would meet a felt want in the study
of criminology in relation to treatment and prevention. In
every country elaborate machinery for the collection of figures
and enumerations exists, and may be doing its work as it
understands it, and all the time it does not convey a true
impression as to the real condition of affairs, because it not
only proceeds on wrong lines, but for the lack of necessary
collateral and qualifying information is incomplete. It goes
without saying that administrators, psychologists, and statis¬
ticians having certain figures presented to them would pro¬
bably interpret them in different lights and from different
standpoints, although there is a common point de vue for the
three investigators, if they know it, and could combine their know¬
ledge. Mulhall, in his Dictionary of Statistics , represents some
countries in a very much worse light than Great Britain as to
the prevalence of the most noxious forms of recidivism. But
it would be hazardous to accept and endorse this, unless the
investigator, making allowance for undoubted differences in
economic conditions, the laws as to land, property, liberty,
education, social characteristics and habits, etc., was prepared
to believe that human nature in its virtuous, as in its erring
aspects, differed to the degree postulated by these figures in
different countries. The factors enumerated above are not all
those that have a close bearing on recidivism. The penal
systems of civilised countries differ vastly, and there can be
no manner of doubt that penal systems have much to do with
the vitality and persistence of recidivism everywhere. If
diagnosis is wrong the treatment must fail to a very large

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578

RECIDIVISM.

[July,

extent because it is empirical. Could one safely judge of
recidivism, which one cannot, by prison populations per 100,000
of the population, then for Great Britain and Ireland it works
out at 63, France 158, Russia 155, Holland 84, Belgium 70,
Italy 217, and the United States of America 132. In British
prisons there is a daily population of 26,190 ( 4 ), in France
60,800, and in Italy 68,800. In the latter country, quite the
reverse of this country, crimes against the person are 36*4 per
cent., and against property 63 per cent. Murders or homicides
in Italy, it is stated, reach the staggering total of 3,000 per
annum, and constitute a principal feature in Italian crime. In
Germany out of every 1000 convicts 378 are said to be
recidivists.

Recidivism is said to be increasing in France, Germany, and
Italy, but no distinction is had between noxious, aggressive,
and dangerous recidivists, and the passive, parasitic kind.

Criminal Anthropology .

Few will be disposed to dispute the classification of criminals
as a whole put forward some years ago by Lombroso, Benedikt,
Havelock Ellis, and others :

First: criminals by passion. —Persons who act on the spur of
the moment, and are known by their good lives and genuine
remorse. There is no deliberation.

Second: occasional criminals. —Not naturally inclined to crime,
but are weak and easily led. Bad heredity is prominent in this
class.

Third: habitual criminals — recidivists. —Made up (1) of the
weak and helpless, mentally and physically, and (2) those
deliberately adopting a career of crime. The professional is
the aristocrat among criminals, and is often skilled and
intelligent.

Fourth: instinctive criminal. —He is the congenital or
criminel nt { of the French, the Fuomo delinquente of the Italian
school, and is decreed by nature- to be such. He is regarded by
Lombroso as morally insane. His type is clearly of the
degenerate stock.

Fifth: the insane criminal. —He is, in the opinion of the
Italian school, an exaggeration of the instinctive.

This, for most purposes, is a reasonable and scientific classi-

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190 /.]

BY J. F. SUTHERLAND, M.D.

579

fication. The fierce disputations of past years have gathered
round the “instinctive” criminal, of whose existence no psycho¬
logist or penologist is in doubt. The majority of observers con¬
tend that he is so rare as to be une quantity ntgligeable , and that
is my own view, but, on the other hand, a minority of brilliant,
tenacious workers hold that he is in evidence everywhere,
and therefore what, in the view of the majority, applies to a
very few is made by the minority to apply to the many, a fact
which, if it were true, and could be substantiated, would make
the costly task of regeneration and reformation a hopeless
one, and would mean for the criminal himself elimination, and
perpetual sequestration. It is alleged by them that more fre¬
quent abnormal conformation and asymmetry of the head
estimated by irregularities, and by the cephalic and facial
indices, by the weight and size of the lower jaw, prominent
cheek bones, prominent and large, outstanding ears (for which
the nurse is much to blame in many instances), palate, genital
organs, the presence of the lemurian appendix, shortness of
stature, etc., are met with.

Physical stigmata of all kinds are also found among non¬
criminals in all grades of society, and it has yet to be proved
that in proportion these are more prevalent among habitual
criminals than among the population as a whole, and especially
among the classes from which criminals come. It is important
to remember that physical degeneration does not necessarily
entail mental degradation, and that criminality may exist
without demonstrable stigmata. And further, it must not
be forgotten that many people presenting several of the
stigmata of physical degeneration are to be found among the
honest, industrious, ethical, and religious members of society.
The contention that a skilled criminal anthropologist can spot
an “ instinctive ” after short observation was put to the test
before the savants in a convict prison in Paris, during the year
of the International Prison Congress there, and in one instance
created much merriment, as well as showing the absurdity of it
all. A mental specialist of great eminence, and a citoyen of
irreproachable character donned the prison garb and fell in line
with the convicts under review in the Mazas prison. He was
asked to step back two paces as one of the “ instinctives ” ?
The tests proved correct in some of the cases. But this case,
as well as other considerations, show, apart from the umbra it

Digitized by CjOOQle

RECIDIVISM,

580

[July,

casts over the regenerative problem engaging the attention of
penologists, legislators, and social reformers, the need for a more
chastened mood on the part of “ cock-sure ” criminal anthropolo¬
gists than has hitherto been manifested. The remedy for
recidivism is assuredly not here.

Criminal Anthropometry .

Its application to criminality is intelligible in two aspects,
as a means of identification and of revealing accurately the
degree of physical degeneration to be met with among recidivists,
just as the psycho-meter of the specialist, to which frequent
allusion has been made in these pages, will, when called into
requisition as it ought to be, reveal psychical defects, moral
insensibility, perversity, and obsessions, with the accessory
moral anomalies, imprudence and lack of forethought, defective
intelligence congenital or supervening before adolescence.
The results of an anthropometrical investigation made in the
case of 370 male convicts and long-term prisoners this year is
submitted along with cartes graphiques ( 6 ). These are conclusive
as to the physical degeneracy which stature reveals when com¬
pared with the general population. On the other hand, is it so far
astray from the mean of those in their own station of life and
engaging in the same kind of work when at liberty ? As yet
this has not been determined even approximately.

The following tables, prepared by Mr. J. F. Tocher from the
data supplied, give the results of the analysis of 370 criminals,
75 P er cent ' °f whom were recidivists :

Table I .—Stature [inches').

Mean.

Standard deviation.

P.E.

No. 1 .

6464

. -II 2 I 2-3683

• ’0795

»»

6498

. -1822 26745

•12S9

>» 3

65-29

. 2038 2-2816

•1441

» 4

<55* 5

. 4186 2-5568

• ‘295s

„ 5 •

64-84

. -0860 24703

•0610

BY J. F. SUTHERLAND, M.D.

581

1907.]

Table 11. —Head Length {mm.).

Mean.

Standard deviation.

P.E.

No. 1

• I 95 ' 3 2

•302

6-3650

*21 14

»» *■'

. 197-16

• ‘419

60565

•2918

n 3

. 198-42

•631

7-0576

•4457

„ 4

• 1 05*3 3

•700

4'oi73

•4648

,, 5

. 19627

*226

64356 .

•1590

Table

III.— Head Breadth (mm.).

Mean.

Standard deviation.

P.E.

No. 1

. 152-90

•223

46988

•1577

» "

• 15393

•289

42358

*2041

>» 3

• 1 5 3*5 1

•432

4-8296

•3050

n 4

. 15206

1064

6-4967

•7516

• 15351

• '! 59

4-5647

*1 127

No. i, burglary, robbery,

and assault; No. 2, theft, fraud, reset,

etc. ; No. 3

murder and assaults; No. 4, offences against chastity; No. 5, total number of
habitual criminals.

P.E. means “ probable error”; mm. millimetres.

Stature .—There is no material difference in stature among
the four classes into which the criminals have been divided.
The greatest difference (‘64 in.) exists between Nos. 1 and 3,
but this has no special significance. The average stature of
the criminals as a whole (64*84 in.) is, however, significantly
less than that of the lunacy population of Scotland, and is less
by about 75 in. than the mean stature of English criminals.
(Macdonell, Biometrika , vol. i, p. 192.) When compared with
the general population the difference is much greater than one
would expect from random sampling, and one concludes, there¬
fore, that in stature the criminals form a special class of the
population, although among themselves the differences in stature
are merely random differences.

Head - length .—The analysis of the data for head-length
shows that there is a considerable difference in this character
between Class 3 (convicted of murder and assault) and the other
classes. On comparing the difference between the mean of
Classes 1 and 3 with its probable error, it is found to be much

582

RECIDIVISM,

[July,

greater than one would expect if it was due merely to sampling
(the difference is more than four times its probable error), and
one concludes that on the average the head-length of this class
of 57 members is greater than Class i with 202 members.
Class 1 (forming as it does the bulk of the criminal population)
has a mean head less than that of the criminal population as a
whole, while Class 2 (thieves) with a head-length of 197*16
mm. approaches Class 3 and differs from Class I by more than
three times the probable error of the difference. One concludes
that Classes 2 and 3 resemble one another in head-length and

'd'tatcire <j Cnmnvalb . (i* , rdkts)

ftrlypn Obartralt 07 >+

* —_ TAewy [formal diftritrtUian)

differ markedly from the other two classes (1 and 4). On an
average Classes 2 and 3 have longer heads than the bulk of
the lunacy population, or of the general population of the
country.

Head-breadth .—Just as in stature, there is no striking or
material difference in head-breadth among the four classes.
The differences are such as we might reasonably expect from
random sampling of the criminal population. The Scottish
criminal has, however, a broader head than the English criminal.
The mean head-breath of the latter is 150*3 mm. (Macdonell,
Biometrika, vol. i, p. 185) while that of the former is 1 53*5 mm.

Digitized by v^ooQle

1907.] BY J. F. SUTHERLAND, M.D. 583

(1) Conclusions. Judging from the data supplied (measure¬
ments of about 370 habitual criminals), the Scottish criminal is
a much shorter man on the average than the general population.
There is, however, very little difference in stature among the
various classes of criminals.

(2) Those habitual criminals who have been convicted of
murder and assault, and, in a lesser degree, those convicted of
theft, differ considerably in head-length from those convicted
of robbery and other crimes. They have, on an average, longer
heads.

(3) Criminals in Scotland have broader heads than English
criminals. They differ considerably in head-breadth from the
general population, but among themselves there is no material
difference when class is compared with class.

From invaluable data ( 6 ) provided by J. F. Tocher regarding
the insane in Scotland it would appear that while the criminal’s
head is on the average longer and broader than the inmates of
Scottish asylums, he is, as stated, somewhat shorter in stature.
It is impossible, for lack of data, to compare either as to stature,
head-lengths and breadths, the cephalic index, pigmentation,
etc., with the general population, but it can be done with
selected classes of the population thus :

Stature

(inches).

Head-length

(mm.).

Breadth

(mm.).

,0 °r

Cambridge graduates

68-86

193*5

iS 4 '°

796

British Association members

67'16

1981

155*5

782

Aberdeenshire rural .

6772

—

General hospital

6716

149*3

785

Scottish lunatic population

6586

195*5

151*5

776

English criminals

65*54

191*7

1504

772

Scottish „ ...

6484

1963

i 53 *i

780

The criminal from this comparison is from three to four
inches shorter in stature than the selected classes. From the
anthropometral survey made by the writer ( 7 ), among the fringes
of the Scottish population in the Hebrides—Orkney, Caith¬
ness and Shetland (including the islands of Foula, Fair Isle,
Unst, Whalsay and Stroma)—there can be no doubt, speaking
from general observation, that the completed analysis of the
returns will show that both the insane and the criminal are
much shorter than those people residing along the northern and
Li 11 . 40

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584

RECIDIVISM

[Ju'y.

western littoral and in those remote islands in which the
callipers and stature meter has not hitherto been applied.
These islanders of Norse extraction will also reveal a stature
as high as Ayrshire, the Stewartry ( s ), and the West-ends of
our cities, and much higher than the average for Scotland.

Criminal Physiognomy .

Whatever is claimed for the existence of mental and physical
shortcomings among a large number of recidivists—and there is
much—the existence of a criminal physiognomy cannot be
gainsaid. There is no name for that elusive yet unmistakable
physiognomy which recidivists present to the observer. It is
as real as the facial types met with in asylums. Coarseness,
scars, expression, and look tell their own tale. They are the
hall-marks of alcoholism, debauchery, ruffianism, dishonesty,
lying, and unchastity, each criminal and delinquent, according
to the vocation he has chosen and followed, presenting appear¬
ances which do not make it a matter of great difficulty to
determine fairly correctly into which class he is to be relegated.
This physiognomy being the result, and by no means an in¬
dication of the causation, of the life and conduct producing
recidivism, its bearing on the subject under consideration is
somewhat remote, and need not be pursued further.

A few typical cases of many illustrative of the insane, de¬
generate, and weak-minded prisoner are submitted in brief, but
before citing them it is proper to touch here, however lightly,
on the question of heredity which arises in this connection.

Heredity .

There is no gainsaying the fact that, in spite of the fluctuating
statistics of different asylums on the point, heredity is still the
most potent causal factor in the production of insanity. The
percentage set down to this cause varies little when compared
with that set down to alcohol and syphilis, which, in a short
space of time, varies so immensely in the returns of the same
institution as at once to suggest that it all depends on the
point-de-vue, and if there is a sudden and striking accession, say,
to the number of general paralytics, there is very likely an equal
diminution in the types of insanity which simulate general

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1907.] BY J. F. SUTHERLAND, M.D. 585

paralysis. It is certain that a union of two persons, one or
both of whom are neurotic, will eventuate in an insane or
neurotic offspring, and that certain forms, some more than
others, of insanity, in one or both parents, from which they
have recovered, are very apt to recur in their offspring, or, if not,
a neurosis of some kind may be looked for. How does this
reasoning apply to the great bulk of professional criminals?

In no way. Criminality of the most noxious kind, as a rule
carried on by persons in no sense mentally unstable, feeble¬
minded, or obsessed, is neither a latent nor an acquired nervous
lesion, and as such it cannot be reproduced by one or both
parents addicted to criminal ways. The female, idle and
debauched, as often as not, is the willing tool of the bold,
scheming male. It is the case that a succession to criminal * •
ways, which has been ascribed to heredity, will be found with
more reason to be traceable to environment in its many con¬
taminating and debasing aspects. It is the climax of absurdity
to suppose that such criminals breed their kind, as dwarfs and
giants physically breed their kind, or mentally as neurotics,
epileptics, deaf-mutes, and persons suffering from certain types
of insanity breed theirs. The professional criminal does not
transmit acquired criminal traits. On this head it is well to hear
what two so eminent authorities as Dr. George Savage and Dr.
Mott have to say :

The former, in the Lumleian lectures, 1907, says : “ I accept
it as a fact that no mutilation of, or late acquisition by a parent
will be passed on to children, but I must insist upon it that
this is a very potent passing of some tendency to neurosis.”
This is the furthest advance made, and accepted by observers
as a fair statement of the case.

Dr. Mott significantly asks : “ Can a stock which is sound
mentally become unsound by its members being subjected to an
unfavourable environment ? Many people deny the possibility
of mutation in the germ-plasm, but as the nervous system is
the latest and most complex and differentiated tissue in
structure and function mutations and variations may occur in
consequence of favourable or unfavourable environment. The
commingling of the germ-cells of two stocks of suitable or
unsuitable temperaments may, by a happy or unfortunate chance,
produce sporadic genius or sporadic insanity.”

The part which heredity is supposed to play in the mani-

586

RECIDIVISM,

[July,

f’estation of criminal tendencies has, by some writers, been
overstated. The heredity of psychical characteristics of one or
both parents, modified by union in relation to genius, mediocrity,
dulness, certain forms of insanity, epilepsy, deaf-mutism, like
the heredity of physical characteristics as to size, colour, feature,
etc., is admitted by the best investigators, but the heredity of
acquired is not, and is otherwise satisfactorily explained. Because
among thousands of genuine criminal recidivists an investigation
of criminal records brings to light a few such with three or four
generations traced, it would be rash to conclude that heredity
in crime is proved. In many families yielding two or three
felons, criminality, for several reasons of a kind adverse to the
criminal and his progeny, and in spite of unfavourable surround¬
ings, ceases to appear.

Criminal genealogical trees, as rare as the Baobabs of West
Africa or the gigantic pines of California, presented in graphic
style by criminological believers in heredity, with broods of
three or four generations in the branches, serve a purpose, but
these do not prove that burglars breed burglars, as wolves do
wolves.

Whatever value there might be in the heredity contention is
obscured and swamped by the environmental factor embracing,
as it does, example, education, ethical and manual training, and
healthy associations, etc. The absence of these sufficiently
explain the rare cases of criminal continuity in criminological
collections. Where, however, the heredity of mental warp and
instability may be looked for and found is in the case of the
congenitally weak or the psycho-pathological specimens met
with about the time of puberty or later, who drift through life
without a settled purpose, without the slightest regard for the
dignity of honest labour, with a striking lack of moral sense
and self-control, and with a great lack of proportion in their
mental outlook. Not a few specimens of such are to be found
among petty thieves, vagrants, prostitutes, and sexual perverts.
But among those where the argument in favour of hereditary
transmission looks most formidable it is sensibly influenced by
the environmental factor.

No one who has had experience of the criminal and the
petty delinquent classes doubts that a considerable number of
the units are weak-minded, and mentally and morally defective,
and obsessed in various directions. A closer scrutiny and

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1907.]

BY J. F. SUTHERLAND, M.D.

587

investigation of them, of their upbringing and habits—and
this requires time, patience, and a special training to discover
the weak points in their moral and psychical armour—at once
reveals the truth of this. The writer, from his own experience,
could give numberless illustrations of individuals whom he either
had not seen, or whose names he did not, at the moment, recollect,
but on glancing over the brief laconic story of crimes, convictions,
and punishments recorded on their police and prison dossiers the
conviction is forced home that mental warp, if not actual and
active insanity, was sufficient to account for their occasional or
frequent breaches of the moral and criminal laws. The criminal
authorities are reluctant to admit special pleas in excuse for, or
in extenuation of crimes. That, for some reason or other, their
training it may be, is not usually their line, and to them a
string of convictions conveys only one meaning, badness and
incorrigibility. They are not altogether to be blamed. They
do not have the necessary training or insight. For such work a
few months with Legrand du Saulle in his bureau at the Paris
correctiohelle and his successors everywhere might change their
views, as a rule very pronounced. This great medical jurist, after
many years’ service at the police depdt of Paris, declared that with
a large proportion of the cases the magistrate had less to do than
the physician, that, in short, their presence at the police office, the
filter of first instance, the prison being the second, was due to
causes with which the mere interpreter of police laws had no
real concern. Into the cabinet of the medical expert there
streamed, night after night, every type of physical and moral
departure, the dipsomaniac, the imbecile, the epicure voluptuary,
the “ tete monte,” the “ vipere a la tete plat,” the youth of the
“beau monde ” to whom nature had denied power of self-con¬
trol, the attractive and refined female with hysterical hallucina¬
tions, etc. Many are put provisionally en observation , and the
honour of a family, as well as of the individual, is preserved,
the mental malady manifesting itself a few weeks afterwards in
the asylum to which the quasi-offender was consigned. Many
are sent right away to private or public asylums, without pass¬
ing the portals of the gaol at all. From what I saw there many
years ago I am satisfied that similar procedure is required for
this country.

It is for the public and administrative bodies and individuals
directly concerned with social order and good government to

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588

RECIDIVISM

[July.

evolve a penal organisation which, without confounding the gaol
with the hospital, can avail itself of the moral clinique as well
as the police coercion required, and thus gradually eliminate
from communities those elements which are unfit for its evolu¬
tion and dangerous to society.

It may be appropriate to cite here a few cases from among
many known to the writer in support of the contention that
the misdeeds which to a trained mind conveys the idea of weak-
mindedness, imbecility, moral insanity, epilepsy, paranoia,
pyromania, dipsomania, general paralysis, obsessions, requiring
pedal treatment, to the guardians of public order, simply
means incorrigibility requiring penal treatment and seclusion.

(1) A. B—, aet. 46.—Record sheet bears that he has had many
charges against him for petty theft and drunken and disorderly
conduct, which he makes no effort to disprove. He wears an
air of nonchalance, is unconcerned and uncomplaining, is rather
well-pleased with himself, and is communicative ; occasionally
contradicts himself; pupils unequal and speech affected. The
articles stolen, and found in his possession, consist of knives,
forks, spoons, not worth many pence in value. The maximum
sentence is repeatedly inflicted and accepted without protest,
unless it be that in the pillory contrast columns of a society
journal contrasting the more lenient attitude of the Criminal Law
towards those who injure property compared with those who
injure the person. The bare record sets one athinking. The
uncomplaining man is examined and found to be suffering from
the first stage of general paralysis, and is at once relegated to
an asylum.

(2) R. F—, £et. 30, has had several convictions with the
maximum penalty of sixty days’ imprisonment for assaults,
restricted as to time (after dusk) and places (common stairs
and public parks). On examination, it is found that he has the
delusion that by Divine authority he has been entrusted with
the duty of putting down immorality and unchastity committed
in these two situations. He also goes to the asylum.

(3) F. G—, senile libidinist and exhibitionist, with enlarged
prostate and bladder difficulties. He is proclaimed a sexual
pervert, and not a criminal.

(4) S. G—, female, aet. 21, betrayed and deserted by her

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KY J. F. SUTHERLAND, M.D.

589

1907.]

paramour (is seven months* enceinlS), steals baby-linen and
bedding, and is sent to gaol for theft. Examination reveals a
state of hysteria and an irresistible desire created by the preg¬
nant state similar to the instincts of birds and animals to pro¬
vide for their offspring. The moral sense for the time being is
affected.

(5) W. Y—, act. 20.—Puny in size, insignificant in appearance,
and presenting the stigmata of degeneration, became a constant
frequenter of the theatre, and, from a prominent place, gives
unstinted applause and throws bouquets at his favourite until
he is removed and placed under arrest. This proved to be a
case of dementia prcecox.

(6) R. T—, a vagrant who begs his way, and who time and
again receives the full penalty for sleeping out, forsooth, beside
a brick-kiln. Verily, the birds of the air have their nests, and
the beasts of the field their lairs, but this man, and many like
him, have no place whereon to lay his head, except an out¬
house, the guard-bed of a police office or prison cell, or the hot-
water pipe on the floor of a night shelter. ( 9 )

(7) S. T—, male inebriate, aet. 37. Was two years in Perth
State Reformatory, and after a few weeks* freedom began his
career of drunkenness and brawling in a provincial town, which
made him a menace to his family and the police. The cost to
the community of his conduct, apart from the nuisance, he failed
to see, and began to point out the defects of the reformatory in
question, especially the smallness of it, seeing there were thou¬
sands of inebriates in Glasgow and Dundee requiring such treat¬
ment. There was an inability to see the enormity of his own
conduct for years in his desire that others might be benefited
by internment.

(8) R. F—, aet. 18, gently reared and educated at the best
secondary school, sets fire to a dormitory in order to ascertain
how his fellow pupils feel being roasted. In other respects his
conduct was shown to be precocious and impulsive. Being a
case of impulsive insanity associated with early adolescence he
very properly was sent to asylum for a time.

(’) Introduction to the Judicial Statistics for England, 1893.— ( 2 ) British
Association, Economic Section, Transactions , 1902.—( a ) British Medical Associa¬
tion, Psychological Section, 1898.—(■*) England 20,760, Scotland 2880, Ireland

Digitize

5 QO GENERAL PARALYSIS AND TABES DORSALIS, [July,

2550.—(*) In this connection the assistance of Dr. Sinclair, Medical Officer, H.M.
Prison, Barlinnie, and Dr. McWalter, Medical Officer to H.M. Convict Prison,
Peterhead, is recognised with thanks.—( B ) “ Anthropometry of Scottish Insane,”
Biornetrika, vol. v, part 3, February, 1907.—(') Aided by the Carnegie Research
Fund.—( M ) The shires of Kirkcudbright and Wigton.—( 9 ) Within living memory
in Glasgow these weary wayfarers in the night shelters, there being no shake-
downs, laid their chests across a taut rope which the keeper in the morning cut
in order to wake them all up, as the gong does the guests at a hotel.

Further Bacteriological and Experimental Investigations
into the Pathology of General Paralysis and Tabes
Dorsalis . By YV. Ford Robertson, M.D., and
Douglas McRae, M.B., C.M., M.R.C.P.Edin.

In previous papers (i) we have recorded observations on the
ground of which we have contended that a diphtheroid bacillus,
having cultural and morphological characters resembling
those of the Klebs-Loffler bacillus, plays the chief part in the
production of the toxaemia of general paralysis. We have at
the same time insisted upon the importance of weakening of
the local and general defences against bacteria, and have attri¬
buted the chief part in the production of this impairment to
syphilis, chronic alcoholic intoxication and the excessive use
of nitrogenous foods. A little more than a year ago we thus
summarised the case in support of the diphtheroid hypothesis:

The evidence that a diphtheroid bacillus—either an attenu¬
ated form of the Klebs-Loffler bacillus or more probably an
altogether distinct micro-organism—is the specific etiological
factor in general paralysis and tabes dorsalis is briefly as
follows : A bacillus of this nature is, according to the results of
our investigations, present in large numbers, either in the ali¬
mentary or respiratory tract, or in both, and in the genito¬
urinary tract, in all cases of advancing general paralysis. This
bacillus has a thread form, which has been found invading the
walls of the respiratory or alimentary tract in five cases of *
general paralysis. It can be shown that this bacillus invade^.- r
the pulmonary tissues in cases of general paralysis, and that it \
is commonly the only micro-organism present in large numbers
in the catarrhal pneumonic foci that occur in most of such
cases dying in congestive attacks. A growth of a diphtheroid ' <.
bacillus has now been obtained in cultures made from the brain

Digitized by v^ooQle

59 i

1907 .] BY FORD RORERTSON AND DOUGLAS MCRAE.

post-mortem in ten cases of general paralysis out of twenty-four
in which cultures were made from this organ. Diphtheroid
bacilli exhibiting metachromatic granules in Neisser prepara¬
tions have been detected in the fresh blood in one case and in
sections of the brain in two cases. It has been ascertained by
experimental methods that these diphtheroid bacilli in contact
with the living blood are rapidly taken up by the polymorpho¬
nuclear leucocytes, and that they may be completely digested
in the course of two or three hours. Bodies exactly corre¬
sponding in appearance to these dissolving bacilli can be
detected in the blood and cerebro-spinal fluid of the living
general paralytic, especially during a congestive attack. Whilst
the fact that most of the bacilli present are in process of disin¬
tegration satisfactorily explains the long succession of negative
results of endeavours to obtain cultures from the blood and
cerebro-spinal fluid, we have, by the use of special methods,
succeeded in obtaining pure growths of a diphtheroid bacillus
from the fresh blood in four cases of general paralysis, and from
the cerebro-spinal fluid withdrawn by lumbar puncture in two
cases. In sections of the brain prepared by special methods
disintegrating diphtheroid bacilli can be recognised in the walls
of the vessels and in the pia-arachnoid in many cases of general
paralysis. The centrifuge deposit from the urine of the general
paralytic, especially during a congestive seizure, commonly
contains abundant diphtheroid bacilli that have been more or
less affected by lysogenic action. In seven consecutive cases of
general paralysis combined with tabes we have found the
centrifuge deposit from the urine to contain, not only these
altered diphtheroid bacilli, but also living ones, showing dis¬
tinct metachromatic granules. In such cases a culture of the
bacillus can be obtained from the urine. Experimental infection
of three rats and a goat with diphtheroid bacilli, isolated from a
case of general paralysis, has resulted in the production of
symptoms and tissue changes resembling those of general
paralysis. Lastly, there is evidence that the active poly¬
morphonuclear leucocytes of the general paralytic have, as a
rule, a greater power of dissolving these diphtheroid bacilli
than that possessed by the normal leucocyte. It would there-
forq appear that the general paralytic has acquired against
these diphtheroid bacilli a certain degree of specific immunity,
by means of which he is enabled to maintain the struggle

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592 GENERAL PARALYSIS AND TABES DORSALIS, [July,

against these bacilli, notwithstanding an otherwise defective
local and general power of resistance.

These views have been opposed in this country by Eyre and
Flashmann (2), Mott (3), Perrier (4), Bulloch (4), Hamilton Marr,
and several of the medical journals. On the other hand, there
have not been wanting those who have recognised that the various
points of evidence we have brought forward are entitled to con¬
sideration, and some have accepted the conclusions that we
have drawn from them. As regards general paralysis, many
of our observations have been confirmed by those of O’Brien
(5) and Langdon (6) in America. O’Brien’s work has been
extensive, and in respect of his experimental observations he
has gone ahead of us. He has isolated an organism resembling
the Klebs-Ldffler bacillus from 95 per cent . of cases of general
paralysis. He has found that lower animals inoculated with
the bacillus have passed through attacks similar to congestive
seizures, hemiplegia, and objectively typical paresis. Post¬
mortem examination revealed conditions similar to those seen
in an early case of general paralysis. He produced a bactericidal
serum in the goat, and found that it had a protective action
upon dogs infected with the bacillus. More recently he has
treated cases with vaccines consisting of the killed cultures,
using the opsonic index as a guide, and has had a considerable
measure of success.

The further observations that we have now to record concern
chiefly the broth reactions and virulence of a series of diphtheroid
bacilli obtained from various sources , the experimental production of
general paralysis in rats , the experimental and clinical study of intra -
corpuscular bacteriolytic indices in relation to certain species of these
diphtheroid bacilli , and also some special phenomena that bear upon
the views maintained.

In 1903, when we first advanced the diphtheroid hypothesis
of the etiology of general paralysis, we provisionally regarded
the organism as an attenuated form of the Klebs-Loffler bacillus,
in accordance with the authoritative teaching of the time, that
an organism differing from the diphtheria bacillus solely in its
want of virulence must be regarded merely as a diphtheria
bacillus in an attenuated condition, and should be spoken of
as such. In taking up this position we left it an open question
whether the bacillus might not be a special one, differing from
the bacillus of acute diphtheria in certain respects afterwards

Digitized by v^ooQle

1907.] BY FORD ROBERTSON AND DOUGLAS MCRAE. 593

to be determined. A year ago, though we could not absolutely
distinguish the cultural and morphological characters of the
organism from those of every other species of the diphtheroid
bacillus, we felt justified, in view of additional evidence we had
collected, in maintaining that the organism is a special one, and
we proposed to refer to it as the Bacillus paralyticans. It was
suggested to us by Dr. M. H. Gordon that we might be helped
in the differentiation of this organism from other diphtheroid
bacilli by applying litmus broth tests to all of the organisms of
this nature that we isolated from time to time in the course
of our investigations. We would take this opportunity of
acknowledging our great indebtedness to Dr. Gordon for
suggesting the application of these tests, and also for other
valuable advice regarding our special bacteriological investi¬
gations. We have applied Dr. Gordon’s method and have
used as test-substances glucose, saccharose, lactose, salicin,
starch and dextrin. The following table shows the reactions
previously ascertained to be given by various of the already
known members of the diphtheroid group to the first five of
these substances. The results are those obtained by Dr.
Gordon, supplemented by some ascertained by Benham
(7). The reaction of each organism to Neisser’s method is
added.

Bacillus.

Glucose.

Saccha-

Starch.

Salicin.

Lactose.

]

Reaction |
to Neisser’s 1

method.

Klebs-Loffler .

Positive.

Hoffmann’s b .

—

Negative.

Xerosis b

—

Negative.

Diphtheroid x

—

1 +

Diphtheroid y

+ 1

—

Bacterium muris

■ Positive.

(Klein)

B. coryzce segmento-

+ or —

| + or —

+ or —

Negative.

The sign + indicates that a distinct acid reaction is produced by the organism
after incubation at 37 0 C. for three days.

The results obtained by Knapp (8) and Graham-Smith
(9) with the media of Hiss, differ as regards the above test-
substances only in certain points that are hardly material for
our present purpose. It is, however, to be noted that both

594 GENERAL PARALYSIS AND TABES DORSALIS, [July,

state that an acid reaction is produced in dextrin broth within
seven days by the Klebs-Loffler bacillus.

It has not been possible for us to make any very extensive
investigation into the broth reactions of the diphtheroid bacilli
that can be isolated from general paralytics and tabetics. We
have simply tested with what appeared to be the most im¬
portant substances the various diphtheroid bacilli that we have
happened to obtain in pure culture in the course of our recent
work. The following table shows our results up to the present
date. All of the strains gave a positive reaction with Neissers
method, but in the case of Nos. 9, 10, and 12 the meta-
chromatic granules were minute, and occurred in only a
comparatively small number of the bacilli.

Table showing the Litmus Broth Reactions of Diphtheroid Bacilli
isolated from Cases of General Paralysis and Tabes Dorsalis .

* V

1 B -

1 .

’ c

No.

Patient.

Disease.

Source of bacillus.

' 0

J 5

, •-»

c /3

G. P.

Cerebro-spinal fluid

G. P. and tabes.

Urine

4 -

—

4 -

—

Bronchial gland

4 -

—

G. P.

4 -

—

G. P. and tabes.

Urine

—

9 9

—

— 1

—

— 1

—

1 — [

—

4 -

—

G. P.

Conjunctiva

—

— 1

—

Peritoneum

4 - 1

—

1 +

—

Tabes

Urine

4 -

—

4 *

—

G. P. and tabes

4- !

—

— 1

—

4 - j

—

G. P.

Cerebro-spinal fluid

+ 1

4- |

—

— 1

—

- Loftier bacil

Urine

+ I

—

Klcbs

lus (virulent)

+ j

—

(from

a case of diph

theria)

In this series, among the strains of bacilli having very
prominent metachromatic granules, it seems to be possible to
recognise two special types, one having the broth reactions of
the Klebs-Loffler bacillus, causing an acid reaction in glucose
broth only, and the other differing from this in producing acid

Digitized by v^.ooQle

I907 ] BY FORD ROBERTSON AND DOUGLAS MCRAE.

595

also in saccharose broth. Two strains, in other respects
similar to the latter, were found to produce acid also in lactose
broth. It seemed to us at one time that the negative reaction
of the first type to dextrin might serve to distinguish it from
the Klebs-Loffler bacillus, but we have been unable with the
dextrin broths we have used to obtain an acid reaction with
the Klebs-Loffler bacillus even after seven days. The reactions
given by the bacillus of the second type do not seem to
correspond exactly to those of any diphtheroid bacillus hitherto
described. The clear differentiation of these two types has
been the main result of the application of these tests.

The virulence of six of these strains (Nos. 1, 4, 13, 16, 18
and 19) has been tested upon guinea-pigs. Hypodermic injec¬
tions of 100 mgrm. of agar cultures have produced no apparent
effects. With bacillus No. 1, the results of hypodermic injection
into mice of doses of from 20 to 60 mgrm. have been inconstant.
Some of the mice, after showing a few morbid symptoms,
remained well. One which received an injection of 40 mgrm.,
and after twenty-three days another injection of 30 mgrm.,
died three days later. Another mouse injected subcutaneously
with 40 mgrm. of the killed culture (heated to 128° C. for half
an hour) died six weeks afterwards. Another mouse injected
with 2*5 cc. of immune sheep’s serum taken from a tube con¬
taining 5 cc. of this serum which had been incubated at 37 0 C.
along with 40 mgrm. of the bacilli for forty-eight hours, became
acutely ill ten minutes after the injection and died within forty-
eight hours. Bacillus No. 4, which, as will presently be
described, has caused acute and chronic disease in rats when
given in the food, has not proved very virulent to mice when
injected subcutaneously. Four successive injections, at inter¬
vals of from nine to fourteen days, resulted in the death of one
mouse about four weeks after the last injection. Single in¬
jections of the usual dose of cultures of bacilli Nos. 8 and 13
had no distinct effect upon mice. Single injections of 40 mm.
of cultures of bacillus No. 18 proved fatal to each of two mice
on the fifteenth day.

The Experimental Production of General Paralysis in Rats.

In previous papers we have described the results of experi¬
ments, carried out by Dr. Shennan and one of us, in which rats

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596 GENERAL PARALYSIS AND TABES DORSALIS, [July,

were fed for several weeks with cultures of a threading
diphtheroid bacillus isolated from the bronchus of a general
paralytic. It is certain that the organism belonged to the first
of the two types that we have reason to believe to be of impor¬
tance in general paralysis. We have recently made a more
complete examination of the tissues of the animals that were
the subjects of this experiment, and find that the lesions
presented by them resemble those that occur in certain cases
of general paralysis even more closely than we have hitherto
claimed. All of four animals in which the experiment was
fully carried out died after manifesting paretic symptoms, and
their cerebral tissues show periarteritis, neuroglia proliferation
and severe nerve-cell lesions. Three out of the four show
extensive invasion by the thread form of the bacillus identical
with that which occurred in the patient from whom the bacillus
was isolated, and with that which has been found in several
cases of general paralysis and in the bladder-wall in one case
of tabes.

Last autumn we commenced another series of similar
experiments with rats. Sixty animals in all have been fed with
cultures of various strains of diphtheroid bacilli derived from
cases of general paralysis or of tabes dorsalis. These cultures
were simply added from time to time to food similar to that
upon which control animals were fed. The strains selected
were Nos. i, 4, 8, 13, and 16 in the foregoing list. Very small
doses were given during the first three or four weeks, the object
being to immunise the animals if possible, and to ascertain the
nature of any morbid changes that might occur as the defences
of the animals gradually broke down before the persistent
attack of the bacilli. This plan was adopted because in the
previous series of experiments the rats succumbed far too
quickly to permit of advanced chronic changes being established.
A certain number of the animals have already died, but the
experiments are not yet completed, and we shall therefore here
deal only very briefly with some of the results so far obtained.

The first experiment has consisted in the feeding of twelve
animals with cultures of a diphtheroid bacillus isolated from
the cerebro-spinal fluid of a case of general paralysis post
mortem. It was originally a threading bacillus, and it was the
only organism that developed in the media. It produces acid
in glucose broth only. It is undoubtedly a bacillus identical

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■Ll_ > _BJl Ml I il HU

I907.] BY FORD ROBERTSON AND DOUGLAS MCRAE.

597

with the one used in the previous set of experiments upon rats.
As yet only three of the animals have died. They did not
exhibit very evident paretic symptoms. All of them were
found to have advanced tuberculosis affecting the lungs. The
cerebral changes are of too slight a nature to be regarded as
of any importance. Some of the remaining rats are now
showing signs of paresis. It is evident that this organism is
one of much less virulence to rats than the bacillus used in the
experiments carried out in 1903.

In the second experiment twelve rats have been fed with a
bacillus isolated from the urine of a case of tabo-paralysis. The
organism has prominent metachromatic granules, but has never
shown any tendency to form threads. It produces acid rapidly
and abundantly in glucose broth, somewhat less rapidly
in saccharose broth. This bacillus has proved much more
virulent than the preceding one. After about seven weeks
one of the animals was seen to be acutely ill. It was
slow in its gait, feeble, and extremely irritable. Next day it
was paralysed in all its limbs. It lay for several hours quite
motionless, excepting for the respiratory movements, which
gradually became reduced in number, until they occurred only
four times per minute. The animal died within thirty hours of
the first appearance of acute symptoms. Tubes inoculated from
the heart’s blood and spinal cord remained sterile. The chief
morbid change revealed by microscopical examination is acute
degeneration of most of the nerve cells of the spinal cord.
The nerve cells of the brain present similar changes, but they
are much less severe. A few days after the death of this
animal two other rats began to show similar but less marked
symptoms. After four or five days the acute symptoms passed
off, but the animals remained lethargic and feeble. Two months
later both of them were noted to be more feeble, very slow and
uncertain in their gait, and much emaciated; they were dull,
drowsy, and stupid. All of these symptoms gradually increased,
and the two animals died within about a fortnight of each other,
twenty-two and twenty-four weeks from the commencement of
the experiment. The remaining nine rats have never had any
acute illness, but all of them have gradually become thin,
enfeebled, lethargic, impaired in their power of co-ordination,
and stupid-looking. Five of them are now dead. The four
that remain are extremely feeble, irresponsive and demented-

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598 GENERAL PARALYSIS AND TABES DORSALIS, [July,

looking. All of the rats of this series that have succumbed to
a chronic illness showed similar changes affecting the nervous
system, differing only in degree in the individual cases. There
are extremely well-marked chronic degenerative changes in the
nerve cells of the spinal cord, less advanced changes of a
similar character in the nerve cells of the cerebral cortex. In
several of the cases the cerebral arterioles show distinct peri¬
arteritis, and the neuroglia also shows some proliferative changes.
Cultures were made from the blood and various internal organs
of most of these rats, but no growth of the bacillus with which
the animals had been continually fed could be obtained.

In the rats the subjects of the three other experiments the
morbid phenomena have been much less distinct, but paretic
symptoms are now developing in some of the animals in two of
the cages.

On the ground of these and other observations that we shall
allude to presently, we maintain that there are at least two
different species of diphtheroid bacilli that are capable of pro¬
ducing general paralysis and tabes dorsalis. The one is an
organism which, morphologically and in its broth reactions, in
so far as we have yet been able to ascertain them, resembles the
Klebs-Loffier bacillus, but is distinguished from it in frequently
being virulent to mice and rats, and in having a thread form,
which is assumed when it invades the partially immunised animal,
and under analogous conditions in vitro . It is the organism
for which we have already suggested the name Bacillus para-
lyticans . The other species of diphtheroid bacillus is one which
has a very similar relationship to the Xerosis bacillus , which
by some observers has been found to produce a small amount
of acid in glucose and saccharose broths. It differs from it,
however, in showing prominent metachromatic granules, in pro¬
ducing acid quickly and abundantly in glucose and saccharose
broths, and in frequently being virulent to mice and rats. This
organism has little or no tendency to form threads. It is thinner
and shorter than the other. We therefore propose to refer to the
first organism as the B. paralyticans longus, and to the second
as the B. paralyticans brevis. Just as it is known that individual
strains of the Klebs-Loffler bacillus vary considerably in their
microscopical and cultural characters and in their virulence, so
also individual strains of these two species that have proved
capable of causing paresis in rats present differences that

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1907.] by FORD ROBERTSON AND DOUGLAS MCRAE.

599

cannot be regarded as essential. Chief among these differences
is that of virulence. Corresponding to infection by one or other
of these two types of diphtheroid bacilli, there are, we maintain,
two different types of general paralysis, closely resembling each
other and yet essentially distinct. Cases of infection by both
organisms are probably common. We believe that in all cases
of advancing general paralysis and tabes dorsalis one or other
of these bacilli, or some other organism endowed with similar
pathogenic powers, is gaining access to the lymph-stream and to
the blood. It seems to us very probable that we have not yet
differentiated all of the species of diphtheroid bacilli that may
occur in such cases and exercise a pathogenic action of a similar
nature.

Intra-corpuscular Bacteriolytic Indices of Immunised Sheep and of
Persons suffering from General Paralysis and Tabes Dorsalis.

In a previous paper we have described a method of estimat¬
ing the bacteriolytic power of the polymorphonuclear leuco¬
cytes in relation to the Bacillus paralyticansj and have contended
that, as a rule, the index expressive of this power is abnormally
high in general paralytics. In the course of the immunisation
of four sheep with bacillus No. 1 in the foregoing list, we have
endeavoured to ascertain the effect of the process upon this
index. The following table shows the results :

Time after commencement of process of
immunisation.

Before

Six

Thirteen

Sheep.

immunisation.

weeks.

months.

No. 1

• 4‘3

—

» 2

—

>» 3

. 2-5

—

595

. 6

—

These results seem to us to justify the conclusions we have
already formed in regard to these indices in cases of general
paralysis, although in the human subject the matter is compli¬
cated by the circumstance that more than one species of
diphtheroid bacillus is capable of causing the disease. The
following table shows the observations that we have made
upon the human subject during the past year:

600 GENERAL PARALYSIS AND TABES DORSALIS, [Jllly,

No.

Nature of case.

Bacillus used.

Index.

'73

Control, healthy

Bacillus paralyticans longus

187

Dementia praecox

* 7*5

188

Control, healthy

189

190

> I 99

196

*»

General paralysis

I 2'5

170

' 7 '

172

I *74

9 9

'75

*»

78*5

1 '77

835

| 186

191

>» I

192

„ 1

„

197

Tabes dorsalis

{

brevis

1 198

General paralysis

{ ::

longus |

brevis >

425

1 199

i »

longus

”

1 ..

brevis |

200

longus ;

\ „

brevis j

7 '

Evidence of the Rapid Destruction of the Bacilli in the Blood .

Although we have succeeded in obtaining cultures of diph¬
theroid bacilli from the blood and from the cerebro-spinal
fluid of general paralytics during life, there can be no doubt
that in the vast majority of cases it is impossible by any
method yet known to obtain such cultures. We have main¬
tained that this difficulty is due, not necessarily to the absence
of the bacilli from these fluids, but to the fact that the organ¬
isms are quickly taken up by phagocytic cells, and devitalised
and dissolved. We have made some observations upon sheep
in process of immunisation to the Bacillus paralyticans longus,
the results of which are consistent with this explanation, as
well as with the failures to obtain growths from the blood of
general paralytics.

Two sheep, which had previously received seven injections of
bacilli in the course of about five weeks, were each injected
subcutaneously with 40 mgrm. of living bacilli, and two hours
afterwards several large platinum loopfuls of blood were
smeared upon agar surfaces. The tubes were allowed to
remain in the cold for two hours, and were then incubated. No

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I 907 -] BY FORD ROBERTSON AND DOUGLAS MCRAE. 6oi

diphtheroid bacilli appeared. In blood films made at the same
time as the inoculations of the tubes, diphtheroid bacilli could
be seen in considerable numbers, especially in the lymphocytes.

After the immunisation of these two sheep had been con¬
tinued for over six months, inoculations were again made from
the blood four hours after the subcutaneous injection of 80
mgrm. of bacilli into each. Two agar tubes and one broth
tube were used. All of the tubes from the first sheep remained
sterile. In the case of the second sheep a few colonies of the
bacilli appeared in one of the agar tubes, and there was also a
growth of the organism in the glucose broth.

Observations in a Case of Tabes .

We also wish to mention some special observations we have
made in a case of early tabes dorsalis, as they support in a
remarkable way some of the views that we have advanced.
The patient’s urine was found to be loaded with two micro¬
organisms, a diphtheroid bacillus of the type described as the
Bacillusparalyticans brevis and a diplococcus resembling the gono¬
coccus, but Gram-fast. For a time we treated the patient by
the vaccine method, injecting definite doses of killed cultures of
the bacillus isolated from his urine. On several occasions these
injections were succeeded, after a few hours, by a recurrence
of the patient’s lightning pains. It was quite clear that these
attacks were consequent upon the injections. Very consider¬
able improvement took place in the patient’s condition when
this treatment had been continued for some weeks. His attacks
of pain became much less frequent and less intense. Having,
with the same bacillus, immunised a sheep in such a way as to
produce a bactericidal serum, we treated the patient for several
weeks with this serum, given first hypodermically and subse¬
quently by the mouth. This treatment has resulted in further
improvement, but it has been found that if four or five days are
allowed to elapse without a dose of the serum there is still some
return of the pains. It is also of interest to note that in this
case the urine is now sterile. The patient has been taking
helmitol for about six months. In another case of tabes with
the same two organisms in the bladder, the continuous admini¬
stration of helmitol has been followed by the disappearance of
the diplococcus, but the bacillus is as abundant as ever. It,

602

GENERAL PARALYSIS AND TABES DORSALIS, [July,

therefore, seems probable that the eradication of the bacillus
from the bladder in the first case was due to the action of the
serum.

The Infective Foci in General Paralysis and Tabes Dorsalis.

In previous papers we have maintained that in all advancing
cases of general paralysis and tabes dorsalis there is some more
or less extensive infective focus in which the pathogenic bacilli
are invading the tissues. We have obtained histological evidence
of the presence of such foci in the alimentary tract and
bronchi of general paralytics, and in the bladder of tabetics.
In the course of the past year we have made some observations
upon the living subject which seem to us to confirm the
doctrine of the infective focus and also to throw some fresh
light upon the subject.

In association with the presence of abundant diphtheroid
bacilli in the female genital tract, we have, in tw r o cases, found
scrapings from inflamed cervix to show numerous diphtheroid
bacilli in the interstices of the tissues, proving that the bacilli
were invading. Similarly, in two cases of chronic conjuncti¬
vitis in general paralytics, scrapings from the conjunctiva
showed diphtheroid bacilli with prominent metachromatic
granules invading the tissues. In another case of advancing
general paralysis, a scaping from the nasal mucosa, taken from
about the middle of the septum, showed abundant similar
diphtheroid bacilli lying between the epithelial cells and among
the connective tissues. Further, we find that general paralytics
usually have more or less swollen and spongy gums, which
readily bleed. This morbid condition occurs especially in
proximity to the teeth. Between the tooth and such a swollen
gum there is almost constantly a distinct pocket in which
material collects, and this material, according to our observa¬
tions, is loaded with diphtheroid bacilli showung prominent
metachromatic granules. In fifteen cases of general paralysis
presenting this swollen and spongy condition of the gums, we
have made a microscopical examination of the spongy tissue
after scraping some of it away with a sharp spoon. In thirteen
of the cases diphtheroid bacilli have been recognised in the
tissue-spaces.

We have previously advanced evidence in support of the

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1907.] BY FORD ROBERTSON AND DOUGLAS MCRAE. 603

view that in tabes dorsalis the special infective focus is in most
cases in the bladder-walls, and we have pointed out how this
opinion harmonises with the results of the experimental work
of Orr and Rows. The more recent observations that we have
made in cases of tabes have served to confirm our view, which we
maintain to be correct notwithstanding the criticisms that have
been passed upon it. We would, however, extend the possible
area of the infective focus to the whole of the genito-urinary
tract and the lower portion of the alimentary canal. We now
feel justified in drawing a similar inference with regard to
general paralysis, and in stating that the infective focus in this
disease is chiefly located in the buccal and naso-pharyngeal
mucosae. We assert that the clinical phenomena of amimia,
affecting mainly the lower part of the face, dysarthria and
facial tremors are essentially dependent upon this local invasion
and consequent formation of toxines, which are in large part
carried to the cranial cavity by way of the cranial nerves.
This view is also in harmony with the more recent experi¬
mental observations of Orr and Rows (10), who have found
that, just as tabetic lesions can be produced by toxins passing
up the sheaths of the spinal nerves, so also certain of the
central lesions that occur in general paralysis can be produced
by toxins that are experimentally made to pass up the sheaths
of the cranial nerves. On the ground of their observations
they definitely apply the lymphogenous theory of infection to
general paralysis as to tabes.

There are one or two points that we should like to emphasise
in concluding this paper. The diphtheroid group is a very
much more extensive one than has generally been supposed,
and the bacillus of acute diphtheria is by no means the only
member of the group that is pathogenic to man. Within the
last two or three years the multiplicity of species in the
diphtheroid group has come to be recognised by various
workers, more especially by Gordon in this country, who has
directed attention to the fact that many of these organisms that
have commonly been regarded as non-virulent diphtheria
bacilli give an acid reaction with saccharose broth, and by
Hamilton and Horton (11) in America, who have isolated very
numerous species. We would endorse the opinion of Benham
that the further study of this group will probably lead to great
advances in our knowledge of the pathology of some obscure

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604 general paralysis and tabes DORSALIS, [July,

diseases. In this large group of organisms there are at least
two species which are capable of causing paresis in rats, and
which can be isolated especially from cases of general paralysis
and tabes dorsalis. In patients suffering from these diseases, as
well as in other persons, the mere presence of these organisms
upon a mucous surface is of little significance. It is necessary
to find evidence of invasion of the tissues by the bacilli. The
occurrence of such invasion can be demonstrated in cases of
general paralysis. There are good grounds for believing that
a bacillus so invading tends gradually to become raised in
virulence, especially towards the individual attacked. The
rational therapeutic aim in cases of general paralysis and of
tabes dorsalis ought to be to eradicate the infective focus.
Our own researches during the past year have been mainly
directed to this end, and we have used as our chief therapeutic
agents bactericidal sera corresponding to the two varieties of
diphtheroid bacilli we have found to be capable of producing
paresis in rats. The work has been beset with very many
difficulties, chief among which, we are now realizing, have
been those occasioned by loss of virulence on the part of the
organisms we have been using. Notwithstanding this, the
results of serum treatment have in many instances been very
encouraging. We hope to deal with this portion of our in¬
vestigation at the Annual Meeting of this Association in July.

References.

(1) Rev. of Neurol, and Psychiat., April, 1903; May, 1903; July,
1903; Brit. Med. Jotirn ., October 24th, 1903; Rev. of Neurol, and
Psychiat., May 1905 ; February, March, April, 1906.

(2) Eyre and Flashman, Brit. Med. Journ., October 28th, 1905 ;
Arch, of Neurol., vol. iii, 1907.

(3) Mott, Brit. Med. Journ., October 28th, 1905.

(4) Ferrier (and Bulloch), The Lumleian Lectures, 1906.

(5) O’Brien, see Brit. Med . Journ., September 29th, 1906.

(6) Langdon, American Journal of Insanity, October, 1906.

(7) Benham, Brit. Med. Journ., May 25th, 1906.

^8) Knapp, Journal of Medical Research, vol. xii, 1904.

(9) Graham-Smith, Journal of Hygiene, July, 1906.

(10) Orr and Rows, Brit. Med. Journ., April 27th, 1907.

(11) Hamilton and Horton, Journal of Infectious Diseases, March,
1906.

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1907 ] by FORD ROBERTSON AND DOUGLAS MCRAE. 605

Discussion

At the Quarterly Meeting in London, May 16th, 1907.

The President (Dr. Robert Jones) said this was a very important paper, and
that if Dr. Ford Robertson was able by his researches to modify in any way that
most awful scourge, general paralysis, he deserved to be looked upon as a bene¬
factor to mankind. The question seemed to be essentially one for the bacterio¬
logist. He had hoped that Dr. Mott would have been present at the meeting, but
he wrote saying he greatly regretted that he was unavoidably prevented. He (the
President), in the name of the Association, invited the visitors to take part in
the discussion. He himself helped Dr. Flashman, who was working at the Clay-
bury Pathological Laboratory, to get cultures from the throats of subjects of
various forms of insanity, and those were taken to Dr. Eyre for further investi¬
gation. Perhaps Dr. Eyre would describe the results of his investigations.

Dr. Eyre thanked the President for his kind invitation to him to hear the
extremely interesting paper of Dr. Ford Robertson. In the first place, he wished
it to be clearly understood that wherever his opinions differed from those of
Dr. Ford Robertson—*.*., where he did not see eye to eye with that gentleman—it
was purely a difference of opinion, for in this matter his aim was the same as that
of the author’s, namely, to get at the ultimate truth, and that there was nothing
beyond that in his remarks. He had hoped to have had rather more time to look
over some of the records of the Bacteriological Department of Guy’s Hospital,
where he had the honour of carrying on the work, to find the number of clinical
specimens in which one could detect micro-organisms which were morphologically
comparable to those which Dr. Ford Robertson had introduced as being closely
associated with the production of general paralysis of the insane. But he had only
had time that day to run over the records of two or three months. But even in
that time he had been able to pick out a lot of cases where organisms which, for
purposes of statistics, he regarded as diphtheroids, had been isolated, and where
he had considered they had not had any causal association with the condition
under investigation, and he had merely made a few observations, so as to sec that
they were not the true diphtheria bacillus—the Klebs-Loffler—and had then
discarded them, and gone on to the other organisms which were present in the
material under examination. He found, for instance, that there was a case of
tuberculous meningitis, where cerebro-spinal fluid was drawn off during life, and
the only organism which could be obtained in the cultures from that material was
an organism which, morphologically, was almost identical with the Klebs-Loffler,
but it was non-virulent, and had certain other cultural peculiarities, which led him
to call it, provisionally, the Xerosis bacillus. Some fluid from the pleura showed
the same thing. Then there were two cultivations of the blood taken during life
from cases of (?) infective endocarditis, and here, again, an organism was cultivated
which was diphtheroid, but not true diphtheria. In tuberculous cystitis, again,
there was found the Xerosis bacillus in company with the tubercle bacillus. In
material from antral disease he had found the Staphylococcus albus and the bacillus
Xerosis. He had not bothered about the film preparations of pus, etc., from chronic
gleets, cases of gonorrhoea, and vaginal discharges, and so on, because, as was
known to those who were accustomed to do much work on material supplied by
general hospitals, the Xerosis bacillus, or at any rate a diphtheroid bacillus, was
the commonest organism found in that material. What he had said was based
upon 500 or 600 ordinary bacteriological examinations, carried out during a period
of about three months. That would go to show that diphtheroid organisms were
quite common contaminations of clinical material; that a diphtheroid organism
was not the diphtheria bacillus, and very frequently it was undoubtedly one or
other of the types of Xerosis bacillus. His own impression was that many of the
organisms which Dr. Ford Robertson had been working with were types of the Xerosis
bacillus. With regard to the cultural characters, Dr. Robertson had given some of
tbe results of his cultivations in sugar media and carbohydrate media generally.
Those reactions for the diphtheria group were worked out first by Knapp, in
America, and he showed that with the organisms he was testing he could make
out a fairly constant and definite difference between the three main types— via.,

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6o6 GENERAL PARALYSIS AND TABES DORSALIS, [July,

Klebs-Loffler bacillus, Hoffman’s bacillus, and the Xerosis bacillus. One of the
peculiarities of His’s medium was not only that it showed the production of acid,
but also that the medium became semi-gelatinous, almost clotted, because it was
prepared with serum-water. Again, Gordon had been able to distinguish those
three or four types by sugar reactions. It seemed to the speaker that when one
commenced to include very large numbers of types, and strains of each of those
types in one’s sugar tests, one found that the reactions were not absolutely
constant, but one found the Klebs-Loffler bacillus fermenting, not only glucose,
but many of the other sugars. Fermentation in dextrin or starch was fairly
characteristic of the diphtheria bacillus ; and if one took a large number of strains
it would be found that the Xerosis bacillus did not usually ferment glucose, though
many of the strains would ferment glucose; and so on with all those organisms.
In fact, the same thing happened with the diphtheria group of bacilli when tested
with sugar reactions as happened with streptococci. Streptococci and staphylo¬
cocci were said to be capable of differentiation according to their sugar reactions,
but when they had been tested at varying intervals, after isolation, it was found
that their sugar reactions were not absolutely constant, but one group would run
imperceptibly into another. Another point upon which Dr. Ford Robertson laid
considerable stress was the reaction to Neisser’s stain. Neisser*s staining method
was not a constant attribute restricted to the bacillus of diphtheria, to start with.
Taking large numbers of diphtheria bacilli examined when first isolated from the
body, it would be found that 70 per cent, or 80 per cent, gave a very definite and
characteristic " Neisser” stain, but the remaining 20 per cent, or 30 per cent, did
not give that reaction. The Hoffman bacillus differed very markedly, in morpho¬
logical character, from the Klebs-Loffler bacillus, so that it scarcely entered into
consideration. But, as a matter of fact, about 40 per cent, of the strains of
Hoffman’s bacillus, when first isolated from the human body, would give a very
typical Neisser reaction, in which metachromatic granules would be apparent.
But they often varied rather from those presented by the diphtheria bacillus in
their arrangement and size. Of the various types of Xerosis bacillus, 70 per cent.
gave a permanent Neisser reaction, with metachromatic granules which were
indistinguishable from those presented by the bacillus of diphtheria. Therefore it
seemed to him that the ” Neisser” differentiation of those diphtheroid organisms
which were responsible for the production of general paralysis of the insane was
hardly sufficient to justify the statement that those were not Xerosis bacilli on the
one hand, or were not, occasionally, diphtheria bacilli on the other. Then, again,
there seemed to be something lacking about the experimental work. For instance,
the animals fed on those micro-organisms for such a long period did not show any
marked symptoms for a long time, and then, when they had been kept in captivity
twenty or forty weeks, and when death occurred, the fact that the organisms were
found in them did not necessarily support the suggestion that death was due to the
organisms. A good deal might happen to animals kept in confinement so long.

Dr. Ford Robertson : But the controls were not affected, though they were in
the same room.

Dr. Kyre said he failed to catch what Dr. Ford Robertson’s objection was, but
probably the meeting would be told more by that gentleman. The only other
point he wished to mention was, that the estimation of the bacteriolytic index of
the sheep before and after immunisation depending on alterations in the bacilli
was surely open to a very big difference of interpretation, just in the same way as
the identification of altered bacilli in the leucocytes of the patient was also open to
a grave fallacy. He would be very glad to hear the exact method of estimating
those alterations, and of the steps taken to render it absolutely certain that what
were suggested to be ” altered bacilli ” in the leucocytes of the patient were really
the remains of diphtheroid bacilli.

Dr. David Ferrier said he had listened with great interest, as he was sure
everyone in the room had done, to this most important communication of Dr.
Ford Robertson. He feared that on most of the subjects brought forward in the
paper he (Dr. Ferrier) was not competent to express an opinion, because he was
not a bacteriologist. But as he had ventured to comment on Dr. Ford Robert¬
son’s views in a spirit of scepticism, he would like, on the present occasion, to define
his attitude exactly in regard to them. He had expressed the view, in harmony
with Dr. Mott and others, that tabes and general paralysis of the insane were the

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1907.] By FORD ROBERTSON AND DOUGLAS MCRAE. 607

same disease, and that in all cases not only was the prime origin, syphilitic infec¬
tion, hereditary or acquired, but the degeneration itself was not syphilitic, in so far
as it did not yield appreciably to anti-syphilitic remedies. He believed the evidence
was in favour of there being a toxin circulating in the blood, which toxin must be
generated continuously in order to cause the progressive deterioration and degene¬
ration in the spinal cord and cerebral cortex. The question was, What was that
toxin? where was it produced? And the further question which now arose in
relation to Dr. Ford Robertson’s paper was, Had he discovered that toxin and its
origin ? That was a question which was essentially bacteriological, and he could
not pretend to express an opinion upon it. The objections which he had urged
against the author’s views, at least as they were propounded in the Morisonian
Lectures, were founded upon the investigations of other bacteriologists. And
one of the chief was that the Bacillus paralyticons of Dr. Ford Robertson was
not sufficiently distinctive from other bacillary and diphtheroid organisms, which
were found, both in health and disease, in almost every tissue. And Dr. Eyre, in
his remarks that day, had indicated the same thing, that those micro-organisms
were always with us. He did not find, in his previous investigations, that the
diphtheroid organisms described by Dr. Ford Robertson were more common in
general paralytics than among other forms of insanity, or even than among ordinary
people. Certainly he, Dr. Ferrier, had never found the slightest trace of any
organism in the cerebro-spinal fluid of patients suffering from tabes or general
paralysis. In conclusion he wished to add that he would be greatly pleased if Dr.
Ford Robertson’s views should be proved to be correct, and thus place him in
the happy position of having made one of the most important discoveries in
medicine.

Dr. George Dean desired to thank the Society for the honour conveyed by the
invitation to be present. He thought the position with regard to the question
under discussion was one of caution, both in regard to criticism and in reference
to the acceptation of Dr. Ford Robertson’s views. In the first place, one must
realise the extraordinarily wide distribution of diphtheroid bacilli in Nature, and
therefore the frequency with which they occurred—he might say the enormous
frequency. For example, they were frequently met, as Dr. Eyre had already
indicated, in accidental association with a pathogenic organism definitely known
to cause the particular morbid condition in which the associated organisms were
found. In addition, diphtheroids had been found in many normal conditions.
For example, they were frequently found in connection with smegma, in both
female and male, in the normal condition. They were frequently found in milk ;
and in the udders of a number of normal cows which he examined he found
diphtheroids present. That might have some relation to the frequency with
which Dr. Robertson found those diphtheroids in the stomach. At any rate,
diphtheroids in milk was a common find. The same organisms were also found
frequently in urine examined under ordinary conditions without any relation to
the particular question under discussion. Therefore, as they were found in
Mnegma and other sebaceous secretions, in urine, in milk, and as associated
organisms in other pathological conditions, great caution ought to be observed in
accepting any diphtheroid as having a causal relation with general paralysis unless
it had very well-marked characteristics, including pathogenic action on experi¬
mental animals. In regard to the sugar fermentations which had been mentioned,
it must be remembered that only a very small number of the diphtheroids which
had been isolated had been submitted to those tests. So that until a much wider
application of those tests had been entered into he thought no great weight should
he placed on them. In regard to the results obtained by Dr. Robertson in the
sheep, no matter whether the bacillus had any relation to tabes or not, the serum
of the sheep would probably yield the results which the author had described.
Taking almost any bacillus, one would expect to find an increase in the action of
the serum after injection. So that in regard to the main issue as to whether the
bacillus in question was the cause of the disease, that observation could not weigh
very heavily. In reading Dr. Robertson’s former paper, a point which struck him
<Dr. Dean) very strongly was the absence of mention in detail of controls in setting
forth the cultural results obtained from other forms of disease. He had read
Dr. Robertson's papers with great interest, and he thought they deserved great
consideration on the ground that they gave evidence of much perseverance

6o8 GENERAL PARALYSIS AND TABES DORSALIS, [July,

and close study of the whole question; and, as several speakers had already
said, it would be an epoch-making discovery if it turned out to be true. He
thought it possible that Dr. Ford Robertson had made the controls, but there was
an absence of statement in regard to them. Recently he and others had been
examining brains and cerebro-spinal fluid. Dr. Arkwright, working in the Lister
Institute, had examined the brains and the cerebro-spinal fluid of cases whose
death was suspected to be due to cerebro-spinal meningitis. Out of seven cases
in which the brain and meninges were examined post mortem he twice found
diphtheroids, and out of twenty-three cases in which he examined cerebro¬
spinal fluid he found diphtheroids on two occasions, and sometimes they were
associated with other organisms, such as the meningococcus. That had been
done in only the few months during which the matter had been worked at in the
Lister Institute. So he thought if a large number of controls had been taken
diphtheroids would have been found in many of them, and that naturally compli¬
cated the question very greatly.

Dr. C. E. Beevor said it seemed to him that if the bacillus was the cause of the
disease it ought always to be found in cases of general paralysis of the insane,
and also in all cases of tabes. Yet they had heard from Dr. Ferrier that in the
observations he had made it was not found. And if Dr. Robertson’s view was
correct the bacillus ought not to be found in healthy people, or in cases of other
diseases. Yet it was found in such circumstances. Moreover, if injected into
animals it ought to produce the disease in them. But, as far as he could gather,
the symptoms which had been caused by such injections were not those of
general paralysis of the insane; neither, he believed, were the pathological
changes resulting the same as those in that disease. He did not notice in the
paper any reference to observations on the pupil. Fixation of the pupil was a
symptom which was common to both general paralysis and locomotor ataxy;
indeed it was the most important symptom there was in the earlier stages of
general paralysis. On the other hand, he did not gather that there were changes
in the posterior columns of the cord. The anterior horns appeared to have been
affected in some of the animals injected, but that was not an evidence of either
locomotor ataxy or general paralysis of the insane. Of course, everyone would
be very delighted if what Dr. Robertson had set forth should prove to be one of
the means of combating such a terrible scourge, but at present he did not think
they could say they were on the high road towards that desirable end.

Dr. Candler asked that he might be allowed to make one or two remarks in
connection with Dr. Ford Robertson’s interesting paper, because he thought some
mention of the work which had been going on at Claybury, in pursuance of Dr.
Eyre and Flashman’s work, might be of interest. Through the kindness of Dr.
Jones, the President, he had been enabled to undertake an investigation with
regard to the incidence of diphtheroid organisms in general paralysis, and in
other forms of insanity, from cases in the wards of Claybury Asylum. The
number of cases which he had examined in that way up to the present was
not sufficient to be judged statistically. First of all, he took post-mortem
material, and examined the blood, cerebro-spinal fluid, the intestinal tract, and the
urinary tract of these cases. The number of post-mortem cases he had examined
was 79, and of those 20 were general paralytics. In 3 of those 20, or 15 per cent.,
he was able to obtain diphtheroid organisms. In one case he isolated it in pure
culture from the blood ; it was isolated from the respiratory tract, where it was
present in association with other organisms, and he could see it in the cerebro¬
spinal fluid, but he failed to isolate it on culture. Another case was from the
stomach of a general paralytic, in which there were some erosions and catarrh. A
third case came from the respiratory tract. Of the 59 cases occurring in insanities
of other kinds than general paralysis he was able to isolate the diphtheroid
organism in 4; in 3 the organism came from the respiratory tract, and in the
fourth from the urethra. He then turned his attention to the examination of the
urine of patients in the wards of the asylum, and he was assisted in drawing off
the urine by Dr. Barham. It was done by inserting a sterile catheter, so as to, as
far as possible, obtain the urine in a proper condition for examination. The
centrifugal deposit was first subjected to microscopical examination, and then the
material was grown. Out of 26 cases of general paralysis he obtained a diphtheroid
bacillus in 2, an average of about 8 per cent. With regard to the urethras, he

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1907.] BY FORD ROBERTSON AND DOUGLAS MCRAE. 609

scraped the mucous membrane of the urethral canal by means of a platinum loop,
after sterilising the tip of the meatus. In general paralysis he examined about 30
cases in that way, and found a diphtheroid organism in 5, or about 16 per cent .
In the urine of cases not associated with general paralysis he obtained the
organism only once out of 28 cases, and in the urethras of such cases 6 times in
44 cases, or 13*6 per cent. The points he wished to bring before the meeting were:
that he had not been able to isolate the diphtheroid organism in any large propor¬
tion of the cases which he had examined for it, and that, therefore, the researches
he had made were more in conformity with Dr. Eyre and Flashman’s work, which
was undertaken one or two years previously. In regard to the urinary tract he
found there was an organism resembling what he believed to be of the Xerosis
type, and that it was fairly prevalent. Recently, he believed, some reports had
been published in foreign journals on the subject of the investigation of urethras
in patients who were not the subjects of insanity, and that the percentage in which
an organism of a diphtheroid type was found was commented upon as being fairly
high. With regard to the circulating blood, he, like Dr. Robertson, had failed to
obtain a diphtheroid organism, or at least in only one case did he find an organism
which he suspected to be diphtheroid. But, though due care was taken to ensure
sterilisation, both of arm and instruments, before venous puncture was carried out,
he had obtained in one or two instances what he believed to be organisms of the
pathogenic group. And although he could not make confirmatory statements on
the subject, he suggested that it might be possible, during the final stages of
general paralysis, for organisms of different varieties to obtain entrance into the
blood-stream, and help in bringing about the end of the case. He desired to ask
Dr. Ford Robertson one question about his investigations, namely, whether, during
his examinations of blood from living patients, he had ever obtained other
organisms as well as diphtheroid ones; or had he obtained nothing but
diphtheroids in pure culture ? He understood that Dr. Ford Robertson also
examined the buccal mucous membrane by making scrapings of it and examining
the stained specimens. Had he obtained pure cultures of the diphtheroid
organism from that region ? He asked those questions because the microscopic
evidence in regard to particular organisms was often very deceptive, and could
only be confirmed by isolation of them in pure culture.

Dr. George Robertson said that it might be remarked about most of the
speakers on the subject that day that their evidence had been more or less of a
negative kind, and it had been, if anything, rather against the theory which had
been put forward by Dr. Ford Robertson than otherwise. Three or four years ago
Dr. Ford Robertson put forward a theory that general paralysis was almost con¬
stantly associated with the presence of a diphtheroid organism, and recently he
had called it the Bacillus paralyttcans, expressing his belief that it was the cause of
general paralysis of the insane. He (Dr. George Robertson) was very pleased to
be able to say he could confirm, right up to the hilt, Dr. Ford Robertson's original
theory that general paralysis was associated with a diphtheroid organism. He and
others had been, during the last six months, making an important series of obser¬
vations in the laboratory of Stirling District Asylum, which confirmed Dr. Ford
Robertson's original thesis. But when he said that, he did not wish anyone to go
off with the idea that he believed that organism to be the cause of general paralysis
of the insane. In the observations at his asylum, out of thirteen cases of general
paralysis examined the organism had been found in eight. Their observations
had been, in some respects, carried out under more severe conditions than those of
Dr. Ford Robertson appeared to have been. Dr. Ford Robertson had himself
very generously stated that the Stirling Asylum observations were in some
respects ahead of his own. In the first place, Dr. Ford Robertson had made a
collection of diphtheroids from various regions of the body—from the nose,
pharynx, throat, bronchi, stomach, intestines, from pneumonic patches, from the
bladder, the urine, and in one case they were discovered in a carious tooth. He
did not know that the fact of diphtheroid organisms being obtained from all those
places was any evidence in support of the idea that they had anything to do with
general paralysis, because a diphtheroid organism, as other speakers had pointed
out, was fairly common in the throats of people who were in perfect health at the
time. They, at Stirling, had restricted their observations almost entirely to the
blood and the cerebro-spinal fluid. The mere presence of an organism in the

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GENERAL PARALYSIS AND TABES DORSALIS, [July,

blood meant a very serious condition, as its presence was bound to have some
effects. Dr. Ferrier and Dr. Beevor had said, if the organism was the cause of the
disease, it should be found in the blood or cerebro-spinal fluid, but they had not
found it. Dr. Ford Robertson had obtained it in the blood in four cases, and in
the cerebro-spinal fluid in two cases, according to the reports. The other respect
in which he believed the Stirling work had been done under more severe conditions
than Dr. Ford Robertson’s was, that the organisms they obtained had been sub¬
jected to very exhaustive cultural tests and study. Instead of having a list of
three or four, or even six, cultural media in which the behaviour of the organism
had been studied, it had at Stirling been studied in more than a score of different
media. And, under those conditions, the same organism had been obtained
in seven out of thirteen cases. He was excluding one case in which the
blood was taken, because in that case all the flasks were contaminated, and there¬
fore it was impossible to say for certain whether the organism was there or not.
In his paper Dr. Ford Robertson said that, owing to various reasons, it was
almost impossible, by any means yet known, to obtain cultures from the blood.
But at Stirling, out of the thirteen cases of general paralysis, cultures had been
obtained from the blood in seven, and from the cerebro-spinal fluid in four. There
was one case in which the result was negative, and that was in a patient who had
a remission of the symptoms of general paralysis. The physical symptoms did
not pass off, but the patient became quiet and sensible, and was able to earn his
living outside the asylum, from which he was accordingly discharged. Only one
examination of his blood was made, and it was found to be sterile. He would
rapidly run over the nine cases he had mentioned, and state what reactions he
obtained. The blood was first examined by means of smears, and in four cases
the organisms were visible in such smears when stained by the Jenner stain. He
had brought for exhibition photographs of organisms obtained in those cases. In
the first photograph there were two groups of organisms, one containing seven
and the other four bacilli. In seven of the cases a culture was made of the
organism from the blood, which culture they sub-cultured and preserved, and
recovered completely. They still had the different stains in their possession. In
four cases the organism was obtained from the cerebro-spinal fluid, and some
of them were duplicate cases. At post-mortem examination the organism was
obtained from the heart-blood in one case, and in three cases from the cerebro¬
spinal fluid. In one case they saw the organism in the blood from the smears, from
the cerebro-spinal fluid and blood during life, from the heart-blood after death, and
from the cerebro-spinal fluid after death, and made cultures from it under every one of
those circumstances. He had been interested in what Dr. Ford Robertson said about
the types of organisms, because in one particular case they were more thread like
than in the others. They had gone through all the culture media in regard to
these organisms, and all the organisms they found responded in exactly the same
manner to the whole list of culture media—over a score of them—with the excep¬
tion of the reactions in litmus milk. The majority of the organisms gave an
acid reaction to milk, but some gave an alkaline reaction to it. He believed
ordinary diphtheria bacilli sometimes gave different reactions to milk litmus, so
that that reaction was not regarded as very important in that group. In one of
the cases the organism was obtained during life from the blood and from the
cerebro-spinal fluid, and it gave an alkaline reaction to the milk litmus.
After death the organisms were obtained from the cerebro-spinal fluid, and
it then gave an acid reaction to milk. Therefore no stress could be laid
on that reaction, and it was the only reaction in which the organisms had
not been alike. Thus they had established a condition which would satisfy
the most strict bacteriologist that they had got hold of an organism which
had been identical through all the cases. Doubtless his hearers would like to know
the way in which the organism was obtained. On the staff of the asylum he had
a lady who was a trained bacteriologist; she had worked for two and a half years
with Dr. Parkes in the Transvaal in the Public Health Laboratory there. Dr.
Parkes and his work were known to many present, and the association of the lady
with him was a guarantee of thorough training. All the operations had been per¬
formed under the very strictest surgical precautions. Some of the members on
various occasions had laughed at him when advocating the employment of trained
hospital nurses for men, but at Stirling they had been found to be of very great

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6l I

benefit, because those nurses had been instructed to prepare the patients exactly as
for a surgical operation, and the assistant medical officer had to perform the opera¬
tion as if it were a surgical one, with gloves on his hands and everything sterilised.
A special syringe had been used for the purpose. It was a glass syringe, with a
needle at the point of it (exhibited). It was put into a glass tube, cotton wool put
into each end, and the whole thing sterilised by being put into a hot-air chamber
at a temperature of 175 0 C. On the patient’s arm, after sterilisation, a tourniquet
was put on, causing the basilic vein to stand out, the cotton wool was taken off
one end of the tube, one end of a rubber tube was slipped over the end of the
syringe and the other end was put into the mouth, the syringe was plunged into
the vein and the blood sucked into the tube. That was an absolutely sterile
procedure. The blood was poured into flasks of broth and they were incubated.
It was a very troublesome process to get the organisms to grow, but they had
succeeded in all those cases. He hoped he had done Dr. Ford Robertson full
justice when he said they had at Stirling confirmed his original statement that
general paralysis was associated almost invariably with a diphtheroid organism.
But he wished to make a further remark before closing in order to do justice to
Dr. Muirhead, their bacteriologist. When they started those observations they
wrote to Dr. Ford Robertson to obtain from him a culture of the Bacillus para-
lyticans. Dr. Ford Robertson sent a culture which he said was, in his opinion,
the /?. paralyticans. A very careful study of the organism was made at Stirling,
with all its cultural reactions, and the organism which Dr. Robertson sent them was
totally different from that which they had themselves discovered, t.e., in many
respects. In the first place, Dr. Ford Robertson’s organism was a very luxuriant
grower in all fluid media. And there was also a pellicle produced on many fluid
media in which it grew. But the organism they obtained in their cases of general
paralysis he had mentioned was not one of luxuriant growth. It grew differently
on gelatine, it grew differently on saccharose broth. The Stirling organism pro¬
duced an acid reaction. Though he said all that, he did not wish his hearers to
suppose that the organism which Dr. Ford Robertson discovered might not also be
associated with general paralysis; it was possible it might be. At Stirling they
had not yet obtained in any case Dr. Ford Robertson’s organism, but possibly
they might come across it later. It was possible that they might yet find that a
large group of diphtheroids produced toxins which reacted on the nervous system
and which, if it could not yet be proved caused general paralysis, probably played
an important part in the symptomatology of the disease.

Dr. Orr said that he felt reluctant to take part in the discussion, as the whole
question seemed to centre round the bacteriological point of view; and unless one
was an absolute expert in bacteriology one could not take up either a positive or
a negative position. Still, he would like to offer a few remarks on the extreme
possibility that tabes and general paralysis of the insane were both the result
either of a toxin or of a bacillary infection of the central nervous system. As to
how that came about there were not very definite data available, or as to the focus
at which those bacilli were situated. But there were absolute data as to there
being an anatomical path leading up the peripheral nerves, both spinal and
cranial, towards the central nervous system. It was well known that toxins
readily ascended in the perineural sheaths, and recently Dr. Rows and he had had
the opportunity of examining one case in which a rod-shaped bacillus, often
assuming a thread-like form, such as Dr. Ford Robertson pointed out, but as to
whose identity he (Dr. Orr) was not yet certain, had been traced all along the
perineural lymph sheaths into the cord, by the anterior and posterior roots, into
the central canal, and along the numerous septa leading into the white matter.
Thus there was definite evidence of the fact. And Dr. Rows and he were of
opinion that the infection in general paralysis did not come about through the
blood-stream, but certainly along the lymph paths. Three gentlemen at that dis¬
cussion had mentioned the occurrence of diphtheroid organisms in the blood¬
stream. His own view was that it was not necessary for the blood-stream to be
infected in order to cause tabes or general paralysis ; either could come about by
infection of the lymph paths. He thought it probable that any invasion of the
blood-stream by the organism came late in the disease, or might be due to some
accident.

Dr. Washington Williams said it appeared to him that before one could

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GENERAL PARALYSIS AND TABES DORSALIS, [July,

6l2

accept as authoritative thr controversion of the statements of Dr. Ford Robertson,
it must be known that the organisms mentioned by those who criticised his
observations were the same as the author spoke of, namely, those which con-
sistently gave certain reactions and did not give others. That had not yet been
stated, and until it had been, he, as a neurologist, would accept with great
diffidence the criticisms directed against Dr. Ford Robertson’s work.

Dr. Charles Mercier said he had the same qualifications, when intervening in
the debate, which certain of the other speakers had, in that he was no bacterio¬
logist. But if medical men applied to the question the ordinary canons of
evidence and of causation, he thought that they would be obliged, at present, to
return a verdict of * not proven.” If they were to accept the doctrine that there
was a certain bacterium which was the cause of general paralysis, then certain
conditions must be satisfied. The organism must be identifiable. At present it
was not identifiable with certainty. In the second place, it must be found in every
case of general paralysis ; but he gathered that it was not yet found in every case
of that disease. In the third place, it must not be found in any case which was
not one of general paralysis, and he gathered that it was found in cases which
were not general paralysis. Those were the ordinary canons of evidence and
causation, and those canons, he thought, must be satisfied before one could admit
the existence of a definite Bacillus paralyticans. It must be remembered that
general paralysis was one of the most distinct of all diseases, and so also was
tabes. It was very rarely that a difficulty arose in connection with a case of
general paralysis or tabes, except in the very early stages. And one would
expect it to have a cause which was equally distinct. One would expect the cause
to be such that it was recognisable in every case. It had also to be remembered
that general paralysis was a disease which led to a very slow death—the patient
died slowly, and as he was dying his tissues were all in a state of what might be
metaphysically called very low vitality for weeks, months, and even years. And
tissues in that state were, he supposed, a most favourable nidus for all kinds of
different micro-organisms, and it would be very strange if, when a patient was in
the later stages of general paralysis, many micro-organisms of many kinds were
not found in the various tissues and fluids. That was how the matter struck him,
as an outsider, judging it by the ordinary canons of evidence, without any special
knowledge of the subject.

Dr. McRae said he thought it would be better if Dr. Ford Robertson would
reply on the discussion, and he (Dr. McRae) would make a few general remarks.
With regard to the point which had been made as to the presence of the bacillus,
the authors had said from the beginning that the mere presence of the organism
was no proof that the bacillus was or was not the cause of the disease. Several
of the bacteriological experts who criticised the paper laid great stress upon finding
the bacillus everywhere. As a matter of fact, it was well known that the skin and
genitalia were commonly infested with diphtheroid bacilli. If one could show by
various methods a specific reaction in animals and human beings to that bacillus,
or, as they had done, to anti-sera produced in animals by that organism—and he
had been working for ten months with sera, and had clinical records which were
being held over until the July meeting—surely they were getting very near to
establishing at least a very strong suspicion that they were dealing with the cause
of a certain specific disease. For fifty years the profession had been subjected to
the tyranny of the belief that in general paralysis all the bacterial infections were
secondary to the degenerative process. But he wished to point out that the
authors were not dealing with terminal infections, but with cases which were going
about and able to work, and blood-films taken from such patients showed those
micro-organisms. With regard to this so-called secondary invasion of organisms,
or, as it had been called, terminal invasion, why should a specific disease like
general paralysis allow itself to be subjected to a particular terminal form of
invasion ? Any form would be sufficient to cause the death of the patient if he
was already suffering from a degenerating disease. It was customary to believe
that general paralysis was a primary degeneration of the brain, but how did a
degenerating disease have remissions? How was it that a man went into the
asylum with the disease, in some instances practically moribund, but subsequently
improved so that he could wheel barrows about? The toxic theory seemed the
most reasonable*; it enabled one to understand how the patient might form immune

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613

bodies which enabled him to get better for a time. With regard to the bacterio¬
logical point, the authors were cognisant of the fact that there were many varieties,
and Hamilton and Horton, of America, had found thirty-three varieties of the
bacillus, eighteen of which had been proved to be virulent. The two species of
bacillus dealt with had specific broth reactions, and when these tests were tried
again after many months they gave the same reactions. These reactions were
distinct from those hitherto described in the case of any other diphtheroid bacillus.

Dr. G. H. Savage, in response to the President, said he came entirely to learn.
He had seen a great number of specimens by Dr. Ford Robertson when he was in
Edinburgh, and he left him with a very open mind. He (Dr. Savage) felt very
strongly that general paralysis had a toxic origin, and that the particular toxin
would be found sooner or later. Such good work as Dr. Ford Robertson was
doing was to be encouraged in every way, and it was recognised by the Society
and by other medical societies in London. He felt very grateful to Dr. Ford
Robertson. He was a botanist himself, and the more knowledge he acquired of
the lower organisms the more impressed was he by the enormous differentiations
between the varieties. He thanked Dr. Ford Robertson, in the name of the older
men, who were too old to work along the lines which he was following out. They
were grateful for what they had heard, and would be glad of more.

Dr. Urquhart said that, as one of the supporters of the Scottish Asylums
Laboratory, he felt very much indebted to Dr. Savage for the way he had spoken
of the work done at that laboratory. He (Dr. Urquhart) did not wish to intervene
between the meeting and Dr. Ford Robertson, because he fully expected that
gentleman to say something about the possibility of mixed toxins, and especially
about the numerous control experiments which had been made during the past
six years.

The President (Dr. Robert Jones) said he would be glad to associate himself
from the chair with the remarks from both Dr. Savage and Dr. Urquhart. Dr.
Ford Robertson had come down to have his opinions challenged, and they had
been challenged from a special expert point of view. He confessed to having
a marked sympathetic appreciation of Dr. Robertson’s work, and was ready to
try the treatment suggested by the investigations on some cases of general
paralysis, and he did hope to do so. He believed that Dr. Mott was arranging
with the Lister Institute to have some special serum prepared of that organism, or
mixed organisms, and he (Dr. Jones) hoped to be able to try that at Claybury.
Dr. McRae referred to one point which he (the President) regarded as very
important, namely, remissions in general paralysis; and one was apt to draw con¬
clusions as to the result of treatment from the fact that spontaneous and ordinary
remissions did occur in some cases of general paralysis. He had two cases in his
memory. On one, at Claybury, succinate of mercury was tried, and that patient
went out very much improved. Another had a thorium hydroxide cap, which
he wore for a time and got very much better, yet he was, so far as his (Dr. Jones’)
diagnosis went, a typical case of general paralysis. He heard of him for nearly
two years afterwards, and he was quite well. One was apt to draw conclusions
from such cases that post hoc was propter hoc . The general opinion seemed to be,
as summarised by Dr. Mercier, that the association of the special bacillus as the
proximate cause of general paralysis was not proven ; but Dr. Ford Robertson’s
paper and his work had had the effect of causing interest and work in others,
and thus was a marked mental stimulus in the profession.

Dr. Ford Robertson, in replying on the discussion, said there were several
points which he would like to meet. It seemed to him that all the examples that
Dr. Eyre had given of diphtheroid bacilli being found in meningitis, infective
endocarditis, etc., were strong presumptive evidence in favour of Dr. Benham’s
view that the further study of the diphtheroid group would probably lead to
important advances in our knowledge of some obscure diseases; but he did not see
any other bearing which those observations had upon this particular research. Dr.
Eyre seemed to think that many of the types described in the paper were simply
the Xerosis bacillus ; he regarded as this bacillus many organisms which could be
shown to produce a strong acid reaction in glucose and saccharose broths. He
(Dr. Robertson) would point out that in making such a contention Dr. Eyre was
differing from other bacteriologists. Dr. Eyre and Dr. Flashman in their paper
tried to classify the diphtheroid bacilli found into three species, but the investiga-

614 general paralysis and tabes dorsalis. [July,

ons of others were proving that there were really very numerous separate species.
Dr. Eyre said Dr. Gordon had followed Dr. Knapp in using the litmus broth tests,
t ut he (Dr. Robertson) believed that Dr. Gordon preceded Dr. Knapp by a con-
iderable time. Dr. Eyre said the reactions were not constant. That might be
his experience, but as far as he (Dr. Robertson) could see from Dr. Eyre’s paper,
he had not studied those broth reactions to a very great extent. He knew that in
the experience of others those broth reactions were remarkable in their constancy.
Dr. McRae and the speaker had tested various strains again and again, at intervals
of many months, and it was remarkable how the results had come out exactly the
ame. Whatever changes in virulence these organisms might undergo with the
lapse of time, they underwent none in their broth reactions. It was simply a
matter of Dr. Eyre’s criteria of differentiating diphtheroid bacilli being different from
those of other people. Dr. McRae and he did not attach very much importance to
the presence or absence of metachromatic granules ; that was largely a matter of the
media on which the organisms were grown. Dr. Eyre had said that their method of
estimating the intra-corpuscular bacteriolytic index was open to grave fallacy. He
(Dr. Robertson) supposed there was a margin of error in all such methods, as there
certainly was, for example, in that of estimating the opsonic index. But Dr.
Eyre had not worked with their method, and was therefore not in a position to say
that it was fallacious. He also said he would like to read the account of the
method, but it had been published in detail. It would conduce more to good
feeling in these discussions if Dr. Eyre read their papers before criticising them.
He desired to make a protest against the action of Dr. Eyre and Dr. Flashman in
re-publishing quite recently a paper which first appeared in the British Medical
Journal in November, 1905. He protested at the time in a letter to the Editor of
the British Medical Journal that it was a gross misrepresentation of the views of
himself and his colleagues, and notwithstanding that protest, the paper had been
re-published in the Archives of Neurology of 1907. Such’a procedure led to
the dissemination of grossly erroneous views of their work. As he said
in his letter, the grounds upon which the contentions of his colleagues and
himself rested were ignored, and the only reference made to the evidence
adduced was an erroneous one. Dr. Ferrier had expressed his adherence to the
view that syphilis was the cause of general paralysis and tabes. He (Dr. Robert¬
son) would be glad to endorse that view if Dr. Ferrier could produce any experi¬
mental evidence in support of the thesis. So far nobody had produced any. He
had listened to Dr. George Dean’s remarks with very great interest. Dr. Beevor
asked about the fixation of the pupil in the experiments on rats. It was very
difficult to examine the pupils of rats. If they had brought the rats with them and
shown them to the meeting, he did not think anyone would have any doubt about
their being general paralytic rats; the condition of the animals simulated that of
general paralytics about as closely as was possible. The histological changes
w ere such that both Dr. McRae and he were convinced that the lesions were those
of early general paralysis. The rats died too soon for the complete picture of the
disease to be developed. Accompanying periarteritis there were in some of the
animals plasma-cells, just as in the general paralytic. Dr. Candler’s observations
were of very great interest; they were careful and painstaking observations, and
l e looked forward with interest to their publication. With regard to finding the
bacilli in other patients besides those suffering from general paralysis, it must be
remembered not only that diphtheroid organisms were very common on mucous
surfaces, but that those other patients were contacts. He had read the paper by
Stanziale, who found diphtheroid bacilli in the urinary tract in control cases and
in patients in his skin clinique at Naples; but that observation did not disprove
nny of their contentions. They had themselves pointed out that diphtheroid
bacilli could be isolated from this tract in some control cases. Such organisms
might be devoid of virulence, and even if virulent they were not necessarily
invading the patient. They did not attach importance to the mere presence of the
organism. The remarks of Dr. Orr were very gratifying, because he and Dr. Rows
had been in this country the pioneers in the experimental investigation of these
Ivmphogenous bacterial invasions, and the work of Dr. McRae and himself was
tending more and more to prove that in general paralysis there was such lympho¬
genous invasion. There was no man whom he (Dr. Robertson) had greater
respect for than Dr. Mercier, and he was sorry to come into conflict with him.

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Dr. Mercier said the organism must be identifiable, and their reply was, that it was
so. They had obtained two varieties, which had special broth reactions and which
produced paresis in rats, and until someone showed there were fallacies in them
these observations must stand. He thought Dr. Mercier was in error in saying
that the bacillus must be found in every case. Sometimes the organism was diffi¬
cult to find; but if it were missed in one place it might be present in another.
It was too much to ask that it must be found in every case. Dr. Mercier also said
the organism must not be found in any case which was not one of general paralysis,
but on that ground one would have to deny the specificity of the true diphtheria
bacillus, because it was found in many healthy people. Importance was not
attached to mere presence, but to invasion. He was much gratified by the
remarks of Dr. Savage and Dr. Urquhart, and thanked the President for his
sympathetic appreciation of their work. Many points in regard to their work were
not included in the paper, bub he thought that if some of those who had spoken
had seen their charts showing the specific reactions with anti-sera, they would hav&
hesitated to make some of their criticisms. He was very glad the discussion had
taken place; it had been very gratifying to both Dr. McRae and himself.

Clinical Notes and Cases.

Study of a Case of Melancholic Folie Raisonnante . By

Dr. M. J. Nolan, Resident Medical Superintendent,
Down District Asylum, Downpatrick.

The following case is of such a rare character, yet it is so
perfectly true to type, and it presents such striking points of
psychological interest, that its consideration is deemed note¬
worthy.

Briefly, the facts of the case are these: M. Mcl—, aet. 50,
spinster, farmer, in easy circumstances, consulted me on several
occasions as a private patient, and was eventually admitted to
the Down District Asylum as a “ paying patient ” on August
17th, 1906. She is the ninth child of a family of eleven, two
only surviving ; her mother and eight brothers and sisters died
of consumption ; one brother exhibited unusual ability; became
“ too learned ” and died of “ exalted mania ” (G. P. ?).

When patient was eighteen years of age her father died very
suddenly of heart disease. She had left him in the morning
apparently in good health, and on returning home some hours
later she found him “ laid out for the wake” in his grave-clothes.
The shock of this sad event “ upset my nerves; I was never
the same.” She ceased to menstruate, and suffered from leucor-
hcea, and later from retroflexion of the uterus. “ Queer sensa-

Llll. 42

6l6 CLINICAL NOTES AND CASES. [July,

tions ” quickly developed. They were of a subjective kind
associated with her cerebro-spinal system; they lasted all
through her life. Towards the early climacteric she had much
discomfort from flushings, headache, backache, and intermittent
insomnia. When the menses ceased her condition became
more pronouncedly miserable, a neuralgic pain ran “ from the
back of the head to the back passage ” ; she became altogether
“ out of sorts,” she could not fix her attention long on anything,
and she found it difficult to give her mind to the management
of her farm, which, by this time, was solely on her hands. The
insomnia became more persistent, and during the night and
day she was disturbed by vague apprehensions, which for some
time assumed no definite shape. Later, when in the fields, she
became unduly anxious about the farm stock, and was obliged
to frequently count the sheep and cows to fix their numbers.
Later still, she became doubtful as to the identity of the
animals, and constantly examined them lest any one of them
should belong to her neighbours. This feeling of doubt as to her
rightful possession by degrees extended itself so as to embrace
all domestic articles, and even her employees. When every¬
thing and everyone in the home circle were included it projected
itself to outside matters and individuals—in fact, every object,
animate and inanimate, became involved in the workings of her
morbid psychical state. Walking on the road she wondered
“why?” the stones were left in heaps by the wayside; she
feared they would cause a fatal accident; she was obliged to
retrace her steps to see for herself what casualty might have
resulted. Meeting a child she was obliged to ask its name,
lest it should be lost, or to fix its identity if it should
meet, as she feared it might, with some untoward fate.
Gradually these doubts increased as to the degree of her
personal implication and responsibility in the misfortunes
concerned—she feared she had caused, in some strange
way, the death or illness of such children or persons as she
had passed by. Water in quantity, whether brook, river,
lakelet, or sea, at first suggested someone’s death by drowing;
later this water gave her the idea that, in a mysterious way
incomprehensible to herself, she was the cause of the imagined
death, and, where possible, she took steps to reassure herself
that there was no visible corpse. Yet, all through this period
of intense anxiety, she remained perfectly strong in her

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consciousness of innocence, and keenly alive to the preposterous
absurdity of her notions. Meanwhile her relations towards her
neighbours remained unaffected. She preserved her mental
capacity to manage her affairs, but could not at all times
personally superintend them. She constantly consulted
physicians respecting her ailment. Getting no marked relief,
she wished for asylum treatment, fearing her miserable state of
doubt and apprehension might lead her to do some undefined
harm. Prior to her admission she had been some months in a
private hospital for nervous diseases, and had been treated by
electric baths and massage, but with no good results. On her
admission she met the clerk casually in the hall, and for some
days later she was in distress, lest her meeting with him had
caused harm to befall him. She also says that she imagines
she is eating human flesh when she is eating bread or meat,
and that she is afraid to go to the water-closet lest she
might find in it a child she had recently seen. She says
“ such imaginations are ridiculous.” She is afraid to knit or
sew lest the needles should get into the food and be swallowed
by someone. She is afraid to walk lest she should tramp some
one of those about her underfoot. “ What queer and silly
notions! ” she exclaims.

It is now some three months since her admission, and, so
far, she has improved mentally and physically. She admits
she is a shade better, and, though suffering from the “ silliest
notions” (particularly in the morning), she is not so miserable,
as they wear off when she collects confirmatory evidence during
the day that her fears are, “ as I know in my real self,”
absurd and groundless. For instance, if in the morning on
looking through a window, she sees a woman spreading clothes
in the laundry yard, she “ has a silly notion ” that the woman
may be drawn up through the radiator or ventilator ; later she
sees the woman at meals and feels reassured. If, however, she
sees a visitor on the avenue, she has “ the same silly notion ”
respecting her, and it persists longer, as she does not see the
person again. The screams of the sea-gulls and the cawing of
the crows she often imagines are the shrieks of children; at
the same time, she knows the utter absurdity of such an idea-
As the day wears along she becomes more and more reassured
on all such points, until at length, at bedtime, she is able to
regard her “ wild imaginations ” with a sense of ridicule. She

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6l8 CLINICAL NOTES AND CASES. [July,

goes to bed smiling at the vain fears of the day; she sleeps
well and without dreams, but only to awake to fresh terrors
and doubts, which are started by the first incident of the
morning. Withal, she preserves a kindly and sympathetic
attitude to those about her, she feels for the sufferings of the
acutely insane, she recognises the insane hallucinations and
delusions of her fellow-patients, she thanks God frequently that
He has left her “ sound senses,” but she says that there is no
suffering so great as the “ pain of mind,” and the agony of the
“ cruel tricks played on me by my imaginations.” Her natural
disposition is in no way perverted—she is truthful, good-
natured, pleasing, and sociable—and in all her conduct and
manner exercises a naturally bright intelligence, overshadowed
now and again, it is true, by the grief arising from the grotesque
and painful imaginations, which, though they partially over¬
shadow her rational judgment, do not completely eclipse it at
any time. With regard to the “ delire du toucher ” usually
involved in this disorder, so far as the symptom is immediately
concerned in this case, the desire is limited to certain inanimate
things, which, she imagines, may possibly conceal some victim;
for instance, the notion that the body of a child she had met
may be under an object makes it imperative on her to touch
the object to dispel her “ absurd notion.” In a general way it
may be said this symptom, in her case, has assumed a negative
phase, since she hesitates to touch persons or things lest her
doing so may result in evil consequence to those with whom
she might come in contact.

In bringing forward this case under its present title I feel
some apology is due to those who entertain and express a dis¬
tinct antagonism to the differentiation of species in the groups
of mental diseases. Such an attitude is one, I find, that is most
difficult, nay, impossible, to understand, since in the accurate
study of every branch of science the minutest attention to
specific detail is deemed a sine qua non. In general medicine,
the term “ fever ” covers “ variola ” ; the latter, however,
conveys a very special idea of the disease in question. More¬
over, we have still such a term as variola sine eruptione to
describe a remarkable sub-variety. The term “amaurosis”
does not convey any suggestion of the nature of hereditary
optic atrophy. In like manner the term “ melancholia,” though
it embraces such a case as that now recorded, does not stamp

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it as a clinical entity as clearly as does the well-considered title,
melancholic folic raisonnante (Krafft-Ebing). At the same time
it is evident that exception may very properly be taken to
the multiplication of synonyms which have arisen from sym-
ptomatological nomenclature ; these synonyms are far too
redundant, and create confusion.

So far, however, as title goes, the case now considered might
be correctly enough classed under any one of the following
clinical species, which are all more or less akin, in many cases
the differences being due, not to the nature of the mental
operations, but to the individual mental acquirements of the
persons affected: Chronic hypertrophy of the attention (Ribot),
cerebral pruritus (Ball), folie du doutc avec delire du touclier
(Legrand du Saulle), grubelschut (Oscar Berger), monomanie
raisonnante (Esquirol), monomanie avec conscience (Baillarger),
neurosis of anguish (Freud and Hecker), obsessive panophobia
(Bianchi), systematised anxiety (Pitres and Regis), alienation
partielle (Falret Jules).

With diligence it would be possible to extend this list, but as
it stands it serves its purpose. Exception may be taken to the
inclusion of grubelschut in the foregoing list, since the term
applies a condition of inquiry, not with the spirit of enlarging
the mind, but rather to gratify its trivial curosity. The latter
motive is far removed from that which actuates the inquiry in
the present case, where the investigations are made the subject
of life and death, and involve the happiness of the investigator.
If, however, the term be taken to indicate pathological inquiry
without reference to the cause or nature of the matters examined
into, it may be permitted to stand. It has been suggested by
Dr. B. Ball that la maladie du doutc (the name given by
FalrePs patient to the disease) is the least open to criticism,
since doubt is the most constant feature in all allied cases. With
this I cannot fall into accord, since doubt may be, and sometimes
is, altogether absent in some cases. Personally, if I may presume
to express an opinion on the subject, I should incline to the view
that all such conditions as involve a derangement of the normal
mental processes, and which involve concepts, judgment, and
imagination, should be treated as a class apart, when such
pathological conditions are associated with a painful consciousness
of their morbid existence in the mind of the sufferer . For such con¬
ditions the term melancholic folie raisonnante seems fairly ade-

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[July,

quate, since it implies a fundamental melancholia based on a
morbid method of exercising judgment—a method in which the
suspension of judgment is unduly and painfully protracted.
That the title is not completely adequate is obvious, since it
takes no account of the consciousness of the infirmity—the
doubt which gives rise to such painful feelings. Underlying
this condition of doubt, which is so prominent a feature, we
have the operation of the imagination, which raises in the mind
the certain diverse conditions which call the judgment into
play. The patient does not debate within herself the question
of her innocence or culpability with regard to external objects
or persons, until, long subsequent to her first perception, she
feels she is accused of guilt, and realises that the accusation
is a product of her morbid state.

But “ to classify is not, in itself, the end and aim of psy¬
chiatry, *' to quote Dr. Farrar, when he urged the biologic
method of investigation : “ a method,” he says, “ which studies
personality first, and disease second, and not despairing of the
ultimate futility of absolute clinical differentiation, it turns
rather to the minute analysis of the perverted functions of the
individual minds, comparing them with each other, point by
point, both in health and disease; under the influence of this
conception whatever further growths the symptomatologic
and clinical methods are capable of will proceed to the best
advantage.”

The life history of this patient is typically classical. Like
all the recorded women sufferers from this disease, she has a
family history of neurotic taint, she is of comfortable pecuniary
circumstances, a private patient, and of more than the average
intelligence and education of her class. She suffered from a
severe shock at a critical epoch of her life ; her general health
was affected, and she became the victim of chronic uterine
trouble. At the climacteric her condition became aggravated,
and the course of her disease, though of steady evolution, was
not such as to complicate her relation to her surroundings;
the inner workings of her mind, up to quite recently, did not
openly colour, though they may have embarrassed, her ordinary
conduct.

It is interesting to attempt to follow the line of mental
operations in this case. To begin with, it must be noted that
every distressing thought at the onset was based on the normal

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621

perception of some object or person. The retina received the
normal impression which excites the psychical functions to
abnormal action. Such complex conditions of mind as those
involved demand something more than passing mention. It is
not, however, possible here to follow the thinking process
through the devious and hypothetical ways ascribed to it by
psychologists of conflicting views. I venture, therefore, to
treat the analysis of the case by what seems to me a fairly
clear working method, which fits in with the life-history of the
patient, and at the same time depends only on authoritative
statements for its support and acceptance.

At the onset of the disorder we have to deal with a girl of
neurotic taint plunged at the period of adolescence into a
stage in which the antecedent symptoms of melancholia—
“ lowness of spirit, groundless forebodings of coming evil, and
brooding abstraction "(Maudsley)—were one and all manifest.
When roused to interest in her surroundings her first obvious
definite doubt was excited by seeing the cattle. There was no
error in her visual perception—she saw ordinary cattle in the
ordinary way. But, as Mercier points out, visual “ perception,
which is often, and not incorrectly, looked upon as one of the
simplest of mental operations, is, in fact, a very complex
process, including sensation, memory, attention, and in the
region of thought, all the forms of syncrisis, as well as imme¬
diate inference. When perception is defective or erroneous
any of these elements may be at fault, or may rest unequally
among them.”

Here, then, we have at once several mental processes bound
together, any one or more of which may have been the weak
link in the chain of reasonable conception; and in the latter
concrete outcome of received ideas we have its constituents—
belief, imagination, and understanding. Taking Bain’s amended
definition of belief to be a primitive disposition to follow out
any sequence that has been once expressed, and to expect the
result (in this instance the counting of the cattle), it is a fact,
or an incident, of our intellectual nature, although dependent
as to its energy upon our active and emotional tendencies. It
is evident there was a failure in the belief process since the
reckoning of the animals was inconclusive and had to be
repeated. This repetition showed the existence of doubt,
and, as Kirchner holds, “ the more a creature can doubt,

622 CLINICAL NOTES AND CASES. [July,

the more conscious it is ”; hence the phase of doubt, with its
ally fear, created a condition of acute attention to discrimina¬
tion between the two ideas, for “doubt requires at least two,
and, in addition, a creature which transcends both.” The
repeated sensory impressions of cattle in number stimulate
the sensuous imagination, and by suggested contrast, the
doubt extends itself from the question as to the number of
her cattle to the question of ownership. As in all cases of
imagination, understanding (in its limited sense as “ the
capacity of thought, which proceeding from what is given
aspires to positive knowledge by its own logical laws”) now
acts as a limiting force and stops the doubt at the threshold of
delusion. Later, in matters of great import, “ doubt is the
name for unspeakable misery” (Bain), but so far the simul¬
taneity of thought is normal, and the queries, all of a minor
character, are answered to her satisfaction and dismissed. As
we have seen, however, time serves to increase the nature of
the doubts, and all the mental processes above noted are called
into play, no longer for the mere solution of mathematical
problems, but to extricate her from the meshes of self-accusa¬
tion, which her imagination nets round her. As in a dream the
ego is, as it were, broken into a plurality, and a condition of
anxious confusion ensues—“ Qui s’excuse, s’accuse ”—she is
forced to explain away auto-accusations. Elementary recogni¬
tion, though still normal, is followed by contemporaneous
ideas of a heterogeneous character. The mental operations
arising from commonplace, normal, visual perceptions result in
bizarre and morbid feelings. Apperception, taking that quality
to express “the process by which a mental system appro¬
priates a new element, or otherwise receives a fresh determina¬
tion ” (Stout), is possibly at fault. That the fresh “determina¬
tion ” is not always in the right direction may arise from cases
of association by contiguity, and resemblance is indicated by
Plato (Phaedo)—“For we saw that this was possible; that
when perceiving something, whether by sight or hearing, or any
other kind of sense, one may from this perception, get a
suggestion from something else which one had forgotten, to
which the first mentioned was contiguous, though unlike, or to
which it was like.” In this patient's case it would seem as if
there was a failure of apperception—the morbid suggestions
evoked by perceiving normal objects are morbid suggestions

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CLINICAL NOTES AND NEWS.

623

drawn from contiguity and resemblance—they are not the
normal suggestions which should be associated with the visual
images per se. At this stage new elements come into play, the
patient recognises the failure of her mental power to deduce
normal rational suggestions from the external stimulus, and she
seeks to correct the false impressions by judgment. Normally,
judgment or reason acts promptly, it “ inhibits.” In her case
both the conditions requiring rational adjustment being pre¬
sented by her own consciousness, the judgment state is
abnormally slow and painful, there is a strain and stress on the
reasoning faculties. She now affords a fairly good illustration
of the analysis of self as made by Ward: she has “ the bodily
self" “ the inner self" and “ the self as person" The perceptions
of the bodily self are normal; the inner self is evidenced in
abnormal emotional disturbance; and self as person indulges
in a reciprocal recognition in which the not-self becomes a
second self with a correspondingly appercipient group.
There is a sense of guilt, which entails a long and painful
introspective analysis, and which is thrown off only when
the weight of internal and external evidence result in the
tardy verdict, which leans rather to “ non proven ” than to
“ not guilty ”! She is at once her own accuser, defender, and
judge. She holds the scales of justice, blindfolded by the con¬
sciousness that she is the victim of her own deception, and
though she feels she shall free herself from the self-made charge,
she is suffering the penalty of a painful and humiliating ordeal.
Such a complex condition of mind demands a close examina¬
tion. The elements involved do not work in harmony—there
is a distinct disequilibrium between the actual visual perception
and the abstract psychical sentiments thereby elicited. There
is, indeed, more than mere disequilibrium—there is a very gross
incongruity which unfortunately is painful to the ego concerned,
inasmuch as it creates, as it were, a bogus case against itself,
and is forced to adjudicate on the same case, weighing the issue
in as impersonal a manner as is possible under such Gilbertian
conditions. Visual images of inconsequent persons and neutral
objects give rise to a sense of self-accusation. A morbid sense
of ill-doing must deeply underlie this person’s normal everyday
commonplace sentiments, which are of a good and kindly
nature; and in the rejection of the imputations suggested by
the inner ego these latter sentiments are excited to a degree

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624 CLINICAL NOTES AND CASES. [July,

which demonstrates their very altruistic character, since the
anxiety is much more to prove others unharmed than herself
innocent. Far down in her inner consciousness are stored
away the inexhaustible tissue of charges from the very mention
of which she shrinks, and the strange natures of which excite
her own wonderment, indignation, and, at times by their very
absurdity, her sense of humour. So wide apart are the con¬
current sentiments that they might be said to differentiate a
double ego. We have synchronous ideas, and yet ideas so
discordant that, were the ideation not complementary, the con¬
dition of double-consciousness might be said to be present. As
it were, we have strongly conflicting and definitely defined
ideation of an antagonistic type. The battle is fought by the
same divided ego, on the same psychical ground, and though
the victory is to the strong in each encounter yet it is truly
Pyrrhic ; delusion is routed, but illusion and obsession hold the
ground.

Delusion is an erroneous belief, the patient not only does
not believe in the reality of her “ imaginations,” but she
repudiates and controverts them; hence she is not delusional.
But some of her imaginations are so crystallised that they have
become obsessions, “ they enforce the doing of acts foreign to
the acting individual.” It is evident that there is a psychical
state which may be classed as one of micropsychosis, since
it is complicated by uncontrollable thoughts, which are not
unlike those wherein the dreamer sees himself, as it were, in
detachment from his acts in the dreams. In this condition of
micropsychosis the thoughts are controlled by sight, inasmuch
as the sights are necessary to elicit the thoughts, though the
secondary thoughts so elicited are subsequently controlled by
the primary and rational thoughts. At this stage the mental
operations are so intricate that disentanglement is practically
impossible. The concurrent thoughts are hostile to each other
and reflect each other in repetition, as in opposed mirrors.
There is, as Professor Boyce puts it, writing of anomalies of self-
consciousness, “ a primary alternating of passing consciousness
such as dimly suggest anomalous situations,” and the sugges¬
tions are readily assimilated. A very insignificant remote
event now causes grave results. One evening, years ago, when
walking, she accidentally trod on a snail and partially crushed
it; after she had passed on a considerable distance she was

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625

obliged to retrace her steps to ascertain if she had caused its
death. Henceforth her accidental contact with people
suggested their suffering in consequence. If she were present
at a “ wake ” she was obliged to get repeated accounts of the
last illness of the deceased in order, to dismiss a vague idea that
she had anything to do with the fatality. Her consciousness
constantly arraigned her and forced her to prove an alibi. This
doubt remained in the penumbra of her consciousness—“ the
peripherally originating spectra of memory” gave rise to
illusions of introspection, excited the recognised confusion of
internal and external experience—and established the sub¬
conscious process of criticism now so prominent a feature in
the case.

Experience, moreover, as Maudsley points out, has established
the fact that “ the primary occasion of an hallucination or an
illusion may be either in the subordinate sensory ganglia, or
in the super-ordinate centres which minister to ideas; and,
secondly, although sensory and ideational centres are commonly in a
conspiracy to produce it, yet they sometimes do not agree, the one
contradicting and convicting the other .”

The mental derangement in this case, then, may be classed
as a disorder of judgment—there is a disintegration of the
necessary unification which is essential to normal judgment—
“the personal identity is confused, uncertain, and ambiguous.”

To sum up. The patient, it will be admitted, is an excellent
illustration of the condition “ in which the personality does not
undergo any transformation further than the afflicted tone that
arises from the tormenting despotism of ideas and emotions
that are recognised to be irrational, and of the inefficiency of
struggle for freedom from these.” The obsessions are also
remarkable for their altruistic type—her systematised anxiety
is less of apprehension as to her own well-being than regard for
the welfare of others. Throughout there is a marked absence
of spiritual doubt or despondency, though her suffering is so
great “ that life is without joy,” and “ death would be hailed a
relief,” yet there is no disposition to self-destruction. There
are, at times, paroxysms of distress, which may be regarded as
“neurosis of anguish.” Of late there has been a chronic
inability to personally administer her affairs, somewhat ana¬
logous to the condition of “ professional dyskineses.” There
is no evidence of insane delusion in the sense of erroneous

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belief; there is no evidence of hallucination of any special
sense, though possibly there may exist some of a psycho-visual
character, when the obsessive panophobia is at its maximum,
and excessive emotivity causes acute confusion. It cannot be
determined that she has any visual illusions; she sees all objects
in their true conformation, and in proper relation to their
surroundings.

Just one word as to prognosis and treatment. It cannot
be expected reasonably that a condition which is the matured
result of a life habit can be overthrown at once, and hence we
find that the authorities generally incline to a pessimistic view.
There are recorded experiences, however, which point in the
reverse direction and stimulate hope. The case now under
care shows a tendency to the latter class. This brings us to
the treatment which, besides general tonic measures to improve
health (and more particularly the nervous system), embraces in
asylum life a comparatively limited environment where the
exciting causes of anxiety are reduced to a minimum, and are
of such a fixed character that time is afforded for the removal
of the doubts indirectly inspired by them. The patient’s field
of psychical vision is, as it were, restricted to a landscape with
some certain figures, whereas in the outer world the patient
was forced to gaze at an ever-moving panorama where crowds
made their entrances and exits in quick succession, creating
confusion and doubt by their rapid passage. Possibly it is not
in such rare cases as this alone that the monotony of asylum
life becomes a restful curative measure. There is at all events
a minimum of the irritation calculated to excite “ cerebral
pruritus ” in such cases as this now recorded.

A Case of Sclerosis of the Cerebellum . By Harvey

Baird, M.D.Edin., Assistant Medical Officer, London
County Asylum, Colney Hatch.

A male imbecile was admitted to Leavesden Asylum in June, 1883.
He was then cet. 16, and appeared undersized. He had very little
memory or reasoning power, but was clean in habits, and worked
outdoors. His mental state remained the same until his death in June,
1904. His speech was stammering, thick, and unintelligible on admis¬
sion, and remained so. He was not epileptic. He died of phthisis.
There is no record of any peculiarity of gait, nor was any such observed
by those in charge of him.

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At the autopsy the following facts were noted : The skull-cap and
dura were normal, as was the pia, except over the cerebellum. The
cerebrum was symmetrical, the convolutions of the usual type ; with
cerebellum it weighed 46 oz. The cerebellum was small and very firm ;
it weighed 2J oz. Naked-eye examination revealed the vallecula to be
much more prominent than usual. The amygdalae were simply small
projections, slightly raised from the adjoining bi-ventral lobes. The
inferior vermiform process was completely exposed in all its length
without lifting the medulla. On raising the latter all the fourth ventricle
was very easily seen. On either side was a marked loss of tissue in
the bi-ventral lobes. Instead of the usual rounded appearance of the
inferior aspect there was a sharp ridge running round outwards and
forwards from the notch, so that each lobe became a wedge with apex
downwards.

On section each lamina was seen to consist almost entirely of
sclerosed tissue, the outer and granular layers being much reduced in
thickness, the outer layer being about a fourth, the granular layer a
third, of the normal thickness. The cells in the granular layer were
not nearly so crowded as in the normal cerebellum. The proportion of
rounded cells to granular cells was considerably diminished. Purkinje’s
cells were absent, no cells in any way resembling them being seen.
The sclerosed tissue in the interior of the lamina was much wider than
the white matter normally is, thereby causing the width of the lamina,
as a whole, to be not much less than the normal. At places the tissue
was very dense, at others fairly loose. It consisted of glia cells and
nuclei, and a network of fibrils. Numerous blood-vessels were seen.
The cells of the dentate nucleus were much atrophied. There was
great thickening of the pia, causing the laminae to adhere together in
many instances. This meningitis was evidently the primary cause of
the sclerosis. Microscopically no lesions were found in the cerebral
hemispheres or in the cord, but in the medulla the cells of the olive
were diminished in number and size.

The case is of interest as showing the possibility of gross
cerebellar disease existing for many years with no special
symptoms pointing to the involvement of that organ. The
literature on cerebellar lesions is fairly extensive, but princi¬
pally refers to cases of tumour, or of experimental lesion in
animals. It is obvious that little can be gained by comparing
the above case to these. During the years the lesion has
existed there has been ample time for other portions of the
central nervous system to assume the functions of the diseased
part. Further, the nature of the lesion precludes the possibility
of the production of any irritation symptoms, as in tumour.

Several cases of cerebellar sclerosis or atrophy have been
described, associated with lesions of the opposite half of the
cerebrum.

Thus, Major (1) recorded a case of left cerebral sclerosis asso-

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628 CLINICAL NOTES AND CASES. [July,

dated with atrophy of the right lobe of the cerebellum.
Dudley (2) reported a case of an old haemorrhagic cavity with
dense sclerous walls, implicating the corpus dentatum, accom¬
panied by degeneration of the opposite olive. Grills (3)
recently described a case of cerebral hemiatrophy with atrophy
of the right side of the cerebellum. The left olivary body and
anterior pyramid were about one-third that of the right. The
cord was normal. The case most similar to the above, how¬
ever, that the writer has had access to, is that reported by
Bond (4). The condition was one of atrophy and sclerosis of
the cerebellum. The naked-eye appearance, weight, and con¬
sistence were similar. The case was of long duration, the
mental state also imbecility without epilepsy, and there was
speech defect. The cells of the medulla, especially the olive,
were small, degenerate, and of indistinct outline. It differed
inasmuch as that the patient became ataxic, the meningitis was
only slight, and there was some sclerosis of the pons.

The slight nature of the pathological changes in other parts
of the central nervous system is noteworthy.

It would appear that compensation of function is compara¬
tively easily obtained in cerebellar lesions, and that localising
symptoms need only be expected if the lesion be recent or
cause pressure effects.

Bibliography.

(1) Major, Journal of Mental Science , July, 1879.

(2) Dudley, Journal of Mental Science , July, 1886.

(3) Grills, British Medical Journal , May 5 th, 1906.

(4) Bond, Journal of Mental Science, July, 1895.

MICRO-PHOTOGRAPH.

•

Micro-photograph of section stained with haematoxylin. Note the meningitis
and adhesion of the laminae, the small number of cells in the outer and granular
layers, the absence of Purkinje’s cells, and the large amount of sclerosis.

Notes on a Case where a large number of Foreign Bodies
were removed from the Vagina of a Chronic Insane
Indian patient . By A. D. Pringle, M.B., Senior

Assistant Medical Officer of the Natal Government
Asylum, Maritzburg.

Patient P—, Indian female, set. about 46, admitted April 5th, 1899,
stated to have been insane eighteen months previous to her admission.

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She had a child with her about one year old, and treated it kindly.
Since her admission no husband or relative has taken any interest in her
or her child, and one is led to the conclusion that her life had been a
somewhat irregular one.

On admission she was acutely maniacal; she is now quarrelsome,
abusive, and extremely dirty in her habits, fighting pretty frequently
with other turbulent inmates.

At intervals she has gone out with the coloured female squad to do
garden-weeding, etc., but appears to have given more moral (!) support
than practical help. In April, 1905, she developed an abscess high up
on the thigh in front; it was offensive and healed after the expiration of
about three months.

In December, 1906, in spite of frequent bathing, it was noticed that
a most offensive odour constantly hung about the patient. Slight
vaginal discharge was seen, and orders were given for douching. After
a few days the nurse in charge reported difficulty in inserting the nozzle
of the douche, and a vaginal examination was made (December 28th).
On separating the labia one could just see a piece of old spring wire
projecting, much like a decayed pessary. It was removed, but it was
quite evident there was something more to come. As item after item
was brought out, one could not help being reminded of the miscellaneous
collection seen in a watch-maker’s or machinist’s workshop.

The following is a list: Parts of three watch chains, eight metal
washers, three dozen beads, five cogged watch-spring wheels, two iron
nuts, two brass ornaments, twenty-eight thick brass finger-rings, two large
silver ear-rings the size of a large walnut, two brooches, two brace-buckles,
bowl of salt-spoon, steel spring, small bolt, bath-plug and part of chain,
eleven buttons, one toy watch, two pennies, one half-penny, one tie-clip,
pipecover, metal screwtop, metal cork, two large belt-buckles, buckle
of rifle-sling, top of safety key to bath, piece of 1 in. square glass, parts
of several iron screws, bolts, and miscellaneous pieces of rusted iron,
beads, hooks-and-eyes, etc.

After about fifty washings the total scrap heap weighed seventeen
ounces, and I calculate that the vagina must have contained nearly one
and a half pounds of foreign matter.

The operation lasted almost an hour and a half, some of the articles
being more or less firmly imbedded in the vaginal wall, which was
fibrous and apparently papillated where parts of the mucous membrane
had been pushed into the chinks and openings in the pieces of metal.
No chloroform was given, although I am confident it would have been
necessary in a sane woman, as some of the watch-wheels, buckles, etc.,
were removed with much difficulty. Every ten minutes the douche
(potassium permanganate solution) was inserted to wash away the
d£bris % and an offensive, black, slimy liquid that oozed out in the intervals
between douching. Most of the articles were in the posterior fornix
(towards Douglas’s pouch), which had stretched to form a large cul-de-
sac. No bleeding took place, neither were there any fissures communi¬
cating with the bladder or rectum. How the last escaped is a marvel,
since the wall between the rectum and vagina was much thinned out,
and many sharp pieces of glass, wire, and metal were removed.

For four days after this the discharge still continued to be black and

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630 OCCASIONAL NOTES. [July,

offensive, evidently remains of dibris . Pulse and temperature remained
normal throughout.

The patient is now well, but much annoyed at losing her “ hidden
treasure,” and not having opportunity for further collection resorts to
secreting bread in the same place when she is not watched.

Looking through the Journal of Mental Science for the last
sixteen years I can find no trace of any other cases excepting
one recorded in July, 1895, by Dr. Russell Strapp (now practis¬
ing in Maritzburg) while assistant medical officer at the
Inverness District Asylum. In this instance a female patient
had inserted a candle extinguisher and a small round brass ball.
All asylum physicians are aware of the anaesthesia found in
the insane ; I have no doubt, however, that most of my readers,
if they saw the collection, would wonder how the patient could
possibly have retained such a quantity of miscellaneous articles
without incurring any fissure or internal septic complication of
some kind. The case naturally suggests sexual perversion, but
although the patient had apparently led a vagrant life before
admission, nothing has been noted by the attendants in charge
beyond the secretion of foreign bodies. However, it is difficult
to trace matters among the insane coloured inmates. One
other factor may have been “ hoarding up of rubbish and
brightly coloured objects,” common in asylums.

When the coloured patients are bathed, usually all rubbish
is taken away; it is therefore possible that this patient may
have secreted these articles in her vagina for greater security.

Occasional Notes.

The Thaw Trial.

The Thaw trial so strikingly demonstrates the existence of
defects in the conduct of judicial inquiries, some of which
directly affect alienists, that some comment on them is not out
of place in the pages of this Journal. These defects, although
more prominent in the American, can be seen in lesser degree
in English courts.

The most disgraceful defect is the prolongation of the trial

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which wealth permits. The penniless murderer of Whiteley is
tried and sentenced in a few hours, whilst the millionaire Thaw
occupies the courts for weeks and months, with a lavish expen¬
diture of funds that is demoralising to lawyers and witnesses
alike. The rich and the poor are certainly not on an equality
under these conditions. Yet the equality of the poor and the
rich is one of the proudest boasts of that free and incorruptible
justice which is so dear to the Anglo-Saxon race.

The unreliability of trial by jury is most unwisely exposed.
The weeks occupied in empanelling the Thaw jury constitute a
scandal, and the bases of objection to the scores of rejected
jurymen are not calculated to make jury service popular, or to
obtain the best men. Every man who wished to evade service
could do so, leaving the jury to be composed of those who for
some motive wished to serve. This is not in accord with
the principle of taking the first twelve good men and true
on the roster, and trusting to their common-sense judgment on
the facts submitted to them, quite apart from anything they
may have heard, or any uninformed opinion they may have
expressed. Indeed, it is hard to see how the most bigoted
defender of the palladium of our liberties can find anything to
say in favour of the selection of the Thaw jury. A crowd of
pot-boys tossing pence in a tavern would have selected the
arbiters of life and death on more ancient, just, and logical
principles.

The multiplicity of heavily subsidised legal advocates, tending
to the introduction of all kinds of irrelevant evidence, the
extreme latitude of cross-examination and the exclusion of real
evidence on technical pleas tend to the confusion of the issues
and the excitation of emotions and prejudices, which so often
lead to a disagreement of the jury.

The introduction of battalions of “ specialist ” witnesses, on
either side, giving evidence in terms usually unintelligible to
the jury, and often unintelligible to anybody, tends to the same
result.

The effects on the “ specialists ” need not be commented on;
they were well described by our American correspondent in
our last issue, and we agree that they are certainly not desir¬
able.

Much of the evil resulting from such trials as the one under
consideration arises from the fact that two distinct issues are
liii. 43

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632 OCCASIONAL NOTES. [July,

being tried at the same time. The main issue—did the accused
commit the criminal act ?—is within the province of a common
jury, if honestly selected, but the second is not. An ordinary
jury is certainly not competent to decide whether a man was
insane at the time of the committal of a crime, or at any other
time, except in the most obvious instances. In all cases in which
there is any shadow of doubt the question should be relegated
to a jury of experts, nominated by the judge. Our judicial
procedure gives a precedent for this in the jury of matrons.
This would avoid the conflicting testimony of experts so
humiliating to our profession, and would avoid that very
unsatisfactory procedure by which one or two experts appointed
by the Home Office revise the decision of the jury at a later
stage. This latter arrangement does not, and should not,
command the confidence of the public. These specialists
practically decide the question of life or death in a manner
that is directly opposed to the principle and practice of our
legal procedure—by avoiding all publicity. That their over¬
ruling of the judge and jury is commonly correct may be true,
but circumstances are conceivable in which this procedure
might be abused. In any case this mode of settling an impor¬
tant judicial decision by a secret medical report to a Home
Secretary, who, being a politician, is probably not judicially
minded, is a very halting method of arriving at justice.

The Registration of Asylum-trained Nurses .

The appeal to the Medico-Psychological Association to
support the petition on behalf of asylum-trained nurses has
been most thoroughly successful.

The petition has been signed by more than 7000 persons,
and is a record that cannot be ignored in any legislation on this
subject.

Two bills are before the House, but it is very improbable
that either of them will be passed in the present session; and,
as before pointed out, it is very doubtful if registration will ever
be carried. In any case this Association can claim to have
supported the interests of asylum-trained nurses with prompti¬
tude and vigour.

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Lombroso and Spiritualism .

Professor Lombroso has publicly acknowledged beliefs in the
existence of psycho-physical powers beyond those hitherto
recognised by science. Honour is due to him for this public
profession, and for the opportunity it gives of examining some
of the data on which his beliefs are founded.

The beliefs of a man of great mental activity, whose repute
is world-wide from his views on criminology, certainly demand
consideration in connection with a subject which is so largely
attracting public attention at the present moment.

Professor Lombroso’s beliefs were primarily founded on
some seances with an Italian medium named Eusepia Paludino,
but in the New York Medico-Legal Journal (September, 1906),
the Professor gives an account of some investigations of
“ haunted ” houses. Three cases are reported. In the first
the phenomena, after existing two or three months, ceased on
the removal by marriage of a young woman of twenty-one.
She produced no new phenomena in her new domicile.

Professor Lombroso saw no phenomena himself in this case,
but obtained written statements from several persons who did,
but not from the young woman herself, thus making the
investigation in regard to facts which occurred ten years
before singularly unconvincing. The principal phenomena
reported were the loud ringing of a bell, after being filled with
“lime and tow,” the repeated falling of a Bersagliere hat, even
after being nailed up, and the falling of water, to the extent
of a tumblerful in a room where no water was.

In the second case the phenomena ceased when a boy was
sent away. Lombroso himself witnessed the chief phenomena
here— viz., the falling of bottles from shelves in the cellar of a
wine and spirit store when the boy was not present. The
owners of the spirit store asserted that they had seen things
disappear before their eyes. No note is made of the .boy’s
health, age, condition, or after-history.

In the third case, also investigated personally by Lombroso,
a child of eight, on going to bed, is supposed to have caused
knockings on the wall so forcible that the “ vibration was very
perceptible.” These continued when the child was removed
to the opposite side of the room. There does not appear to
have been any examination of the other side of the wall. The

634 OCCASIONAL NOTES. [July,

knockings were intelligent, answering verbal questions on a
code, “ in which the letters of the alphabet were denoted by
blows. Some of the things thus communicated were correct,
some incorrect, and others inconclusive.’*

After a quarter of an hour the boy fell asleep, the blows
became more inconclusive, and finally ceased. The blows
were less resounding when the boy was ill of “ grippe.” The
boy presented no abnormal peculiarity, and it is not stated
whether his intelligence was equal to the information displayed
in the conversation carried on by knocks. Whether his
mediumistic powers continue is not stated.

It is to be regretted that these two mediumistic boys were
not more thoroughly studied. If isolated for a few days from
the scenes of their activity the continuance of their powers
would have been absolutely convincing, if observed under
strictly scientific conditions.

The absence of this continued observation renders these cases
distinctly unsatisfactory.

These “ phenomena,” if we accept them as facts, would
indicate that in two cases of immature brain-development, and
in that of a young woman who was a rickety, sickly neurasthenic,
a power was evolved which could, at a distance from these
brains, be converted into mechanical force—moving bodies,
inflicting blows, etc. This force, however, would not be, in all
respects, ordinary force, since it could overcome resistance of
intervening matter, as in the ringing of the packed bell, and
could either overcome gravity by removing water through space
into an empty room or produce it in a room where no water
was. Whether the water was carried or created by this miracle-
working force is about equally unbelievable.

This power or force, developed in immature or unhealthy
brain-matter, even in sleep in one case, was not enhanced, but
weakened by ill-health in the case of the child, and this,
Lombroso asserts, is also the case with the “ medium ” Eusepia
Paludino.

The tendency of modern publishing is to induce men who
have attained any widespread notoriety, as scientists, writers,
talkers, etc.—men who perhaps are really able, on some small
branch of human knowledge, to set up as authorities, and
lecture humanity on every subject under the sun. The public,
that reads and never thinks, is only too ready to accept their

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635

utterances as gospel, not appreciating that a man may have
hypertrophy of some brain-areas and atrophy of others, just as
an athlete with hypertrophic shoulder-muscles may be feeble on
his legs.

Lombroso, however, certainly does not fall into this category,
and we may be sure that if he discovers that he has been
duped he will as frankly own to this as to his beliefs.

A course of training of some few months under a professor
of legerdemain should be prescribed to all scientists before
entering on an investigation of mediumistic seances and
haunted houses, and probably the number of conversions after
such a course would be considerably reduced.

Professor Lombroso’s beliefs imply that the laws of the
universe governing every known activity, from the falling of a
drop of water to the guidance of the stars in their courses, are
set aside and overruled by brain action of a defective type for
the most ridiculously puerile and purposeless results. If the
Creator could be imagined thus to stultify His omnipotence
by giving man the power of overruling the laws governing the
universe, such a power would surely manifest itself in the most
highly-developed men, and for objects that would teach man¬
kind some really great truths in regard to man’s knowledge of
the universe, which is the end and aim of all science.

The Treatment of Insanity in Asylums .

Medical critics, who have often an unseen axe to grind or an
ancient grudge to gratify, are constantly ventilating in the
public press or a medical journal the time-worn allegations of
the want of scientific spirit in asylums.

One of these critics, in a recent contribution, begs the
question as usual, in his opening paragraph, asserting that “ in
real medical treatment, directed to the causes, nature, and cure
of insanity, very little has been done, very little is being done,
and the methods found fertile in other fields are not being
pursued,” and he then goes on to explain why this is, from his
point of view.

A critic who is so little acquainted with the medical literature
of the day as to make the above assertion a basis of his
contention, it may be argued, is too wanting in knowledge of
his subject to need consideration.

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An examination of his further utterances shows that he does
possess some acquaintance with asylums, if even of somewhat
remote date, and that his assumptions are not entirely due to
mere want of information.

This critic is, or professes to be, ignorant of the work done
by Drs. Bolton, Bruce, Campbell, Bevan Lewis, Mott, Orr,
Ford Robertson, Rows, Turner, and a host of other workers,
whose work is in evidence not only in this and all other
medical journals, but in special archives, and occasionally in
the Reports of the Royal Society; work, in fact, which in its
originality, variety, and scientific method will compare favour--
ably with the output of that produced by an equal number of
medical men engaged in hospital practice. Indeed, if there
are eliminated from the ranks of our specialty a large number
of junior medical officers, who tire mere birds of passage, it
may be safely asserted that the contrast of scientific output
would be in favour of the alienist in the public asylum.

Pathology trt Asylums.

The criticisms on the scientific work of asylum medical
officers suggest that to remove the ignorance which prevails in
regard to the investigations being made in asylums, especially
in pathological matters, there should be a closer connection
between the asylums and universities or medical colleges in this
respect.

The clinical opportunities offered by asylums for the teaching
of a general knowledge of mental diseases are very generally
made use of, but the pathological side is almost entirely
neglected. The pathological laboratories in connection with
asylums arc numerous; some of them are admirably equipped,
and conducted by men whose repute is well established in Con¬
tinental and American scientific circles, even if unknown to,
or ignored by, our home critics. Prophets, as usual, are not
without honour away from home.

The teaching of the pathology of the brain, etc., is urgently
needed, and the Medico-Psychological Association, which has
been so successful in obtaining the recognition of the value of
its clinical material, should now devote its energies to pressing
on the universities and medical colleges the urgent necessity

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REVIEWS.

637

for the teaching of brain pathology, by establishing lectures
and demonstrations by asylum pathologists wherever this is
possible.

The pathologists of our asylums would be greatly benefited
and stimulated by such a connection with our teaching bodies.
A lectureship in a university or medical college would be a
great incentive, and would probably enable a certain proportion
of them to make this work their life aim and occupation,
instead of being, as it occasionally is, a stepping-stone to more
lucrative positions, or, more frequently, a loss of time, so far as
professional advancement is concerned, leading to the abandon¬
ment of the work by men who have obtained very valuable
experience and achieved no inconsiderable success. Further,
the establishment of such lectureships should form a very
efficient means of enlisting the student’s interest in the
pathology of insanity at that stage of his career when he is
inclined to emulate the enthusiasm of his teachers. This is
greatly to be desired and would doubtless result in attracting a
due proportion of the abler students to this special branch of
medicine, and, eventually, in a great increase in the knowledge
of it by the general body of the profession.

It is to be hoped, therefore, that the asylum pathological
laboratories, of which we are so justly proud, should no longer
be allowed to “ waste their fragrance ” on the English medical
desert, as, judging from some criticisms, they now appear to do,
but should be brought into prominence and usefulness by
becoming associated with our professional teaching institutions.

The need is urgent, and there should be no delay in pressing
on this matter. It is to be hoped that the annual meeting will
not pass by without some effort being made by the Medico-
Psychological Association to assert the claims of our pathologists
and pathological laboratories.

Part II.—Reviews.

Das SexualUben unserer Zeii \The Sexual Life of our Time\ By Dr.
Iwan Bloch. Berlin : Marcus, 1907. Pp. 822, 8vo. Price 12 m.

Dr. Bloch is widely known as the author of various able and learned
works on various subjects in which history and medicine meet,

638

REVIEWS.

[July,

and more especially by the remarkable work, Dtr Ur sprung dcr
Syphilis , in which he has exhaustively discussed the evidence which
seems to demonstrate the American origin of syphilis. This latest
volume is, however, perhaps the most important work he has put forth,
and certainly the most ambitious. It is designed as nothing less than
“ an encyclopaedia of sexual science,” and it is not easy to find any aspect
of this many-sided subject which has here been neglected. One is
tempted to compare Dr. Bloch’s work with the scarcely less compre¬
hensive work by Dr. Forel, Der Sexuclle Frage (now translated into
French), which was briefly reviewed in the Journal last year. Such
a comparison well brings out the essentially unlike character of the
two books, although there is no very wide divergence of opinion on
most of the main topics, and both writers place themselves at the
point of view of modern science and culture. The marked individuality
of each writer makes itself clearly felt. Forel, a man of strong and
sometimes even somewhat extravagant independence, and pronounced
personal moral convictions, relies mainly on his own practical experi¬
ence and on his own intuitions; while these generally guide him
aright, his indifference to the results of other workers and his disdain
of the minutiae of exact research and scholarship sometimes lead him
into error or eccentricity. Bloch, who is not only a physician but
a patient and indefatigable scholar, tireless in research, perpetually
testing his own work and modifying his results when modification seems
necessary, approaches his task in a much more objective spirit. His
erudition in respect to every department of his subject is amazing and
prodigious, and scarcely less remarkable is his power of presenting it in
a condensed and attractive form. Anyone who has mastered this book,
it may be confidently said, not only possesses all the main results
attained in this field up to date, but also has in his hands the necessary
clues for further investigation.

The volume contains as many as thirty-three chapters, each discussing
some separate important problem. The psychic and physical aspects of
love are first considered, the secondary sexual characters in their
relation to love, the woman question in the same connection, modesty,
sexuality, and religion, individualisation in love. Then the author
turns successively to free love, marriage, prostitution, venereal diseases,
and the questions connected with the control of venereal disease;
here Dr. Bloch is in his own special department, and writes in his most
vigorous and illuminative manner. Formerly an adherent of the old
view in favour of the official registration and regulation of brothels, he
has now joined the increasing number of distinguished authorities who,
following Blaschko, recognise the futility of all such attempts. But he
approaches the problem of syphilis hopefully, as merely an episode of
European civilisation, a drama in five acts, each lasting a century; we
are now, he believes, at the beginning of the fifth act, and it is the task
of the present century, working through medicine and hygiene in
co-operation with social measures, to bring that drama to a conclusion.

Eight chapters are devoted to the chief forms of sexual perversion,
special attention being given to the question of homo-sexuality. In
former works the author adopted the now somewhat antiquated view
that homo-sexuality is mainly acquired, but with his alert mind, ever

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ready to modify his attitude with riper knowledge, he has now abandoned
that position. During the last few years he has given special study to
sexual inversion, investigating many cases, and has come to the con¬
clusion that a very large number of such cases are congenital; he
would, indeed, confine the term “ homo sexuality ” to such congenital
cases, and establish a separate group, under the heading of “ pseudo-
homo-sexuality,” for acquired cases. With Magnus Hirschfeld, who
undoubtedly has a wider acquaintance with sexual inversion than any
other living authority, he believes there can no longer be any doubt
that “homo-sexuality may be associated with complete mental and
physical health.” In regard to the very difficult question of the treat¬
ment of perversions, Bloch lays weight on personal influence through
suggestion: actual hypnotism he is not enthusiastic about, but he
considers that very much good is done to the patient even by mere
intercourse with a wise physician experienced in such cases. A chapter
is given to the question of sexual offences before the law, the conclusion
being that these matters mainly concern medicine, and that the judge
of the future in this field must be the physician. The last nine
chapters are devoted to various miscellaneous subjects, the question of
sexual abstinence, sexual hygiene, neo-Malthusianism, pornographic
literature, etc.

The author has written a weighty, learned, comprehensive, and even
brilliant treatise which cannot fail to be helpful and instructive
even to those who have given most study to the subjects here discussed.
Is it too much to hope that the book will some day be translated into
English ? Havelock Ellis.

Epilepsy: A Study of the Idiopathic Disease. By William Aldren

Turner, M.D.Edin. London: Macmillan, 1907. 8vo. Pp. 272.

Dr. Aldren Turner has given us a well-arranged and carefully-thought-
out study of idiopathic epilepsy. He has embodied in his book the
views of all the principal authorities, and has also given his own
personal observations, which have been deduced from 1000 cases
which were under his care at the National Hospital for the Paralysed
and Epileptic, and also at the Colony for Epileptics, Chalfont St. Peter.
The book is written from a clinical standpoint, and all the different
features of the disease are well brought out and placed under definite
headings in such a way as to make it an excellent book for consulta¬
tion.

The first chapter is introductory, and here is discussed in general the
various conditions underlying the epileptic convulsions and psychoses.
In regarding epilepsy as an organic disease of the brain, he points out
that he may b^going further than some other observers, but he supports
his view by “ the unsatisfactory results of treatment in the majority of
cases, the overwhelming numbers of epileptics who become victims of
the confirmed disease, and the progressive character of both the
paroxysmal and inter-paroxysmal symptoms/’ The next two chapters
are devoted to etiology, which is taken up in all its aspects, and

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numerous tables are supplied. As is usual, the author assigns the chief
predisposing cause to hereditary influences, and he finds that 37*2 per
cent . of his cases are due to ancestral epilepsy, the number being brought
to 51 per cent . when other hereditary neuropathic influences are
included. He thinks that this is really under the number, for when
hospital and private cases are analysed separately a heredity occurs in
19 per cent more cases in the latter than in the former. The determin¬
ing causes, both physiological and pathological, are closely scrutinised,
and he summarises his views as follows : “An endeavour has been made
in the preceding pages to show that the epileptic tendency is a sign, or
stigma, of a neuropathic inherited disposition, the anatomical biisof
which is seen in certain well-defined structural peculiarities, both of the
body and of the cerebral cortex. In those who have inherited the
epilepsy tendency a convulsive habit may be established, either in the
course of natural development, or as a result of certain occasional or
accidental causes. Once the convulsive habit has been established
there is a tendency to its perpetuation in the form of recurring epileptic
seizures. Thus, infantile convulsions are frequently the starting-point
of subsequent epilepsy, either as a direct sequence of the convulsions,
or in later years at or about the onset of puberty.” This view brings
epilepsy, etiologically, very near to insanity, and shows how much they
have in common.

Two chapters are given to the clinical study of epileptic fits, and in
connection with these we may quote the following passage, in which the
psychical factor is most properly brought into great prominence: “In
the earlier days the convulsion or fit was regarded as the sole element
of importance in the clinical study of epilepsy, but in more recent yean
the psychical factor has come to be looked upon as of almost equal
importance, and both are regarded as manifestations of a predisposition
associated with inheritance.” We would wish to draw special attention
to a series of excellently designed “ day-and-night ” charts for recording
fits, which show at a glance the number and kind of fit for each day and
night over a period of a whole year, each chart being only the size of
one page. They would be of great service in asylums. In discussing
remissions, he notes a point of interest, which is the occasional existence
of a remission extending over the ages of puberty, and early adolescence
in those who have previously suffered from fits and who have eventually
become confirmed epileptics. There is a chapter on the mental states,
which are well known to all alienists, and he defines as psychical
equivalents “the mental phenomena of the pre- and post-convulsive
states when they occur without convulsion or spasm,” and he adds that
he has never seen any psychical equivalent that had not its counterpart
in the pre- and post-paroxysmal psychoses of epileptics.

The chapter on pathological anatomy is written by Dr. John Turner,
of Essex County Asylum, and is now familiar to readers of the Journal
of Mental Science . His opinion that the immediate cause of the fit is
cortical stasis, resulting from obstruction to the blood-supply by intra¬
vascular clotting in a brain hereditarily and structurally predisposed to
instability and convulsion, is distinctly novel and interesting, and,
although convulsions may not arise from a local anaemia in every part
of the brain, the occurrence of thrombi in vessels supplying the silent

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areas may be the cause of the attacks of stupidity and confusion, or
excitement, from which epileptics occasionally suffer. Dr. Aldren Turner
gives a clear resutne of the chemical pathology, and discusses the auto¬
intoxication theory, which he is inclined to favour, believing that there
are arguments in support of it. He does not go so far as to say that all
types of epilepsy may be explained by this theory, yet, when taken in
conjunction with the results of the researches of Dr. John Turner,
“ there would appear to be proof that some types of epileptic paroxysms
may be ascribed to auto-intoxication in persons hereditarily and
structurally predisposed to convulsion. These are, serial epilepsy, the
status epilepticus, and fits associated with acute psychoses, as post-
convulsive symptoms.” With regard to recovery, his standard is nine
years without a fit, and, in his experience, about 10 per cent . may be
regarded as possible cures.

Under treatment he urges prophylaxis by care in the upbringing of a
neuropathic child, that over-exertion and strain, both intellectual and
physical, should be avoided, and that the peculiarities of each child
should be carefully studied. He deprecates the use of bromide salts in
larger doses than 60 grains in the day ; if benefit does not follow, some
of the various other remedies should then be tried. Treatment in an
institution, although not always possible, is often the best, on account
of the ease with which patients can be brought under satisfactory super¬
vision. There is a short description of epileptic colonies in the appen¬
dix, which is of value, as these are gradually being recognised as the
most convenient way of dealing with the unfortunate sufferers from
epilepsy in the present state of science. A good index completes the
book.

Throughout the book there is continuous evidence of clear insight,
an open mind, and broad views on the part of the author, enabling him
to treat his own numerous observations and his extensive knowledge of
the ideas of others in a careful and judicial manner. The result has
been that this volume will certainly take its place as a work of authority,
and it has enhanced the reputation of the author. It is a study of
epilepsy which is very satisfactory to the asylum physician, as it brings
all epileptics into line with the class he sees daily, and with the
psychoses generally. C. H. G. G.

Lectures on Neurasthenia. By Thomas D. Savill, M.D.Lond.

London: H. J. Glaisher, 57, Wigmore Street, W. Pp. 216.

Price 7 s. 6 d.

The third edition of these Lectures deserves perusal by every student
of mental diseases, for the author’s special experience of the various
forms of exhaustion psychoses will be a fitting complement to that of
the asylum physician who has the later care of not a few of those so
lucidly and instructively described by Dr. Savill. The period in the
history of several cases of insanity before that of actual registration is
that described by Dr. Savill in these lectures, which are concise, clearly
written, and eminently practical. The whole volume reminds us of

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642 EPITOME. [July,

Trousseau’s beautiful lectures. It is pleasurably written, well arranged,
provided with a most useful bibliography, and it has a serviceable index.
In it is a clinician’s experience logically put forward after thorough
investigation, the differential diagnosis of these perplexing cases is
clearly described, the pathology is sound, and the treatment practical

Part III.—Epitome of Current Literature.

1. Neurology.

A New Method of Testing the Hearing of Dogs [Eine neue HorpriiJtings
methode bei Hunden\ ( Neur . CbL, Nr. 7, 1907.) Kalischer , 0 .

Dr. Otto Kalischer has followed his valuable researches on the extir¬
pation of the brain in parrots by a noteworthy inquiry into the function
of the temporal lobe. In former ablations of portions of the brain, the
significance of after-effects was left to observations dependent upon
casual circumstances, sometimes under the influence of the whole
cerebral cortex. Kalischer has hit upon the idea of subjecting the dogs
upon whom he operated to a preliminary drill. He taught them not to
seize upon a piece of flesh till a particular note was played on the organ,
or on the piano. Ordinary dogs learned this lesson in about a fortnight,
and arrived at such perfection that the dogs understood the smallest
musical interval half tones higher and lower than the prescribed note.
Even amongst pronounced dissonances the note for food was promptly
recognised. It is worthy of remark that the dogs in general can hear
the whole gamut, a capacity which few men with a musical ear are
possessed of.

In his experiments, Dr. Kalischer took precautions to isolate the
hearing function by blinding the drilled animals. In others, he removed
the cochlea ; if one of these organs was removed, there was no change in
the dog’s behaviour, but when both cochleae were destroyed, the lessons
of the drill were lost.

Kalischer now went on to the ablation of the temporal lobe. It need
not surprise us that the notes were still recognised when but one tem¬
poral lobe was removed, but, w hat is singular, when both temporal lobes
were extirpated in the second week after the animal, recognising the
notes, was able to go through its former drill; Kalischer was even able to
teach the animal to learn to observe a new note.

By the former less precise methods of observation, animals deprived
of the temporal lobes ceased to show a response by obeying orders, or
erecting the ears, or wagging the head; w'hile Kaiischeris dogs, as
described, were attentive to the notes he had taught them. After a time,
a slight reaction to sounds appeared with the dogs under ordinary
observation.

Kalischer is of opinion that there are reactions to hearing from
nerve tracts below the cerebrum. All those reactions which depend

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upon the awakening of the attention of the animals, that is upon a con¬
nection of the hearing organs with the functions of the upper brain,
cease to occur when the temporal lobes are removed, while with the
dogs subjected to the drill, the sound of the note only served for the
invitation or summons of the process of eating.

Further experiments upon the destruction of the corpora quadrige-
mina went to show that tne hearing process concerned in the drill may
fall below these ganglia.

William W. Ireland.

2. Psychology.

Psychopathology in Schiller's and Ibsen's Plays [Fsychopathologisches bei
Schiller und Ibsen\ {Centralb. f Ncrvenheilk. u. Psychiat '., March
15//*, 1907.) Hoppe , A.

The psychiatrical investigation of the imaginary beings created by
dramatists has long been a favourite amusement of alienists. Not long
since a Paris thesis was devoted to an examination of the mental state
of all Ibsen’s leading heroes and heroines. The lawyers are now
beginning to join in from their point of view. Wulffen, a Dresden
lawyer, has published a criminological study of the Moor family in
the Robbers and of Nora in the Doffs House, and Dr. Hoppe, as an
alienist, now criticises Will (Ten and sets forth what he conceives to be
the sound psychiatrical view of these personages. As Hoppe very truly
remarks, the poet, in pursuing his own ends, is not bound to be
scientifically exact; it is impossible to give an exact diagnosis of the
insanity of Faust’s Gretchen, yet the prison scene is just as moving to
an alienist as to anyone else. The layman, however, is apt to think
that medical handbooks will yield the names of mental conditions
depicted by the poet, and Wulffen, Hoppe believes, has not quite
escaped this tendency. He regards the Moors as a family in the
course of hereditary degeneration. Franz Moor, in Wulffen’s opinion,
is a “ bom criminal,” though without “ moral insanity,” and represented
with profound insight; “from the present standpoint of science he is
not criminally responsible.” Hoppe considers that even if this diagnosis
were correct, from the dramatic artist’s point of view there would be
loss rather than gain, for the artist desires that his creations should
share the common characters of humanity, and if they are mere mental
monstrosities, working according to laws of their own, they lose in
human interest. While Hoppe is not in agreement with those who
hold that Schiller avoided the introduction of psychopathic elements,
he thinks such elements are much vaguer than is maintained by Wulflen,
who also believes that Karl Moor is a picture of paranoia, a contention
Hoppe will by no means agree to. With regard to Nora, however, he
agrees with Wulffen in seeing a case of hysteria, or at all events a
character who may be fairly regarded as hysterical. It is interesting to
note that Wulflen does not regard Nora’s proceedings as coming within
criminal law. While differing from Wulffen at many points, Hoppe
considers that his discussion is marked by great dialectical skill.

Havelock Ellis.

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3. Aetiology of Insanity.

On the Etiology of Congenital and Early Acquired Mental Deficiency
[Zur Kenntnis der Atiologie der angeborenen und friihzeitig erwor-
beneti psychischen Defektzustdnde\ (. Psychiat . neurol. IVochensch .,

Nr. 48, 49, und 50, 8 Jahr.) Schloss , H.

Dr. Schloss, of Kierling-Gugging, in his inquiries into this subject
has carefully examined 300 cases—150 of either sex. Rarely could the
mental deficiency be attributed to one cause alone. Even when there
was insanity or nervous disease in the parents, there were subsidiary
factors, such as injury in intra-uterine life or during child-birth.
Drunkenness in the parents seemed principally to be the cause of
idiocy indirectly by transmitting a disposition to eclampsic attacks.

Dr. Schloss has noted this tendency in several children of one family
without being able to find any trace of nervous disorders in the ascen¬
dants or the collateral relations, although the occurrence of such
eclampsic fits is undoubtedly commoner in neurotic families. The
attacks often come on in teething, especially from the sixth to the
eighth month. When the intelligence is permanently affected, the
deficiency is generally observable shortly after the attacks, although
sometimes it supervenes later. Eclampsia favours the disposition to
epilepsy. Most children who show mental weakness following epilepsy
have had eclampsic fits. In these cases there w r as generally a hereditary
neurosis. He has remarked that rachitic children who have suffered
from eclampsic attacks rarely fall into epilepsy. Not unfrequently
paralyses followed these eclampsic fits. The commonest forms were
right-sided hemiplegia, then paralysis of the left or right arm, left-sided
hemiplegia, paralysis of the right leg, or paraplegia.

Amongst the infectious diseases of children, Dr. Schloss signalises
whooping-cough as particularly dangerous for causing eclampsic fits
and effusions of blood within the cranium.

The most critical time against acquired idiocy falls in the second and
third year of life. He mentions some remarkable cases in which
imbecility was held to come on after surgical operations. A boy with
no neurotic heredity had remained in a normal condition up to his
third year. He was much alarmed at the prospect of an operation for
the removal of nasal polypi, and after the operation he became nervous,
timid, anxious, had night terrors, and ceased to advance in intelligence.
A girl, aet. 5, whose mother was mentally abnormal and sister weak-
minded, was operated on for caries of the bones of the hand. The
parents attributed the subsequent feeble-mindedness to the narcosis.
In a third case, a boy, set. 7J, who had a neurotic heredity, epileptic
troubles followed an operation on the bladder which ended in a
demented condition.

William W. Ireland.

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4. Clinical Psychiatry.

Hypochondria \De Thypochondrie\. (Arch, de Neurol ., September , 1905.).

Roy, P.

Between the hypochondria minor, met with by every general prac¬
titioner, and the hypochondria major, which is practically encountered
only by alienists, every intermediate grade exists. The study of its
pathogenesis should, however, limit itself to the milder forms, and
neglect those complex cases in which ideas of negation exist. There
is considerable difference of opinion as to whether the morbid preoccupa¬
tion is to be regarded as originating in imaginary, or in real, sensations.
The two opposing schools which thus arise may be termed the psychical
and the visceral—and the author thinks that they may be represented
by Dubois (of Berne) and Head respectively. Dubois maintains that
hypochondria lends itself peculiarly to psychical therapeutics, and con¬
siders that it is dangerous to look for peripheral affections, for, in these
cases, to look for them is to establish them. Head, as a result of his
researches into the zones of cutaneous hyperesthesia existing in his
cardiac and tubercular patients, concluded that the mental symptoms
arose from an abnormal state of the viscera, which caused the sensa¬
tions resulting from the internal organs to rise above the threshold of
consciousness. Modern authors tend to assign a more and more impor¬
tant place to the ccenesthesia in both normal and pathological affective
states. From an anatomical point of view the ccenaesthesia may be
regarded as the consciousness of the sympathetic system. Everyone
admits that in certain cases, at any rate, hypochondria may be
symptomatic, e.g ., zoopathy in gastric cancer, and the proportion of
such cases increases with the improvement in our diagnostic methods.

The author’s opinion is that hypochondria invariably contains both a
visceral and a psychical factor. That lesions of the sympathetic occur
in mental diseases is evidenced by the occurrence of visceral analgesias
in tabes and general paralysis. Similarly, hydrochondriacal paralytics
have exhibited lesions of the semilunar ganglia and of the splanchnic
nerves. These organic troubles are, however, in themselves not
sufficient; a special psychical constitution is also necessary—a veritable
hypochondriacal temperament. The rdle of the intellectual element is
well seen in the nosophobia of medical students. Although both the
organic and psychical factors are necessary, their relative importance
varies in individual cases.

The two factors may be encountered in numerous mental diseases,
and their co-existence will produce a state of hypochondria. Hypo¬
chondria does not exist as a distinct entity; there are only hypo¬
chondriacal states symptomatic of some other affection. Thus they
may occur in the various dementias—senile, alcoholic, dementia precox,
and above all in general paralysis. They are frequent in chronic
alcoholism and other toxic conditions, a fact explained by the
ccenaesthetic troubles prevalent in these cases. A hypochondriacal
paranoia has also been described under various names by different
authors. Lastly, a whole group of minor hypochondriacs belong to
neurasthenia. This last group is peculiarly susceptible to psycho¬
therapeutics. Bernard Hart.

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Fugues in the Psychoses and Dementias \Les Fugues dans les Psychoses et
les Dimcnees\ (Arch, de Neurol ., January , February , 1907.)
Ducostt , M.

Fugues in epileptics, hysterics, and degenerates, have been fre¬
quently described, but fugues occurring in the psychoses have not
received sufficient attention. The author defines a “fugue” as a
temporary state of nomadism occurring without motive. Distinction
must be made between motive and end. Except in the fugues of
dements, the patients are going to a particular place, and know that
they are going there. The above definition distinguishes fugues, by
their accidental and temporary character, from cases of habitual
vagrancy, though in some cases they ultimately pass into the latter.

Alcoholism. —(1) Fugues of instability: Contrary to the opinion
generally held, the role of hallucinations is here very unimportant The
fugues are rather a result of that need of activity and movement which
is developed at an early stage in alcoholic intoxication. They are
generally short, conscious, and without subsequent amnesia. In the
diagnosis it must always be remembered that alcoholism is often a
symptom of another disease, and not a primary factor. Thus fugues
accompanied by alcoholic excess occur in manic-depressive insanity.
(2) Second-state fugues resemble the epileptic or hysterical fugues, and
are followed by amnesia. In these cases the degree of intoxication has
usually been deeper.

Manic-depressive insanity .—The author has only met with fugues in
the manic phase. They are conscious and well co-ordinated, often
accompanied by psycho-motor agitation, and tendencies to alcoholic
and sexual excess. Subsequent memory is preserved intact. The
patient’s recovery is accompanied by insight into his previous condi¬
tion, and he recognises that the fugue was performed without motive.
In this respect these individuals differ from degenerates, who attempt,
with their feeble powers of invention, to legitimate their fugues.

General paralysis .—The fugues have the demential stamp, with that
absurdity in the details which characterises the paralytic. They are
accomplished without end and without motive, or perhaps with some
inadequate and ridiculous motive. Consciousness is, if not absent, at
least very enfeebled, and subsequent memory of the places traversed is
either altogether lost or very confused. Often the patients walk up to
the point of exhaustion without eating or sleeping. Occasionally, how¬
ever, fugues occur during the early stages of general paralysis, the so-
called medico-legal period, which lack to a considerable extent the
demential imprint.

Senile dementia .—The fugues are performed without motive or end.
The patients lack synthetic consciousness, frequently lose themselves in
the streets, forget their address, and wander all night aimlessly. After¬
wards they have no recollection of w here they have been.

Dementia prcecox. —(1) Fugues of instability: these resemble those
occurring in alcoholic cases. (2) Impulsive fugues: consciousness and
memory obscured. The fugue commences abruptly, is generally violent,
accompanied by disorder in acts and words, and of short duration.
(3) Fugues of intellectual deficiency: conscious, fairly well carried

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out, subsequent memory preserved. (4) Fugues of profound dementia :
unconscious, without end, with complete, or almost complete, sub¬
sequent amnesia. Bernard Hart.

A Contribution to the Study of the Eye in the Insane [Contribution
a Ftude de PCEil chez les Aliittes\. (Arch, de Neurol.^January,
1907.) Mezie , A. t et Bailliart , P,

More than 200 subjects were examined, and a considerable number
of visual fields, varying from 3 to 84 per patient, were obtained; control
observations were made amongst the attendants.

In all the patients hallucinatory states, and states of depression or
excitement, were accompanied by variations in the extent of the visual
field. These variations manifested themselves several hours before
the appearance of the mental trouble, and persisted for several hours
after its cessation. The degree of the variation was proportional to the
intensity of the mental symptoms.

The hallucinatory states are characterised by a retraction of the
field, constantly affecting its upper portion, and very frequently its outer
portion also. The retraction is always similar in form in the two eyes,
though sometimes differing in degree.

In states of depression, the field is constantly retracted in its upper
part. This is usually accompanied by variations due to the presence of
complicating factors, hallucinations, etc. In states of excitement an
expansion of the visual field in ail directions occurs. In the congeni¬
tally feeble-minded there is always retraction, invariably affecting the
upper part of the field, sometimes concentric. In manic-depressive
insanity the alterations in the mental condition are preceded by sudden
variations in the visual field, enabling one to anticipate the outbreaks
of excitement and depression.

As regards general paralysis, no characteristic alterations were
observed—the visual field varied as in other forms of insanity, according
as hallucinations, excitement, or depression were present.

In addition to their researches upon the visual fields, the authors also
examined in each case the pupils, the fundus, and the refraction. They
were unable, however, to draw any very definite general conclusions,
and this portion of their paper, though of great interest, does not lend
itself to an epitome. Bernard Hart.

A Case of Negativistic Amnesia [ Un cas de NPgativisme Mnisique\
(Journ, de Psych . Norm . et Path ., March , 1907.) Stglas.

The presentcase might also be designated, “ fixed idea of forgetfulness.”
The patient, V—, strenuously maintains that he has lost his memory, and
that he is incapable of giving any information concerning either his former
history or his present surroundings. It is obvious, however, that he makes
no real effort to recall the past, and it is possible, by means of various
indirect methods, to demonstrate that V — not only registers new
acquisitions, but evokes them at the proper moment. He is in no
way disorientated; he knows the attendants, and when necessary calls
them by name. He is employed in the refectory, and when patients
are ill he no longer lays for them. If appeal is made directly to his

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EPITOME.

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memory V— knows nothing, but by various subterfuges a complete
personal and family history has ultimately been obtained from him.
Dates, however, he professes himself incapable of retaining, and they
cannot be elicited either by the direct of indirect method. The date
question has become a kind of obsession. V—is always examining the
calendar, asking the patients the date, and noting the answers on
various pieces of paper. Immediately afterwards he is incapable of
repeating the information, but he remembers the exact number of times
he has written it down, and never confuses the particular piece of paper
with the notes of a preceding day. This date ignorance is a primary
fact upon which V— bases the plea that he has lost his memory. If
a souvenir has been elicited by the indirect method he comments “ I
don’t call that remembering—I cannot even remember the date.”

The above phenomena present a superficial resemblance to those
occurring in certain obsessional cases, but the symptoms usually
accompanying the obsession, anguish, etc., are entirely lacking. We
have really to deal with a more profound lesion, negativism, systematised
in the domain of memory. V—’s case differs essentially from those des¬
cribed as “ continuous amnesia.” In the former the patient’s souvenirs
are woven into his intelligent action, in the latter they are only recalled
in second states, dreams, etc., and even then only in a fragmentary
manner. Again, the “continuous amnesic” strenuously endeavours to
recall the lost memories, whereas V— makes no such effort The one
cannot, the other will not; the one is aboulic, the other negativistic.

Bernard Hart.

Contribution to the Study of Family Deformities of Congenital Origin
affecting the Extremities [ Contributo alio studio delle deformita con¬
ge nit e familiari della estremitd ]. {Ann. delFIstituto Psichiat. dell
R. Univ . di Roma, vol. iv, 1905.) Fabrizi v. Forli.

This paper describes in detail, with anthropometrical data, photo¬
graphs and radiographs, a remarkable series of malformations of the
extremities occurring in four members of the same family. The only
points to be noted regarding the parents were that the father was
alcoholic and suffered from Dupuytren’s contraction, and that the
mother was mentally below the average. There were eight children, of
whom the first four (two boys and two girls) died in infancy ; they all,
according to the mother’s statement, had contracted fingers or toes.
The remaining four, all girls, still living and aged from twenty-three to
thirteen years, present well-marked deformities in the hands or feet, or
in both. In the eldest the fingers of both hands are contracted, the
degree of flexion increasing from the index, where it is just perceptible,
to the little finger, which is bent almost into the palm ; the thumb is
flexed at the metacarpo-phalangeal joint; the feet are flat. In the next
child the same condition of flexion exists in both thumbs; all the fingers
of the right hand and the index finger of the left hand are bent at the
first interphalangeal joint; the left foot is flat and the right clubbed.
The third girl has the thumbs similarly contracted, and the little and
ring-fingers of both hands flexed at the first inter-phalangeal joint; she
is also flat-footed. In the youngest child all the fingers of the right
hand are flexed to a right angle at the first interphalangeal articulation,

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PATHOLOGY OF INSANITY.

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and the left medius is bent at the same joint to a slighter extent; both
feet are clubbed. The girls are all below the average in intelligence,
and in addition to the deformities described bear numerous stigmata of
degeneracy. Discussing the origin of this condition, the author con¬
cludes in favour of the view that it depends on a germinal variation. He
suggests that the Dupuytren’s contraction from which the father suffers
may indicate a tendency to such a deviation, and that this tendency
has been stimulated by the teratogenic influence of alcoholism.

W. C. Sullivan.

Psychic Hyperesthesia and Homicide [THyperesthlsie Psychique ct FHomi¬
cide]. (Arch, di Psichiat ., vol. xxviii ) fasc.i, //, 1907.) Marro.

Marro finds that the cerebral condition which determines homicide
is essentially a psychic hyperaesthesia, physiological or morbid, which
renders the individual unduly sensitive to impressions affecting his
personality, while it lowers the level of tolerance for disagreeable stimuli
to such a degree that they cannot fail to excite a violent and immediate
reaction against the persons who are their source. Developing this
explanation—which, as it stands, recalls somewhat the virtus dormiiiva
assigned as the reason of the soporific action of opium—the author goes
on to refer to the influences which promote this hyperaesthesia, giving a
prominent place amongst them to the period of puberty. In this con¬
nection he points out that during the years 1890-95, in Italy 41 per
cent, of homicides were committed by persons under twenty-five years
of age. Another factor to which he attributes much importance is that
of climate. From the statistics of crime in Italy he shows, in agreement
with what has been found in other countries, that homicides and crimes
of lust are much more frequent in the southern districts, while crimes of
acquisitiveness, which are more under the influence of economic con¬
ditions, show no such correspondence with climate. As a means of
combating this cerebral hyperaesthesia, Marro would lay much stress on
hydropathic exercises as a part of school training.

W. C. Sullivan.

5. Pathology of Insanity.

Contributions to the Pathological Anatomy of the Brains of Cretins.
(Zeitschr. f He ilk., 1906, S. 57-97 ; reported in Neur. Clb.,
Nov. $lh, 1907). Scholz and Zingerle.

Scholz and Zingerle, as the outcome of the examination of numerous
cases of cretinism, and of a comprehensive study of the literature of
the subject, consider that the injuries to the nervous system are pro¬
duced under the influence of disturbance of the function of the thyroid
gland. Some parts of the nervous system are more affected, while
others are less so. They recognise deficiencies in development, and,
more rarely, traces of inflammation. The dura mater is found thickened
through inflammatory processes. The cortical grey matter is more
prominent than the white matter. The brain substance is generally
firmer than usual. Hydrocephalus is often present. No uniform

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EPITOME.

[July,

alterations can be found; hence the clinical symptoms vary, although
they generally unite to form the characteristic type of cretinism.

There are asymmetries of the hemispheres, sclerosis of the gyri,
small size of the cerebellum compared to that of the cerebrum. To
the naked eye the most characteristic alterations are anomalies of the
convolutions; under the microscope there are observed the lesions of
sclerosis in imperfect growth of the nervous tissues.

The pathological anatomy of the cretin’s brain has much resemblance
to that of some forms of idiocy, both to the naked eye and under the
microscope. William W. Ireland.

Cerebral Asymmetry in the Normal and the Criminal [Asimmetrie Cere -
brali nei Normali e nei Delinquenti\ (Archiv di Psyckiat '., voL
xxviiij fuse. /, ii, 1907). Lattes .

In this interesting contribution to the question of cerebral morphology
in the criminal, the author records the results of his study of fifty brains,
considering more particularly the differences in convolutional pattern
between the hemispheres of the same brain. From his own observations,
and from those published by others, he finds that, in the points where
there are the most characteristic variations in the surface morphology,
asymmetry is relatively much more common in criminals than in normal
individuals. In the occipital lobe—with regard to which he follows
the description of Elliot Smith ( Records of the Egyptian School ofAledi-
ane , 1904)—a well-marked sulcus lunatus, giving a pithecoid type to
this region, is found to occur in a single hemisphere only, much more
often in the criminal than in the normal brain. Still more pronounced
is the difference in respect of the subdivision of the frontal lobe into
four horizontal convolutions. This condition in normal brains is found
to show a slight degree of asymmetry with predominance in the right
hemisphere, while in the criminal the asymmetry is very much more
frequent, and the four convolution type occurs more often in the left
hemisphere. It could not be made out that this greater degree of
asymmetry in the criminal brain was related to a definitely regressive or
a definitely progressive tendency. It appeared, on the contraiy, some¬
times to be due to the greater frequency of characters, such as the
Affenspalt or well-marked sulcus lunatus, to which a pithecoid signifi¬
cance is generally attributed, and sometimes to the development of
variations towards a more complex and higher type, as, for instance, in
the case of the interrupted interparietal sulcus. The author points out
that this combination of conditions above and below the average level
of evolution is met with in other regions of the body in the degenerate,
and he suggests that it is paralleled by the combination of genius with
criminality. The paper is illustrated with very good photographs.

W. C. Sullivan.

6 . Treatment of Insanity.

The Injection of Alcohol into Peripheral Nerve Trunks {A Paper read
at the SociiU de Neurologie , July $th, 1906). (Gas. des I/bp.,
July 1 o/7/, 1906.) Brissaud , Sicard and Tanon.

The results reported are of considerable importance in connection

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TREATMENT OF INSANITY.

651

with the treatment of affections of the nervous system. In the first
place, jthe investigators confirm the statement that favourable results
follow the injection of alcohol into the branches of the trigeminal
nerve, according to the procedure of L£vi and Baudouin. In six
cases of trigeminal neuralgia, and in three cases of facial spasm (one of
which was of fifteen years’ standing), a few injections resulted in a
partial cure. In two cases of facial spasm treated in this way by MM.
Valude and Dupuy-Dutemps, the patients remained free from spasm,
in one case for six months, and in the other for a year. But of still
greater interest is the fact that the writers have used this method with
quite remarkable results in cases of contracture of the extremities
occurring as sequels of hemiplegia and paraplegia from organic disease
(hemiplegia following embolism in a case of mitral disease, for instance,
and paraplegia from haemato-myelia in a diver), also in a case of spasm
of the foot of fifteen years’ duration ; and finally in two cases of
paralysis agitans.

Alcohol at 80 degrees was used for injection ; the nerve trunk was
exposed by incision, and from one to three cubic centimetres injected
into the interior of the nerve-trunk. Immediately after the injection,
the contracture, the exaggeration in the reflexes, the clonus, and
Babinski’s sign disappeared ; soon there ensued paresia and partial
anaesthesia, lasting from three to five days or even longer. A week
after the operation there was R. D., which disappeared in the course
of the following fortnight; but the increase in the reflexes and the
clonus did not reappear. A serious drawback to the success of the
treatment, however, is the onset, towards the end of the first week, of
numbness and formication, even of distinct pains, in the area of
distribution of the nerve, and these symptoms may continue for two or
three weeks. This may be a question of dosage ; probably the alcohol
employed is too concentrated ; the investigation is being pursued in
order to ascertain what strength it is best to employ in order to secure
the benefits of the treatment while avoiding the consecutive neuritis.
Care must be exercised in the selection of cases for this treatment.
In cases of hemiplegia of very long standing and in cases of “ pseudo¬
bulbar paralysis ” no benefit was obtained from the injection. Again,
in one patient in whom an injection was made into the external
popliteal nerve, there ensued intense pains and trophic troubles. To
obtain the desired effects the alcohol must be injected into the nerve-
trunk itself and not merely into its neighbourhood. That the alcohol
is actually passing into the nerve during the injection is manifested by
the pain referred to its area of distribution.

M. Eden Paul.

Cases of Acute Mania with Depression ( Matiisch-deprcssives Irresein)
treated by Prolonged Administration of TrionaL ( Cbl. f nerveti-
heilk. u. Psychiat., February, 1907.) Wolff.

In the same journal (May and September, 1901) Dr. Wolff published
a paper on the “Trional Cure,” to which the present contribution is
supplementary, containing a report of seven additional cases. The
cases would, for the most part, in England be classified simply as
acute mania. The mental disorder was sudden in onset, there was

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EPITOME.

652

[Ju'y.

great excitement, with loss of the normal sense of relation to the
environment, and hallucinations. (As the cases were in an asylum at
Beirut, and were all Mohammedans, the question of alcoholic causation
hardly arises.) The administration of trional was begun immediately
on admission, the drug was given in divided doses, ranging from 15 gr.
to 45 gr- daily, usually by oesophageal tube ; administration was generally
continued for a fortnight. The motor excitement gradually subsided,
the patient became calm, and during the second week there was an
almost continuous state of sleep or stupor. It seems evident that the
action of the drug was cumulative. After its use had been discontinued
the patients took several days to wake up properly, and then for a few
days were either depressed or irritable. Soon, however, their mental
state became perfectly normal. The author does not claim that the
action of trional in cases of the type described is in any way specific;
indeed, everyone knows that such cases commonly get well without the
administration of any drugs at all. But he considers that their duration
is markedly shortened by the “ trional cure,” the therapeutic value of
which depends on the prolonged narcosis. An equally satisfactory
result could, he says, probably be secured by the use of veronal, or
some other allied hypnotic. He did not see any serious symptoms of
trional intoxication in any of his cases. He regards the treatment as
perfectly safe in an asylum, but unsuitable for private practice.

M. Eden Paul.

Heroin and Heroinomaniacs . (Le Prog. Afed., February 23rd, 1907.)

Duhcnii P.

During recent years, Drs. Duhem and Sollier have had under
observation a number of cases of heroinomania (as they term it), or
heroinism (as it is, perhaps, more suitably named). The object of their
paper is to describe the peculiar symptoms that occur during the with¬
drawal of the drug, and to draw attention to the dangers attending its
use. Pouchet pointed out the close resemblance between the chemical
composition of heroin and that of morphine—heroin is, in fact, diacetyl-
morphine—and expressed doubts whether a body so similar could be
safely used as a morphine substitute in cases of morphinism (for which
purpose it was at one time widely advocated). [Some years ago, in his
work on The Cure of the Aforfhia Habit , Dr. Oscar Jennings stated
that, while it was quite easy to substitute the heroin habit for the
morphine habit, the change was one greatly for the worse.]

As regards the independent therapeutic use of the drug, it has been
used chiefly in diseases of the respiratory organs, being especially valued
for its anti-dyspnceic powers and its calmative action on the respiratory
system in general. It has also been largely used in chronic, painful
disorders, and many consider its analgesic effects by no means inferior
to those of morphine. Duhem admits the activity of heroin in relieving
the symptoms of respiratory disorders ; but he considers that the effects
are transient, that the dose has rapidly to be increased, that habituation
soon follows, and that the heroin habit is worse than the morphine
habit, and less easy to cure. During the last year or so cases of
heroinism have become extremely frequent—as frequent as a few years
ago were cases of combined morphine and cocaine habituation, in which

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TREATMENT OF INSANITY.

1907.]

653

morphinists had acquired the additional cocaine habit in the effort to
substitute the use of cocaine for that of morphine.

The cases of heroinism treated by Duhem and Sollier were sixteen in
number. Of these patients, three acquired the habit through the
administration of the drug for the relief of spasmodic asthma; four
were morphinists in whom the use of heroin had been substituted in the
hope of curing the morphine habit; in three cases the use of the drug
as an analgesic had led to habituation; in the remaining six cases the
cause was one of the well-recognised causes of morphinism and other
drug habits, the narcotic having been taken to relieve fatigue (intellectual
or physical), overwork, insomnia, grief—the whole gamut of nervous
symptoms, of which morphinism is so frequently the climax. The daily
dose of the drug taken by these patients was a very variable one,
ranging from 1 to 20 gr.

The method of withdrawal of the heroin was similar to that employed
by Sollier in cases of morphinism. The patient was secluded; the
primae vise were cleared; the dose was then rapidly diminished during
about a week, after which it was completely withdrawn, the eliminative
organs being suitably stimulated throughout this period. Subsequently, as
indicated, care was taken to bring about “ the eliminatory crises
necessary for the proper redintegration of the glandular epithelia ”;
finally, the patient was fortified after the withdrawal, more especially by
a process of hyperalimentation. But whereas on these lines demorphini-
sation is commonly effected with sufficient ease, and without interruption
or disturbance, deheroinisation is accompanied by alarming and dis¬
agreeable symptoms, for which the physician must be ever on the alert.

In the earlier cases treated, just as in the withdrawal of morphine,
that drug was given in gradually diminishing doses, so heroin in
diminishing doses was used during the process of deheroinisation.
During demorphinisation, when, as sometimes happens, the cardiac
weakness common during this process takes the extreme form of actual
syncope, a minimal dose of morphine hypodermically suffices to restore
cardiac activity ; but serious symptoms occurring during deheroinisation
are not similarly relieved by the administration of heroin, while a small
dose of morphine is promptly beneficial. Therefore Drs. Duhem and
Sollier soon treated their cases of heroinism by substituting morphine
for heroin, and then proceeding with demorphinisation in the usual
manner. But even in this way all the dangers of deheroinisation are
not avoided. The elective action of heroin is on the bulbar respiratory
centre, and it is, above all, respiratory activity which fails during the
withdrawal of the drug. “ During the first days of the withdrawal, the
phenomena observed are similar in most respects to those that are seen
in morphinists during the withdrawal of morphine, but the prostration is
far more severe, perspiration is more abundant, the leaden tint of
countenance indicates a more severe intoxication. . . . With

further reduction of dose a condition of mental torpor ensues, the
circulation and respiration become sluggish, hsematosis is inactive,
paroxysms of dyspnoea ensue, and in the absence of extreme watchful¬
ness severe respiratory syncope is a very probable occurrence. More¬
over, the onset of this respiratory failure is most insidious, . . . the

pulse gives no warning whatever, but quite suddenly the respiration

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654

EPITOME.

[July,

ceases. In such cases the patient can only be restored by a combined
injection of morphine and ether. Heroin, we repeat, is absolutely
useless.”

Apart from the greater difficulties and dangers of the period of actual
withdrawal of the drug, the cure of heroinism compares unfavourably
with that of morphinism in the far more protracted period of con¬
valescence. After the withdrawal of heroin, the natural functions are
much less rapidly re-established ; appetite returns very slowly (rendering
the necessary hyperalimentation far more difficult than after demor-
phinisation); insomnia also is far more protracted and stubborn; the
loss of weight during suppression is apt to be greater, and the normal
weight is far less quickly regained. Duhem and Sollier conclude that
while morphine is a dangerous drug which should be used only with
great caution, heroin is a drug which should never be used at ail. Its
sedative effects are not superior to those of morphine, its cumulative
effects are more dangerous than those of morphine, and the drug-habit
to which it frequently gives rise is more serious than the morphine
habit. Of two ills, choose the lesser. “ But in prescribing morphine,
even the medical man should never lose sight of the fact that in the
majority of instances morphinism originates in the excessive, sometimes
culpable, complaisance of the patient’s medical adviser.”

M. Eden Paul.

( i ) Surgery for the Relief of Insane Conditions . Max E. Witte. (2)
Preliminary Report of Gynecological Surgery in the Manhattan
State Hospital \ West . Leroy Broun. (3) Observations on Some
Recent Surgical Cases in the Manhattan. State Hospital , East.
J. R. Knapp . (An/er. Journ. of Insanity , January , 1906.)

The most important and interesting of these papers is Dr. Witte’s,
dealing as it does with the general theory of surgical intervention in
cases of mental disorder. In the first place he considers that benefit is
often erroneously claimed as the result of a surgical procedure, when
it is more likely that time has been the principal factor in relief ; and,
again, he insists that in some cases the nature of the operation may be
indifferent, the improvement observed to follow it depending upon the
“crisis” in the organism, with its attendant changes in innervation,
circulation, nutrition, and metabolism. He compares the benefit of
simple laparotomy in cases of tubercular peritonitis, and he details two
cases of insanity in which cure followed organic crises of a non-operative
character. One of these was chronic mania of twelve years' standing
in which recovery occurred immediately after an attack of acute lobar
pneumonia; the other patient, a man who had been considered hope¬
lessly insane for years, broke his humerus in an endeavour to escape
from the asylum in which he was confined. He recovered promptly,
not only from the fracture of the humerus, but also mentally.

Dr. Witte lays it down as an axiomatic principle that in the treatment
of the insane, surgical intervention should be employed under precisely
the same conditions as in the sane. There are, however, two fields of
surgical enterprise to which considerable importance has been attached
in regard to the relief of mental disorder: these are cerebral surgery
and gynaecological operations. As regards both, moreover, the evidence

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TREATMENT OF INSANITY.

655

is conflicting, and the time for a final judgment has hardly yet arrived.
Whilst on the axiom already laid down there would arise no question
as to the need for surgical intervention in cases of recent injury to the
skull, with depressed fracture, or signs of meningeal haemorrhage,
Witte's experience leads him to anticipate little benefit from operative
interference for the relief of mental disturbance in cases of head injury
when a considerable period has elapsed since the receipt of the injury.
He gives several interesting cases in support of this view, and deduces
the maxim, “Operate early, before the insane condition has become
fully developed and fixed.” He considered that as time elapses, after
serious injury to the brain, the morbid nutritive conditions become
fixed, and relief can no longer be hoped from operation. When, in
long-standing cases of mental alienation after head injury, the friends
are eager for operation, it is right to give the patient the benefit of the
doubt; but it is not right to raise illusive hopes of success, and the
surgeon should insist that permanent benefit from operation is no more
than an unlikely possibility. Doubtless, remarkable benefit does occa¬
sionally follow operation in such cases, but Witte opines that in this
surgical field, as in others, it is chiefly the striking successes that see
the light in the medical press, whilst the failures, probably far more
numerous, are commonly left unrecorded.

As regards gynaecological operations in patients suffering from mental
disorder, Witte states that the following maxims are the result of his
experience and the guide of his practice at the present time :

(1) Unless there is actual disease of the pelvic organs requiring
operative aid, relief to mental disorder is not to be anticipated from
operative interference with these organs.

(2) Where there is disease of the pelvic organs as a complication of
mental disorder, less heroic measures than surgical interference often
do much good in the way of improving general health and comfort, and
thereby of aiding and promoting mental restoration.

(3) Pelvic disease in which surgical interference would be indicated
if the patient were sane, should be similarly treated if the patient is
insane.

(4) The annulling of procreative power by surgical intervention is
indicated and justified in certain types of insanity, deficiency, and
degeneracy depending on inherited and transmissible constitutional
tendency or abnormality.

In regard to the first of these maxims, Witte states that a few years
ago, when odphorectomy had attained the evil status of a surgical
fashion, he himself was infected with the prevailing enthusiasm, and
expected much from the artificial induction of the menopause in patients
in whom mental disorder was aggravated during the menstrual period,
but in whom no positive intra-pelvic disease could be shown to exist.
Experience has, however, doomed these hopes to bitter disappointment,
though in some cases, indeed, the operation was justified by his fourth
maxim, or by the relief given to sexual visceral irritation. Witte thinks
there has been a tendency of late to exaggerate the influence of the
genetic function in the life of women. He concludes his paper by
stating that he does not restrict to the female sex the desirability of the
sterilisation of the unfit.

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EPITOME.

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Leroy Broun publishes a table of several hundred operations, major
and minor, and the result of these (both as regards the physical and
the mental condition of the patient). The operations were for the
most part gynaecological, and were all performed on the female inmates
of the asylum. The length of time during which he has been conduct¬
ing them is, he thinks, too short for the conclusions drawn to be as yet
of very great value ; there are, however, some facts which he regards as
well established:

(1) If the operation, when needed, has been properly done and the
patient is not mutilated by an uncalled-for castration the mental con¬
dition is never aggravated by such a procedure. This, as stated, has
been the experience of Manton, who has been operating for over twenty
years; also that of Picque, whose operations have extended over a
period of twelve years, and of himself in the entire range of his surgical
work among the insane.

(2) There exists among the patients confined in the various insane
asylums many pathological conditions which can, and do, give rise to
symptoms detrimental to the patient’s physical well-being and mental
recovery. Those, with such conditions, have a right to be given relief,
irrespective of their mental state.

(3) Under the stimulus of the improved somatic state resulting from
surgical relief some of the patients show greater mental advancement
under the moral and therapeutic care than were shown before such
relief was given. At times this improved mental state continues to one
of recovery.

The primary object of surgical operations upon the insane should be
to improve the physical status of the patient with one end only in view—
of relieving them of physical suffering and nervous disturbances.

If, as a result of this relief, they are mentally improved, it is a sequel
not primarily sought, yet welcomed.

Dr. Knapp’s paper gives details of several interesting cases of opera¬
tion on insane patients, but does not deal at any length with the
theoretical aspects of the problem. The results of operations on the
insane, in carefully selected cases, fully demonstrate, in his opinion,
that surgery is one of the valuable means at our command for the
alleviation of physical suffering, and, in many instances, if judiciously
employed, will also be attended by an amelioration of the mental state.

M. Eden Paul

Hydrotherapy in Mental Diseases [Balneation et Hydrothlrapie dans les
Maladies Afentales\ {Arch, de Neurol., September , 1905.) Pailhas, B.

The application of hydrotherapy to mental diseases reaches back at
least to the time of Hippocrates. It was first systematically employed,
however, by Pomme, a French physician of the eighteenth century,
who prescribed for the “ vaporeux,” baths of various kinds, including,
notably, the prolonged warm bath. Pinel, though he praises the simple
bath, makes no mention of Pomme’s prolonged method. The practice
was revived by Turck and Brierre de Boismont, and its modem
development may be ascribed to Bonnefous, Guislain, Baillarger, Morel,
and more particularly to Kraepelin.

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1907.] TREATMENT OF INSANITY 657

All hydrotherapeutic procedures are based upon an excitation of the
periphery of the body, but their effects differ according to the tempera¬
ture of the water, the duration and mode of application, and the
characteristics of the patient. The last condition depends far more on
individual peculiarities than on the particular nosological class in which
the patient may be ranged. The state of the various bodily organs
must be taken into account, and it must not be forgotten that the
functional depression of the nervous centres is not proportional to their
organic depression, and that the latter is frequently disguised by excite¬
ment and agitation. Therefore in asthenic states, prolonged baths, on
account of their depressive action, should be in general avoided ;
recourse may here be had to warm baths of short duration associated
with friction, or to wet packing. Foot-baths, with or without mustard,
may be used in cases where there is prolonged circulatory trouble with
cyanosis of the extremities. The effect, however, must be carefully
watched, and supplemented with friction, passive movements, etc. In
the lighter degrees of depression, where the general state is relatively
good, hot baths may be employed at the outset, with cold baths or
douches later.

States of excitement are, as a rule, benefited by prolonged baths at a
temperature of 28° to 34°C., low-pressure douches, or rain baths.
Certain cases of. excitement, sthenic in character, such as occur in
hysteria, are best treated by cold plunge baths. Cold baths have also
been recommended in acute alcoholic delirium, but the procedure is
not exempt from danger, and should only be employed in the presence
of the physician. Acute delirium with high temperature may be treated
by cold wet packs, frequently renewed.

In certain patients of rheumatic, gouty, or plethoric constitution,
sudorific measures may be usefully employed, such as Russian or
Turkish baths.

Insanities of organic origin, such as general paralysis, and those
which coexist with cardiac or pulmonary disease, contra-indicate treat¬
ment capable of causing congestion of the affected organs, or of
depressing their functions. Hydrotherapy must here be partial and
symptomatic, and it is only exceptionally, e.g ., where bed-sores are
present, that prolonged baths are of value.

In subacute prolonged states of excitement, stimulating applications,
as, for example, the cold or Scotch douche, may be beneficially
substituted for the usual sedative procedures. This applies especially
to those cases where an amelioration in the physical condition is not
accompanied by a return to sound mentality.

Chronic cases will be submitted to an ordinary hygienic hydro¬
therapy, while attacks of excitement or depression occurring in the
course of such cases will be treated on the general principles mentioned
above.

Morel advocated hydrotherapy in general, and prolonged baths in
particular, as a prophylactic measure in the prodromal stages of insanity.

Bernard Hart.

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658 EPITOME. [July,

On the Thyroid Treatment of Endemic Cretinism [Zweiter Bericht ubtr
die Behandlung des Endemischen Kretinismus mit Schildrusen -
subsianz], (Wien, klin Wochenschr ., No 2, 1907, andNeur. Cbl. %
No. 5, 1907.) Wagner.

Dr. Wagner has been able to give a gratifying report of the success
of his treatment of cretins with the thyroid substance, which he has
now been prosecuting in Styria for above five years.

In most cases of cretinism the growth is much stunted. This is not
apparent before the fourth or fifth year of childhood; indeed, in the
earlier years the increase in length is sometimes greater than normal.

As it is important that the treatment should be begun as soon as
possible an early diagnosis is desirable. Wagner lays much stress
upon an abnormal size of the tongue, and the appearance of a goitre at
birth. The peculiar form of the nose is less characteristic; the pale
complexion and loosening of the skin often do not present themselves
before the second year. In later years, the malady is indicated by the
child not learning at the usual time to walk or to speak, by the dirty-
white complexion and tumidness of the skin, the dulness and apathy,
the late closing of the fontanelles, and the delay of the teething, the
peculiar form of the nose, and the slowness of growth. From the
observations of Alexander it appears that the deficiency of hearing is
often connected with a specific adenoid vegetation, with catarrh of the
aural passages. This affection is favourably influenced by the thyroid
treatmentwhere the labyrinth is involved improvement is less easily
obtained. Dr. Wagner presents the following conclusions.

Cretinism may be favourably influenced in all its stages, even as late
as the twenty-seventh year, by the use of the thyroid substance. The
earlier the treatment the better the result.

In the less severe cases (mostly of acquired cretinism) without much
deficiency of hearing, a complete cure may be attained if the treatment
is begun from the first to the third year. In one case in w’hich it was
in use from the sixth week the result was most gratifying. It is, there¬
fore, very important that the parents, in the districts where cretinism is
endemic, should be instructed about the means of rescuing their children
by having recourse to early treatment.

The stimulus given to the general bodily growth by the thyroid sub¬
stance is very striking. One patient, who was as old as nineteen years
when treatment was began, increased in height by 15, by 7, and by
6 cm., in all by 28 cm. during the next three years.

In the original paper in the Vienna Wochenschrift^ Dr. Wagner
describes in detail a number of most interesting cases.

William W. Ireland.

A Year of Treatment of Cretinism with Thyroid Substance [.Ein Jahr -
Kretinen-behandlung mit Schi/driisen-substanz]. ( Wien . nted.
Wochenschr ., Nos. 1-3, 1907.) Klimpely , E.

In the same number of the Neurologisches Centralblatt there is a
report of Dr. Klimpely’s experience of the treatment of endemic creti¬
nism in Moravia. 'This comprised twenty-seven male and nineteen
female cretins. The thyroid was administered in tablets, the doses

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TREATMENT OF INSANITY.

1907.]

659

cautiously increased. In a few cases unpleasant symptoms—diarrhoea,
vomiting, and tremulousness—were observed.

Increase in growth generally began in the first three months of the
treatment. In one cretin, who was already twenty-two years of age, there
was an increase of height of 5*5 cm. during the twelve months.

In cretins from fourteen to eighteen years old, the milk teeth still
lasted, and in one of these cases the second dentition commenced. In
two young women, one aet. 18, another set. 24, the menses came, the
breasts enlarged, and other signs of puberty appeared.

With his patients, Dr. Klimpely observed an increased appetite,
rendered more striking by the thinness following the change in the
condition of the skin, which ceased to be dry and tumid, the cessation
of the habitual constipation, the disappearance of the goitre, and, above
all, the alteration in the apathetic and torpid temperament. The degree
of improvement in the intelligence of the cretin is not specified in these
reports. William W. Ireland.

On the Treatment of Exophthalmic Goitre by Mobius's Anti-thy raid
Serum . (Neur. Cb /., Nr. 5, 1907.)

In this number, there is a collection of reports upon the treatment of
exophthalmic goitre with anti-thyroid serum.

Vilhelm Magnus, a Norwegian physician, has tried it in four cases.
He has come to the conclusion that this medicament should be used
in all cases of the disease. In fresh cases, it may bring an improvement
nearly approaching to cure ; in more severe cases it gives relief from the
most distressing symptoms.

Dr. Magnus observes that a complete cure cannot be expected unless
a portion of the thyroid gland be removed. As this operation is diffi¬
cult and hazardous, he recommends the serum treatment.

Dr. Aronheim, who had previously reported upon two cases of
Basedow’s disease, in which he had employed Mobius’s anti-thyroid
serum with decided improvement, describes another favourable instance
of the treatment. The patient was a woman, aet. 30. The cessation of
the menses was followed by weariness, palpftation, a feeling of distress,
and cough with expectoration, and night sweats; pulse small and
irregular, 90, circumference of neck 365, no exophthalmos. There were
no tubercle bacilli in the sputum. After taking several doses of the
serum there was a decided improvement. The heart, which had
extended on both sides, diminished to the normal size ; the heart’s
action became again regular, pulsations fell to 80, and the catarrhal
symptoms in the lungs disappeared. The struma remained unaltered.

Dr. Vermes, of Buda Pesth, had a patient, aet. 53, who, after the
removal of a uterine tumour, showed the typical symptoms of
exophthalmic goitre. Other treatment failing, he tried the anti-thyroid
serum in doses of from 30 to 90 drops a day. After using ten bottles
there followed improvement in some symptoms, and the disappearance
of others. The circumference of the neck diminished slightly; the
pulse fell from 140 to 80 beats, while the tremulousness and feeling of
heat troubled her no more.

Dr. Mayer, treating a young woman with the customary remedies for

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66 o

EPITOME.

[July-

exophthalmic goitre, had recourse to the anti-thyroid serumf from which
he speedily obtained a favourable and enduring result. He used doses
of 5 drops, slowly rising to 30 drops thrice a day. On the third day the
patient felt better; the pulse fell from 150 or 140 to 120 or 100; the
exophthalmos abated and the struma diminished. After six months the
improvement was found to be maintained.

The favourable reports of Dr. Somerville in the Glasgow Medical
Journal , vol. lxv, and of Dr. Gevers Leuven, of Munich, are also quoted.

Dr. Heinze, writing in Deutsch. med, Wochenschrift '. (No. 19, 1906),
had made trial of the anti-thyroid serum, but with such poor results that
he abandoned the use of it. William W. Ireland.

Case oj Basedow's Disease Treated with the Milk of a Goat deprived of
the Thyroid. (Norsk. Mag. for Liigevid , p. 707, 1905.) E. /.
Thrap-Meyer.

A married woman, aet. 41, who had been suckled by a nurse with
very prominent eyes, had become nervous after the birth of her first
child in 1883. She had palpitation and heavy perspiration. After the
birth of a second child, in 1887, the thyroid began to enlarge, and her
general health declined, so that she became very feeble. Various
medicines were tried without any benefit. She was then treated with
blood from a goat deprived of the thyroid; but the only improvement
was an abatement in the frequency of the pulse. When milk from a
goat thus treated was used the benefit speedily followed. The bodily
weight increased, and the pulse became slower. On January 15th the
heart appeared to be normal, the eyes to be less protuberant, and the
swelling of the thyroid subsided. If the patient discontinued the milk
for a few days the old symptoms again began to appear.

William W. Ireland.

A Visit to the Asylums and other Institutions of the United Stales
\Eine Studienreise zum Besuche der Irren- tend venvandten Anstalien
in den Vereinigten Staaten Nordatnerikas\ (Psyehiat. Neurol.
Wochenschr ., Nos. 45-52, 8 th fahr.) Hochauf.

This is contained in a series of papers descriptive of the asylums for
the insane, the idiotic, and the epileptic, and similar institutions, of
the United States, the product of personal visits by Dr. A. Hochauf, of
Gugging. The author gives painstaking descriptions of the several
institutions. He praises the treatment of the insane which he
witnessed in America, and was impressed by the after-care associations
which serve for a halfway stage between the lunatic asylums and the
outer world. This Dr. Hochauf would like to see in operation in his
own country. The author’s descriptions are illustrated by nineteen
engravings of asylums and hospitals, and plans of the buildings.

He visited the great Agnew asylum, in California, before it was thrown
down by the recent earthquake, and adds a short account of the
catastrophe. Out of 770 patients there were killed no individuals,
including 2 physicians and 12 attendants; 70 were severely injured,
having bones broken and limbs crushed ; 100 were less seriously hurt

William W. Ireland.

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NOTES AND NEWS.

661

Part IV.—Notes and News.

MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN
AND IRELAND.

A Quarterly Meeting of the Medico-Psychological Association was held at
ii, Chandos Street, Cavendish Square, London, W., on Thursday, May 16th,
1907, at 3 p.m., under the presidency of Dr. Robert Jones.

Members present:—Chas. Aldridge, A. J. Alliott, H. T. S. Aveline, G. F.
Barham, Fletcher Beach, G. F. Blandford, H. F. Bodvel-Roberts, C. Hubert Bond,
David Bower, James Chambers, R. H. Cole, H. Corner, Maurice Craig, W. R.
Dawson, H. Devine, T. O’C. Donelan, A. C. Dove, T. Drapes, F. W. Edridge-
Green, J. A. Ewan, W. F. Farquharson, David Ferrier, N. J. H. Gavin, B. Hart,
H. E. Haynes, J. W. Higginson, G. T. Hine, T. B. Hyslop, A. M. Jackson,
Robert Jones, P. L. Langdon-Down, R. L. Langdon-Down, P. W. MacDonald,

G. D. McRae, W. F. Menzies, C. A. Mercier, C. S. Morrison, W. F. Nelis,

H. Hayes Newington, D. Orr, Bedford Pierce, W. Rawes, H. Rayner, W. Ford
Robertson, R. G. Rows, E. T. Sail, G. H. Savage, G. E. Shuttleworth, P. C.
Smith, R. Percy Smith, J.G. Soutar, R. H. Steen, R. C. Stewart, D. G. Thomson,
J. Turner, A. R. Urquhart, F. Watson, R. Whittington, T. Outterson Wood.

Visitors: Drs. Arkwright, E. H. Bashford, C. E. Beevor, J. P. Candler,
G. W. Dean, J. Eyre, H. E. Hedingham, G. M. Hine, G. W. F. Holmes,
Howard Horder (Ohio), G. H. Johnston, W. E. Marshall, C. J. Martin, Purves
Stewart, W. Williams (B.C.).

Apologies were received from Drs. Bolton, Clouston, Douglas, J. H. MacDonald,
Mott, Turnbull, and others.

The following members had been present at the Council Meeting which was
held prior to the Quarterly Meeting: Drs. Aveline, Beach, Bond, Bower, Chambers,
Craig, Dawson, Drapes, Ewan, Hayes Newington, Robert Jones, P. W. MacDonald,
Miller, Pierce, Rayner, Percy Smith, Steen, Thomson, Turner, Urquhart, and
Outterson Wood.

The minutes of the previous quarterly meeting having appeared in the Journal
were taken as read.

The following candidates were elected ordinary members of the Association :
Sidney Herbert Clarke, M.A., M.B., B.C.Cantab., M.R.C.S., L.R.C.P.Lond.,
Assistant Medical Officer, County Asylum, Prestwich (proposed by David Orr,
N. J. H. Gavin, and Bedford Pierce) ; Alfred Wilson Daniel, B.A., M.D.,
B.C.Cantab., M.R.C.S., L.R.C.P.Lond., Senior Assistant Medical Officer, London
County Asylum, Hanwell (proposed by Percy J. Baily, Percy Spark, and C. Hubert
Bond); Mary Edith Martin, L.R.C.P.&S.Edin., L.F.P.S.Glasg., L.S.A.Lond.,
House Surgeon, Lewes Road Hospital, Brighton (late Medical Officer, Victoria
Settlement, Liverpool (proposed by A. Helen A. Boyle, Robert Jones, and C.
Hubert Bond); Arthur Edward O’Reilly, L.R.C.S.I., L.&L.M.R.C.P.I., Assistant
Medical Officer, North Riding Asylum, Clifton, York (proposed by John B. Tighe,

A. I. Eades, and Bedford Pierce); Ernest Septimus Reynolds, M.D.Lond.,

B. Sc.Vict., F.R.C.P.Lond., Assistant Physician, Manchester Royal Infirmary,
2, St. Peter’s Square, Manchester (proposed by Bedford Pierce, David Orr, and
William Starkey); Henry Watson Smith, M.B., Ch.B., Assistant Medical Officer,
Durham County Asylum, Winterton, Ferryhill (proposed by Wm. St.J. Skeen,
John W. Geddes, and C. Hubert Bond) ; John Archibald Taylor, M.B., Ch.B.Edin.,
Assistant Medical Officer, County and City Asylum, Powick, Worcester (pro¬
posed by Geo. M. P. Braine-Hartncll, H. T. S. Aveline, and C. Hubert Bond).

Irish Lunacy Legislation.

The Presipent said that at the Council meeting which had just been held the
following resolution was passed, and he had been requested to bring the matter

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662

NOTES AND NEWS.

[J^y.

before the general meeting: “That the Medico-Psychological Association of
Great Britain and Ireland approves of the resolutions passed by the Lunacy
Legislation Sub-Committee of the Parliamentary Committee of the Association
with reference to Irish lunacy legislation, on April 3rd, 1907, and also those by the
Irish Division, passed on April nth, 1907 (with the exception of the concluding
paragraph), and that a copy of this resolution be forwarded to the Chief Secretary
to the Lord-Lieutenant of Ireland.” Those present were aware that there were
impending changes, which had been discussed in Parliament, with regard to lunacy
matters in Ireland, and the Council of that Association had taken certain steps to
place certain resolutions before the Chief Secretary. They related in part to the
admission of patients, in part to the care of patients, and in part, also, to the
classification of patients, as to whether they should be in asylums or whether they
should be boarded out. Dr. Dawson, the Secretary for Ireland, was present, and
he could briefly explain to the meeting what had been done.

Dr. Dawson said that when it became a matter of common report that a Bill
to amend the Irish administration was being drafted it seemed desirable that
certain considerations connected with lunacy administration in the country should
be brought before the framers of the Bill. He therefore wrote to the Secretary of
the Parliamentary Committee, who summoned a special meeting of the Legislation
Sub-Committee, and that Sub-Committee at their meeting adopted certain
resolutions, which were forwarded to the Chief Secretary for Ireland. He would
state to the meeting what was the gist of those resolutions. One was that the
usual method of certification for admission to the Irish public asylums required
amendment. The second set forth that facilities should be provided for the
admission of voluntary boarders in Irish asylums. Thirdly, that provision should
be made for boarding out pauper patients. Fourthly, that the chronic insane were
more likely, in the opinion of the Sub-Committee, to be treated properly in
annexes to existing asylums rather than in workhouses or other institutions with
separate administration. Fifthly, that there should be an extension of the Idiots
Act to Ireland. Sixthly, that the qualifications of the Resident Medical Super¬
intendent, as set forth in the Irish Local Government Act, should be retained, and
that the mode of election of medical officers should be clearly defined by statute;
and, in order to secure a better class of nurses, that superannuation of the officers
should be made compulsory. Finally, that with the extended duties and
responsibilities, an increase in the numbers and in the powers of the inspectors of
lunatics in Ireland is necessary. In addition to that, and partly by the suggestion
of the President and other members of the Sub-Committee, he brought the matter
before the Irish Division, at a meeting on April nth,and they passed a resolution,
which was a little more strongly worded, perhaps, but essentially the same as that
forwarded by the Sub-Committee of the Association. The only important addition
made was one stating that in the event of any legislation dealing with Irish lunacy
matters an enactment should be introduced whose object was to extend to Ireland
the provisions of the Act of Settlement concerning the matter of the deportation
of pauper lunatics. The object of that was to place Ireland in the same position
as Scotland at present occupied. In Scotland, if a person belonging to anv other
part of the United Kingdom—England, Ireland, or Wales—became insane,
and had not been for twelve years in one situation, he could be deported to the
place of his birth, whereas in Ireland there were no corresponding powers for
deporting Scotsmen or Englishmen to the places of their birth ; they were obliged
to keep them in Ireland. But Ireland did not want to keep them, and it was with
the object of assimilating the legislation of Ireland to that of Scotland in that
respect that the clause was introduced. It was a matter which was regarded by
the asylum medical officers in Ireland as one of importance. The other point to
which the Council of the Association took exception at their meeting that day was
a mere suggestion, and did not form an essential part of the recommendations of
the Irish Division ; but as it was specially mentioned in the resolution he thought
it would be better to read it: “ In connection with the above suggestions, the
question of converting the asylum service into a national service might well receive
consideration. Weighty arguments have been brought forward lately in support
of this step in the case of the Poor-Law service, and any such arguments on the
grounds of justice, efficiency, and economy, may be urged with even greater force
regarding the asylum service.”

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I 907 -] NOTES AND NEWS. 663

Dr. Drapes seconded the resolution, and on being put to the meeting it was
carried unanimously.

The Death op Dr. Charles F£r£.

Dr. Urquhart said that, with the kind permission of the President, he desired
to call the attention of the meeting to the death of Dr. Charles Fdrd, which took
place on April ioth. He had been an honorary member of the Association since
1892, and his name was very familiar to everyone as a distinguished physician, and
as an indefatigable worker in the speciality. He was sure those who had the
honour and privilege of his personal friendship must regret his death very much.
Dr. Urquhart said he did not wish to detain the meeting with a recital of his
brilliant achievements in psychiatry, to which, however, he would return later in
the Journal. He merely desired that the President might convey to Madame Fdrd
their deep sense of loss by his death, and their feeling of condolence with his
family.

The President said he was sure every member of the Association would agree
to that. Dr. Fdrd had been an honorary member for the last fifteen years, and a
very valuable and distinguished one.

It was agreed that the general secretary should enter on the minutes an expres¬
sion of profound sorrow and regret occasioned by the calamity to medical science,
so premature and unexpected, and that he should convey to Madame Fdrd and
family their sincere and respectful sympathy.

The President referred to an assault on Dr. John Carswell by an insane person,
who recently shot him because he had failed to recover damages from Dr. Carswell
in the Court of Session. The President moved, and it was agreed that the general
secretary should be instructed to enter on the minutes the regret of the meeting,
and to convey to Dr. Carswell the expression of their sincere sympathy, and hopes
for his early recovery.

Workmen’s Compensation Act.

The President called on Dr. Hayes Newington, who, in accordance with notice
given, made the following statement:

" It is a matter of common knowledge that the Workmen’s Compensation Act
of last year has imposed fresh responsibilities on all classes of institutions for the
insane; and it is also very generally known that insurance offices have taken a
view of the risks connected with work in asylums that will appear exaggerated to
us, who are in constant touch with the insane. Most will know, too, that several of
the principal offices have joined together to establish a uniform tariff for all
accident risks, no departure from this tariff being permitted. There are other
offices which have not joined this combination, and underwriters at Lloyds are
entering freely into the business created by the new Act. Both the non-tariff
offices and Lloyds seem disposed to be less apprehensive of the risks, and they in
many cases offer lower terms. Into the intricate question of the relations that are
supposed to exist between higher prices and increased security I do not propose to
enter, but it may be stated with certainty that the contemplated scale of premiums
has but little relation to actual experience It is not too much to say that, for
want of proper data on which to found reasonable calculations, every one is at sea
in attempting to estimate risks. Insuring corporations very naturally wish to pro¬
tect themselves, and no doubt when fixing their rates they have been largely
guided by obsolete ideas of the interior of asylums and of the life therein. A relic
of the past, indeed, is the frequent appearance of the term 1 keeper ’ in combination
with 'attendants and nurses ’ in schedules of rates. Doubtless if it could be shown
that the rates asked were beyond requirements, business instincts would lead to
their being reduced to a point that could be justified by facts.

“ I propose to give one or two illustrations of the effect of tariff rates in order
to show that some reconsideration is called for. Domestic servants of all kinds
can be insured for 3s. each. Taking the wages and allowances of, say, a parlour¬
maid at .£50 per annum, the sum first quoted would mean a rate of 6s. per £100
LIII. 4 5

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664

NOTES AND NEWS.

[July,

of wages and allowances combined. We may take the same average value of
wages and allowances for the asylum nurse, but the rate asked for her is not 6 s. per
cent. t but 205. per cent. It follows that the ordinary domestic risk which is
present, and must be met in both cases, is in the instance of the nurse loaded with
233 per cent, for the special asylum risk. Now we all know, in fact we have always
insisted in relation to the pension question and we still insist, that there is a con¬
siderable risk, but we cannot admit for a moment that the calling is hazardous to
the extent indicated by such a differentiation. Nor is this all. We should, 1
think, be unhappy if, say, 10 per cent, of our patients could at any time be con¬
sidered to expose those in charge of them to special risk by reason of homicidal
propensities, or from a turbulence of disposition such as would lead directly or
indirectly to injury by violence. If this is so, then the payment of the higher
premium asked for over all the nursing staff would have the effect of enormously
increasing a charge that we may well think to be already inordinately high. Again,

I estimate from figures at my disposal that the payment of the tariff rate for
attendants and nurses only in the county and borough asylums of England and
Wales would exceed £6000 per annum. Will it not be difficult in our experience
to recall assaults and accidents sufficient in frequency and gravity to absorb even
a fraction of this sum ? The same excessive fear of risks is reflected in the charge
for other asylum officers who are not in direct charge of patients.

“The only method of obtaining approximate accuracy of estimate is to get
records of facts during the last few years, and it would appear that this Association
alone possesses the machinery for conveniently obtaining and elaborating these
facts. I think I may say with some authority that insurance offices will welcome
sound information, while our own position will be the stronger if we have it to
support our opinion as to what will be a just and proper scale of rates for our
service.

“Before moving the resolution, which aims at giving effect to these views, I
should wish to point out another direction in which the Association can do a
neighbourly action. Let us think for a moment on the large number of attendants
and nurses earning their living outside institutions, and let us think of what might
befall the head of a house driven by emergency to call in the aid of any of them.
In such a case it would be practically certain that his risks would not at first be
covered by a policy, while it might well be that his danger would never be brought
home to him till injury had turned the risk into accomplished loss. Then if a
nurse comes from a registry, who employs her, the head of the house or the pro¬
prietor of the registry? Would the service, under any circumstances, be deemed
to be casual and therefore excluded from the benefits of the Act? These and
similar questions can best be raised and considered on general principles with a
due regard to the protection of all interests by the agency of our Association. For
instance, our knowledge of this branch of nursing might enable us to make such a
suggestion as that a nurse should be allowed to insure herself, thus carrying
immunity to all who engaged her, the remuneration being suitably increased. In
any case the Association can secure immediate and efficient consideration of the
interests of many who owe their allegiance to us.

“ As the motion shows it is sought to appoint a small committee to take neces¬
sary action. The Committee must consist of those who can readily meet and
consult together, as time is so short. I might say that the necessity for taking
action at all has only been caused by the establishment of the tariff a few weeks
ago. Before that time competition promised to lead to a proper adjustment of
rates. The reference to the Committee is shown in the motion but perhaps it
will be wise to point out that it is not asked that the Committee shall have power
to agree to anything in the name of the Association—indeed, no such power could
be given. It will therefore be useless for anyone to suggest terms or conditions
implying the approval of the Association. All that the Committee can do will be
to ascertain and communicate facts, and to exert any influence that it may have in
procuring for these facts due appreciation. It will be for the insurance offices to
complete the task by offering, either individually or conjointly, such rates as appear
to be justified by the circumstances.”

Dr. Hayes Newington begged to move the appointment of a committee, and if
the Association agreed to it, he would propose that it consist of the President
(Dr. Jones), Dr. Percy Smith, Dr. Outterson Wood, Dr. Hyslop, and himself.

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1907]

NOTES AND NEWS.

665

The President said the association was very much indebted to Dr. Hayes
Newington. £6000 a year was a very great price for insuring the nursing staff of
the institutions for the insane in this country, and he thought that too gloomy a
view was taken of their risks. The course suggested would be a great help to
those who are administering asylums.

Dr. Outterson Wood seconded the proposition, and it was agreed to.

Dr. R. C. Stewart asked when the Committee was likely to report, because his
asylum was dealing with the question, and such information would be very valu¬
able if it could be received in time. Could it be had in three or four weeks P

Dr. Hayes Newington, in reply, said it was hoped, if the committee was
appointed, that a short meeting might be held that day, at the close of the general
meeting, to approve the necessary form. A form was ready for settlement by the
committee, which would be sent round to the superintendents of every asylum,
registered hospital, and licensed house, with the request that particulars should be
sent in as soon as possible. The main question which would be put to medical
superintendents would be, What number of injuries resulting from the action of
patients occurred within so many years involving permanent incapacity or tempo¬
rary incapacity ? He was personally in communication with several insurance
offices, and he hoped that the committee would meet some representatives of
those bodies, if desired, and put the facts before them. The result would be seen
in the lower rates issued.

Dr. R. C. Stewart asked whether Dr. Hayes Newington could give the meeting
any information with regard to what the County Council would do. He had
information on the preceding day from his own County Council that they were not
sure whether they would have to insure the superintendent and medical officers.
They were going to have another meeting of the County Councils' Association
before very long to consider that matter.

Dr. Hayes Newington, in reply, said that was a legal question. It was curious
that one office did express, an opinion, in spite of the apparent plainness of the
Act, that the medical officer would come within the Act, although his salary and
allowances exceeded £250 a year. But he thought that that was probably
wrong. He believed it might be taken as certain that the medical superintendent
and other officers who received £250 money and allowances were outside the Act.
With regard to what the County Councils would do one could not say, because
each Council was acting for itself. But he knew that in some cases they pro¬
posed to hold their judgment over until they received further information, if it
could be got, from the inquiries made by the Committee of the Medico-Psycho¬
logical Association.

Dr. D. G. Thompson asked whether it might be assumed that the Committee
would report at the next quarterly meeting of the Association, i.e., at the annual
meeting. There would be no council meeting until then, so it would be three
months hence.

Dr. Hayes Newington said the Committee would report as a matter of
routine, but before the Association met again any good it could do would have been
done. The most they could do was to make representations, and take such action
as they thought fit.

Dr. Ford Robertson read a paper contributed by himself and Dr. Douglas
McRae, entitled “ Further Bacteriological and Experimental Investigations into the
Pathology of General Paralysis and Tabes Dorsalis." See p. 590.

In consequence of the lateness of the hour it was agreed to defer the other
paper announced on the agenda until the annual meeting.

In the evening between thirty and forty members and their friends dined together
at the Cate Monico.

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NOTES AND NEWS.

U^y.

SOUTH-EASTERN DIVISION.

The Spring Meeting of the South-Eastern Division was held by the courtesy
of Dr. F. R. P. Taylor at the East Sussex County Asylum, Hellingly, on
April 17th, 1907.

Among those present were Drs. Robert Jones (President), H. H. Newington,
Crochley Clapham, A. Helen Boyle, Josephine Brown, A. S. Newington, J. Francis
Dixon, Richard Whittington, P. D. Hunter, E. S. Pasmore, Thomas O'C.
Donelan, B. Hart, M. A. Collins, J. P. Race, W. T. Crawford, F. W. Stewart,
C. H. Fennell, William Rawes, Thomas B. Worthington, William Ireland Donald¬
son, Francis H. Edwards, H. A. Kidd, A. Rotherham, H. Stilwell, David Hunter,
G. N. O. Slater, R. H. Cole, H. E. Haynes, F. R. P. Taylor, and R. H. Steen
(Hon. Sec.).

The visitors included Dr. Jeffery (member of the Visiting Committee), and Drs.
Henry Colegate, E. Faulks, Edith Martin, and Herbert Berncastle.

Apologies were received from Drs. Crookshank, Boycott, Douglas, T. Out-
terson Wood, A. Bowles, Harvey Baird, Chambers, Moore, Smith, and Langdon-
Down.

The asylum and grounds were inspected, and subsequently Dr. Taylor enter*
tained the members to luncheon. At the termination of the lunch the President
proposed a vote of thanks to Dr. Taylor for his kindness in so hospitably receiving
the Division.

The meeting of the Divisional Committee was held at 2.30, Drs. Rawes, Hunter,
Slater, Donaldson, and Steen being present.

The general meeting of the Division was held at 3 p.m., Dr. Robert Jones in the
chair. The minutes of the last meeting having appeared in the Journal were
taken as read and confirmed.

The following members were elected by voting papers to take office for 1907-8:

Hon. Secretary of the Division.—Dr. R. H. Steen.

Representative members of the Division on the Council.—Drs. Boycott, Fennell,
Mercier, E. W. White.

The following gentlemen were elected as ordinary members of the Association:

George A. Fleming, L.R.C.S.I., L.R.C.P.I., Lie Rotunda Hospital; Assistant
Medical Officer, Camberwell House.

George Henry Keene, M.D.(T.C.D-), Assistant Medical Officer, Essex County
Asylum, Brentwood.

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

Charles Mollyson Smith, M.B., Ch.B.(Aberd.), Assistant Medical Officer, Kent
County Asylum, Banning Heath.

Charles E. C. Williams, B.A., B.Ch., M.B.(Dub.), Assistant Medical Officer,
Holloway Sanatorium, Virginia Water.

Drs. Taylor, Reginald Langdon-Down, and Dixon were elected as members of
the South-Eastern Divisional Committee of Management, which now consists of
the following:

Retire in 1908. Retire in 1909. Retire in 1910.

Dr. Boycott. Dr. Donaldson. Dr. Taylor.

Dr. Kennedy Will. Dr. Crookshank. Dr. R. Langdon-Down.

Dr. G. N. O. Slater. Dr. Stoddart. Dr. Dixon.

A letter was read from the Hon. General Secretary requesting the Division to
ascertain the names of members willing to serve on the National Committee of
the International Commission to co-ordinate the work of studying the causes of
mental disease and their prevention.

The following were nominated by the meeting, and the Divisional Secretary was
instructed to communicate with those not present to ascertain if they were willing
to serve: Drs. Robert Jones, Mercier, Bond, Mott, Hyslop, Rawes, and John
Turner.

The invitation of Dr. Reginald Stilwell to hold the autumn meeting of the
Division at Moorcroft, Hillingdon, was unanimously accepted with much pleasure.
The date was fixed for October 8th, 1907. April 21 st, 1908, was fixed for the date
of the spring meeting.

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1907.] NOTES AND NEWS. 667

Dr. Charles H. Fennell read a paper on 11 The Care of Children in County and
Borough Asylums” (see p. 541).

Dr. Taylor showed the case of a female patient (E. B.) suffering from recurrent
insanity associated with ophthalmia. He stated that the patient had been in the
asylum three times. On the first occasion she was restless and depressed on
admission, but on the others was suffering from acute excitement. On each
occasion, shortly after admission, she developed ophthalmia, which was charac¬
terised by severe pain, swelling of the eyelids, and conjunctivitis. Whilst the
inflammation of the eye was present the patient was quite well mentally. The
ophthalmia lasted about a fortnight and then got suddenly better, the patient at
this time becoming mentally worse, at first being somewhat depressed and then
passing into a condition of acute mania, during which she was extremely restless
and noisy, and had marked hallucinations of hearing and of sight. This condition
lasted about a fortnight to three we^ks, and then she became well mentally. On
two occasions she had a relapse within two months, each relapse being preceded
by ophthalmia; then she became well, and was discharged recovered. On the
first occasion she stayed in' one of the asylums four months and on the second six
months. She was twenty-seven years of age on first admission. She is stated to
have had an attack of insanity when seventeen years of age, but was not in an
asylum. No history of hereditary predisposition was obtained. When well
patient is of good intelligence.

Dr. Crawford described the last attack. She was admitted to the Asylum on
March 7th, 1907, having been discharged on August 25th, 1906. She was in a
condition of simple excitement of a joyful nature. She had opacity of the right
cornea and some conjunctivitis. Within a few days of admission she became much
better mentally. She now complained of severe pain at the back of the right eye
and in the temporal region. The eyelids and conjunctiva became very much
swollen, and the cornea was covered with flaky deposit, but there was no ulceration.
The eye was fomented, washed out with boracic lotion and atropine instilled.
Patient was quite well mentally. A fortnight later the eye got rapidly well, and
patient passed into a condition of acute mania. She remained excited for about a
week, and then became quite well.

The President proposed that the thanks of the Division should be sent to the
Chairman and Visiting Committee for the great privilege they had in holding their
meeting at the East Sussex Asylum, and of seeing the very full and complete
arrangements made at that institution for the care, curative and custodial, of those
suffering from every form of mental disease.

This was unanimously agreed to, and it was requested that the Divisional
Secretary should convey the thanks of the Division to the Chairman.

Dr. Jeffery, on behalf of the Visiting Committee, replied.

SOUTH-WESTERN DIVISION.

The Spring Meeting of the Division was held at the County and City Asylum,
Burghill, Hereford, on Thursday, April 18th, 1907.

The members were kindly entertained to lunch by Dr. Morrison, who subse¬
quently showed them over the Asylum.

The following members were present: Drs. Baskin, Braine-Hartnell, Bullen,
Glendinning, Jex-Blake, W. F. MacDonald, Morrison, Nelis, Rambaut, Soutar,
and the Hon. Div. Sec.

The visitors were Drs. Thos. Turner, Edgar Morris, J. Oswald Lane, Herbert
Jones, Warren Swettenhkm, Arthur Wood, and Thos. Mendes.

Dr. Glendinning was voted to the Chair.

The minutes of the Autumn Meeting were read and signed.

Letters from the relatives of the late Drs. Craddock and Stewart returning
thanks for votes of sympathy were also read.

The following candidates were elected members of the Association:

Humphrey P. Blackmore, M.D., Physician, Salisbury Infirmary. Proposed by
Drs. Baskin, Aveline, and W. F. MacDonald.

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668

NOTES AND NEWS.

[July,

James Whigham Rutherford, L.R.C.P.I., L.R.C.S.I., L.M., Assistant Medical
Officer, Somerset and Bath Asylum, Cotford, near Taunton. Proposed by Drs.
Aveline, Rorie, and W. F. MacDonald.

Mr. H. T. S. Aveline was re-elected Hon. Divisional Secretary, and Drs.
Goodall and Bullen representative members on the Council.

Drs. Baskin and Goodall were elected on the Committee of Management, and
Dr. Soutar kindly consented to act for a further period of twelve months in place
of the late Dr. Stewart.

The next meeting was fixed to take place at Fisherton House, Salisbury, on
Friday, October 25th next, by kind invitation of Dr. Baskin, and the Spring
Meeting at Barnwood House, Gloucester, on Friday, April 24th, 1908, by kind
invitation of Dr. Soutar.

Dr. Baskin exhibited his new form of case for the protection of clinical thermo¬
meters during use, and gave a short explanation.

Dr. W. F. MacDonald read a paper on the “ Bacteriology of Asylum Dysentery,”
describing the clinical features of cases coming under his notice and pointing out
their association with the presence of a bacillus of the Flexner type.

The paper was discussed by the Chairman, Drs. Soutar, Morrison, Brainc-
Hartnell, and the Hon. Div. Sec., and Dr. MacDonald suitably replied.

Dr. Morrison read a paper on “ The Inference of Degeneracy in Herefordshire
supplied by Vital and Medical Statistics,” and the important conclusions drawn
were commented on by several of the visitors.

On the motion of the Chairman a hearty vote of thanks was accorded to Dr.
Morrison for the hospitable manner in which he had received and entertained the
members, and also for his most able and interesting address, and the proceedings
closed with a vote of thanks to Dr. Glendinning for presiding.

NORTHERN AND MIDLAND DIVISION.

The Spring Meeting of the Northern and Midland Division was held, by the
courtesy of Dr. Perceval, at Lancashire County Asylum, Prestwich, near Manchester,
on April 18th, 1907. Dr. Perceval presided.

The following members were present:—Drs. Stewart Adair, Archdale, Legge,
Cowan, MacDougall, Mackenzie, Macphail, Pierce, Middlemass, G. E. Mould, Orr,
Powell, M. Rhodes, Rows, Simpson and Starkey. There were seven visitors.

1. The minutes of last meeting were read and confirmed.

2. John Exley, L.R.C.P.I. and M.R.C.S., Medical Officer to H.M. Prison, Leeds,
was unanimously elected a member of the Association.

3. It was resolved to suggest the names of Dr. Bedford Pierce and Dr. Richard
Legge to the Council as members of the International Committee on the Causes of
Insanity.

4. Dr. Bedford Pierce was re-elected Secretary to the Division.

5. Drs. T. W. McDowall and Ewan were unanimously re-elected Representative
Members of Council.

As it was expected that the number of members of the Division would reach 150
next month Dr. David Orr was unanimously elected Representative Member of
Council in place of Dr. Edgerley who retired.

6. Cordial invitations having been received from Dr. Stewart Adair and Dr.
Middlemass, it was decided to hold the Autumn Meeting at the Sunderland Borough
Asylum, at Ryhope, on October 17th, and the Spring Meeting next year at the
Storthes Hall Asylum, near Huddersfield, on April 30th, 1908.

7. Dr. Clarke was unavoidably prevented from reading the paper announced in
the agenda.

8. The meeting adjourned to the Laboratory, and Dr. David Orr and Dr.
Rows demonstrated a number of recent researches in Pathology, in particular the
effect of toxins upon the brain and spinal cord, showing the degeneration produced
by toxins reaching the central nervous system along the peri-vascular lymphatic
channels.

Specimens were also shown demonstrating the presence of a specific micro¬
organism in the walls of the alimentary canal, and in the spinal cord in a case of
acute insanity.

After the meeting ten members and three visitors dined at the Midland Hotel.

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1907 ]

NOTES AND NEWS.

669

SCOTTISH DIVISION.

A meeting of the Scottish Division of the Medico-Psychological Association was
held at Ayr District Asylum, Glengal, Ayr, on Friday, March 22nd, 1907.

The following members were present:—Drs. Baugh, Easterbrook, Gostwyck,
Havelock, Hotchkis, Carlyle Johnstone, Keay, Kerr, A. R. MacIntyre, Macllraith,
McMillan, McRae, Marr, G. M. Robertson, Turnbull, Urquhart, Wilson, and
Bruce, Divisional Secretary.

Dr. Carlyle Johnstone was called to the chair.

Letters of apology were intimated from Dr. Robert Jones (President), Sir William
Gairdner, Drs. Campbell, Ireland, Marshall, A. Robertson, and Watson.

The minute of last meeting was read, agreed to, and signed.

Drs. Turnbull and Bruce were appointed Representative Members of Council,
and Dr. Hamilton C. Marr, Divisional Secretary.

Applications for admission as members were received from:—Patrick Steele,
M.B., Ch.B.(Edinburgh), Assistant Medical Officer, Edinburgh District Asylum,
Bangour, Uphall (proposed by Drs. Keay, Rutherford, and Bruce); and Stewart
Carlisle Howard, M.B., Ch.B.(Aberdeen), Assistant Physician, Perth District
Asylum, Murthly (proposed by Drs. Urquhart, Bruce, and Alcock).

After ballot these applicants were declared unanimously elected.

Dr. Easterbrook showed the members over the new hospital, and gave a
clinical demonstration upon a few cases of special interest.

Drs. Urquhart, Ireland, Marr, Easterbrook, Ford Robertson, and G. M.
Robertson were nominated members of the National Committee appointed to
co-operate in the work of studying the causes of mental diseases and their
prevention.

Dr. Urquhart gave the following notice of motion :

“ That the Division at the next meeting proceed to elect a Business Committee
for the Scottish Division, that it consist of three members who are at the
same time ordinaiy members of the Council and of the Association.”

Votes of thanks to the Chairman and Dr. Easterbrook terminated the meeting.

The members afterwards dined together in the Ayr Station Hotel.

IRISH DIVISION.

The Spring Meeting of the Division was held at Portrane Asylum on Thursday,
April nth, 1907, by the kindness of Dr. Donelan, who entertained the members
at luncheon after first escorting them round the Institution.

At the meeting afterwards the chair was occupied by Dr. Donelan, and there
were also present:—Drs. M. J. Nolan, T. Drapes, F. O’Mara, H. M. Cullinan,
R. R. Leeper, J. J. Fitzgerald, H. M. Eustace, F. E. Rainsford, M. J. Forde, and
W. R. Dawson (Hon. Sec.).

A vote of sympathy with the relatives of the late Dr. R. A. L. Graham was
passed unanimously.

A letter regretting inability to be present was read from the President of the
Association.

The minutes of the previous meeting were read, confirmed, and signed.

A letter was read from Mrs. Woods, thanking the members of the Division for
the vote of condolence passed at the last meeting.

Dr. W. R. Dawson was elected Divisional Secretary, and Drs. M. J. Nolan and
T. Drapes Representative Members of Council, for the ensuing year.

The dates of the meetings of the Irish Division in the ensuing year were fixed
as follows:—Tuesday, November 5th, 1907; Thursday, April 30th, 1908; and
Thursday, July 2nd, 1908.

Dr. Nolan cordially assented to the unanimous wish of the members that the
Summer Meeting should be held at Downpatrick Asylum.

The names of Drs. Norman, Nolan, and Dawson were directed to be forwarded
to the General Secretary for service on the National Committee of the proposed
International Commission for the Study of the Causes and Prevention of Mental
Diseases.

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NOTES AND NEWS.

□«iy.

The Secretary reported that, the matter being urgent, he had ventured to send
a memorandum to the Parliamentary Committee suggesting certain changes in the
Lunacy Law of Ireland, with the request that they would bring the subject under
the notice of the framers of the proposed Irish Council Bill. The Lunacy
Legislation Sub-committee had met on April 3rd and drawn up a modified
resolution, which had been forwarded to the Chief Secretary for Ireland.

The action of the Secretary was approved, and after a prolonged discussion a
modification of his Memorandum was agreed on, and copies were directed to be
forwarded to the General Secretary in time for the May General Meeting of the
Association, and to the Royal Commission on the Feeble-minded. The amended
Memorandum was essentially the same as that of the Lunacy Legislation Sub-
Committee, as published in the April number of the Journal, with the addition
of the following clause :

“ In the event of any legislation dealing with Irish Lunacy matters, an enact¬
ment should be introduced to extend to Ireland the provisions of the Act
of Settlement in the matter of deportation of Pauper Lunatics."

It was also suggested that the question of the conversion of the asylum service
into a National Service might receive consideration.

The following were constituted a Committee to watch the Irish Council Bill, and
if necessary take action, with reference to lunacy administration :—Drs. Rainsford,
O’Mara, Norman, Donelan, W. Graham, Nolan, Fitzgerald, Leeper, Drapes, and
Dawson.

A vote of thanks to the Secretary for his action in the matter was passed unani¬
mously, and he replied.

Communication.

Dr. R. R. Leeper read a paper entitled “ Notes on some Cases of Melancholia."

The proceedings terminated with a cordial vote of thanks to Dr. Donelan for
his kind hospitality.

OBITUARY.

Dr. Charles F£r6.

Charles Samson Fdrfe was born at Auffay, in Normandy, half way b etwe en
Dieppe and Rouen, on the 13th June, 1852. He began his medical studies at
Rouen in 1870, and, two years later, proceeded to Paris, where he had the advan¬
tage of such teachers as Broca, Gudriot, Panot, and Guyon. At that time he
desired to become a surgeon, but he fell under the powerful influence of Charcot
at the Salpdtridre, and thereafter devoted himself to neuropathology. His
inaugural thesis (1882) was entitled Functional Disorders of Sight caused by
Cerebral Lesion. In 1884 he was successful in the competition for the appoint¬
ment of Assistant Physician at the Salpdtridre, and in 1887 was promoted to the
post of Chief Physician at the Bicdtre, which he held until his untimely death.

I do not intend to present even a short account of the work accomplished by
Fdrd, which is, on the whole, familiar to those interested in psychiatry. Hypno¬
tism, hysteria, the heredity of degeneration, criminals, and epileptics have been
the subjects of his special scientific investigations. His earlier study of surgery
had rendered him a good anatomist, and resulted in the publication of his useful
book on the anatomy of the nervous system. Philosophical researches had a
strong attraction for Fdrd, and issued in the contribution of many papers on the
pathology of the emotions, on sexual instinct, on work and pleasure, on the
disorders of intellect. For a considerable number of years he was a member of
the Society of Biology, and submitted most interesting and important studies on
muscular work, on the physiology of voluntary movements, on sensory excitations,
on muscular fatigue, on teratology, and on teratogeny from the experimental
standpoint.

Fdrd was a tall man, with a long black beard, a high broad forehead, large and
pensive eyes. His strongly marked features were expressive of a gentle melan¬
choly. At a first glance he appeared rather rough and cold in manner, but he was
truly kind, gentle, and exquisitely sensitive. Fdrd led a simple life, and sought
neither honours or rewards. His life was passed in the hospital, the laboratory,

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671

1907.]

and the library, constantly at work in spite of frequent and severe headaches. His
indomitable will and steady perseverance did not fail until he was completely
exhausted. He died on the 22nd of April.

During the course of his too short life he maintained his sweet remembrance of
his beloved Normandy, of the ancient city of Rouen, and especially of his native
village. He liked to speak of Auffay and its Roman origin—the place of the high
beech tree. There he lies at rest— sub tegmine fagi.

A List of the More Important of F£r£’s Works.

Contribution h l 9 etude des troubles fonctionnels de la vision par Usion cerebrate.
These , Paris, 1882.

“ Notes pour servir k Phistoire de l’hystdro-^pilepsie.” Archives de Neurologic ,
1882, N. 3, p. 160, 281.

"La mldecine d’imagination.” Progrbs medical } 1884, no. 16; 1886, nos. 35,
3 < 5 . 37 -

" La polarisation psychique” (avec Binet). Revue philosophique , 1885.
"Sensation et mouvement.” Revue philosophique , octobre, 1885.

“ Le magnetisme animal 1884. 4c edit. 1894.

" A Contribution to the Pathology of Dreams and of Hysterical Paralysis.”
Brain , January, 1887.

" La famille n^vropathique.” Archives de Neurologie t 1884, N. 7, p. 1 et 173.
1894. 2? edit. 1898.

Traite ilementaire cC anatomic medicate du systeme neroeux. 1886 (242 figs).
2* edit. 1891.

Sensation et mouvement, Studes experiment ales de psycho-micanique. 1887.
2« edit. 1900.

Dightbrescence et criminality. 1888.

Du traitement des aliSnSs dans les families. 1889.

Les ipilepsies et les Spileptiques. 1890. (67 grav., 12 planches.)

Pathologic des tmotions. 1892.

"Contribution & Phistoire du choc moral chez les enfants.” Bulletin de la
Socitti de medecine mentale de Belgique , septembre, 1894.

“ Hysteria, Epilepsy, and Spasmodic Neuroses.” Twentieth Century Practice
of Medicine. Vol. x. New York, 1897.

L % instinct sexuel. 1889. 2 e edit. 1902.

" Les troubles de Pintelligence.” Traite de patologie gentrale de Bouchard.
Travail et plaisir. 1904.

R£n£ Semelaigne.

Frank Schofield, M.D.

We regret to record the death of Dr. Frank Schofield, who was for many years
a colleague of the late Dr. Paul at Camberwell House. Dr. Schofield received
his medical education at St. George’s Hospital, where he proved to be an able
and diligent student, and where he was for a time Demonstrator of Anatomy and
Physiology. In his capacity as Demonstrator he had the gratification of receiving
from the members of his class at the end of the session a valuable presentation.
He took the diplomas of M.R.C.S.Eng. and L.S.A. in 1861, and the degree of
M.D.St. Andrews in 1862. On the advice and through the influence of the late
Sir Benjamin Ward Richardson, who was a life-long friend, he was appointed
Assistant Medical Officer to Camberwell House in 1861. He was then in his 23rd
year. His predecessor was Dr. Murray Lindsay. Later he was promoted to be
Medical Superintendent at Camberwell House, and he held this post till the
autumn of 1899, when the delicate state of his health compelled him to resign.

On his retirement he went with his wife and family to reside at Weymouth.
For a few years he to some degree regained strength, and he enjoyed the rest from
the strenuous professional life of London. In the end of last year his health
markedly failed, and after a severe illness of four months’ duration, borne with
great patience and fortitude, he passed away peacefully, greatly beloved and keenly
regretted by a wide circle of friends.

LIII. 46

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NOTES AND NEWS.

[July,

NOMINATIONS TO SERVE ON THE INTERNATIONAL COMMITTEE
RE THE CAUSATION OF INSANITY.

Baskin, Joseph Lougheed, L.R.C.P. & S.Edin., Medical Superintendent, Fisherton
House, Salisbury.

Bond, C. Hubert, D.Sc., M.D., Medical Superintendent, London County Asylum,
Long Grove, Epsom.

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

Dawson, William Richard, B.A., M.D., F.R.C.P., Medical Superintendent, Farn-
ham House, Finglas, Dublin.

Easterbrook, Charles C., M.A., M.D., F.R.C.P., Medical Superintendent, District
Asylum, Ayr, Scotland.

Goodall, Edwin, M.D., F.R.C.P., Medical Superintendent, City Asylum, Cardiff.

Hyslop, Theo. B., M.D., Resident Physician, Bethlem Royal Hospital, London,
S.E.

Ireland, W. W., M.D., Musselburgh, Scotland.

Jones, Robert, M.D., F.R.C.P., F.R.C.S., Medical Superintendent, London County
Asylum, Claybury, Essex.

Leggb, Richard John, M.D., Medical Superintendent, Derby County Asylum,
Mickleover.

Marr, Hamilton Clelland, M.D., F.F.P.S., Medical Superintendent, District
Asylum, Lenzie, Glasgow.

Mercier, Charles, M.D., F.R.C.P., F.R.C.S., Flower House, Catford, London, S.E.

Mott, Frederick Walker, M.D., F.R.C.P., F.R.S., Director of the Pathological
Laboratory, London County Asylum, Claybury, Essex, and Pathologist to the
London County Asylums.

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

Norman, Conolly, F.R.C.P., F.R.C.S., Medical Superintendent, Richmond Asylum,
Dublin.

Rawes, William, M.D., F.R.C.S., Medical Superintendent, St. Luke’s Hospital,
London, S.E.

Robertson, William Ford, M.D., Pathologist to the Scottish Asylums, 10, Morning-
side Terrace, Edinburgh.

Robertson, Geo. M., M.B., F.R.C.P., Medical Superintendent, Larbert Asylum,
Stirling.

Rows, Richard Gundry, M.D., Pathologist, County Asylum, Lancaster.

Urquhart, Alex. Reid, M.D., F.R.C.P., Physician-Superintendent, Murray’s
Royal Asylum, Perth.

The above are exclusive of Drs. R. Percy Smith and J. H. MacDonald, who

were nominated at Milan to serve on the International Committee.

NOTICES BY THE REGISTRAR.

Examination for the Nursing Certificate.

List of the successful candidates at the examination for the Nursing Certificate
held in May, 1907.

Ireland.

Armagh. —Male: David McAlister. Females : Annie Vallely, Maggie Mallon.
Ballinasloe. —Males: Thomas Flynn, Michael Broderick, Michael Meyers.
Females: Mary Costello, Ellen Ledwith, Ellie Mannion, Bridget Flynn, Mary
Donohor.

Carlow. —Male : John Lambe. Females: Lizzie Cummins, Maggie Roche.
Clonmel. —Males: Richard Maher, Patrick Dunne, Edmond Gallagher. Female:
Mary Murphy.

Enniscorthy. —Females : Norah Gowan, Gretta Thorpe, Dermot Lee.

Kilkenny. —Males : Michael McEvoy, James Keane.

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> 907 ]

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673

Portrane. —Males: John Dowling, Patrick Gavin, Owen O’Connor, James
Morahan. Females: Annie Brosnan, Margret Coates, Hannah Garry, Annie
Heenan, Kathleen Meagher, Mary Jane McCormack.

Richmond District {Dublin). —Males: John Kelleher, Michael Hughes, James
Scully, James Fagan, William Lee, Michael Gibney, Patrick Bums, Patrick
Neville. Females: Mary Anne McCarney, Mary Clarke, Mary T. McGuire,
Katie Murphy, Jane Matthews, Julia Phelan, Nellie Duffy, Lizzie Scully.

Bloomfield House , Dublin. — Females: Alice Wood Sampson, Gertrude
Oldershaw.

Farnham House. —Females: Susan Fry, Margaret S. Gordon.

St. Edmundsbury {Lucan). —Female : Annie Brannigan.

St. Patrick's Hospital. —Male: James Johnston.

Scotland.

Aberdeen Royal. —Males: William Still, Robert Fraser. Females: Marjory
Baxter, Helen Stalker.

Ayr District. —Females : Sophia S. Taylor, Jemima R. Smith.

Bangour Village. —Females : Jessie E. D. McCulloch, Mary J. O’Gorman.
Crichton Royal. —Males: Archibald Nicolson, John J. Young, David Christison,
Alexander McDonald, William Richardson. Females: Jemima S. McWhannel,
Amelia C. Norrie, Mary Jane Spiers, Joan Scott Young, Margaret Macauley,
Maggie Ann Angus.

Dundee District. — Males: David F. Mudie, James R. Robertson, Andrew
Guthrie, Joseph Dudley, William Aitchison. Female : Edith Weir.

Momingside. —Males: Patrick Sheridan, Andrew John Wilson. Female.* May
Cross.

Craig House. —Male: John William Thomson. Female; Elsie Russell.
Gartloch. —Males: James Thomson, Angus Laing. Females: Mary Anne
Rogers, Jessie A. Waugh, Martha Baird, Anne Helena Kane.

Gartnavel .—Males.* Alexander Watson, Clement G. Cooper. Females: Jane
Gibb, Grace Allan Parvin, Agnes M. Whitson, Jeannette G. Campbell.

Govan District. —Males: William Winter, John A. Macauley. Females: Nellie
0 . 0 . Rennie, Annie Kerr, Elsie Burnett.

Lanark District. —Male: Stuart Wilkins. Females : Annie Burdett, Cathleen
Dowie, Janet M. Murdoch, Elizabeth O’Hara, Catherine G. Munro.

Midlothian and Peebles. —Females : Susan Patterson, Jean Winton.

Montrose Royal. —Male: Charles Heron.

Murray's Royal {Perth).— Males: William Forbes, Robert James Patton.
Riccartsbar. —Male : John Bruce.

Roxburgh District. —Male: Alexander W. Newlands.

Smithston. —Males: James Francis Burns, William Fowler, John Downie,
George Christie. Female: Mary W. Agnew.

Kingseat. —Male: George Davidson. Female : Maggie Edington.

England.

London County {Bexley). —Males: Alexander McKinnon, John James King.
Females: Lucy Woollett, Nellie Smith, Constance E. Dozell.

London County {Cane Hill). —Males: Ernest C. Hughes, Henry Wade, Charles
Curry, George J.Cusack, Ernest Elliott, Frederick J. Spittles. Females: Alice M.
Wilkie, Agnes E. Harris, Lily K. M. Bishop, Mary Anne Scally.

London County {Claybury). —Females: Edith M. M. Errington, Margaret M.
Collins, Catherine L. Pullen, Kate Guerin, Rosina A. Grimes, Violet G. Beasley,
Florence E. Isard, Violet E. Ford, Florence S. Bricknell, Bride Malone, Louisa F.
Franklin, Jennie Kirby, Winifred Z. Davis, Emily Lewis.

London County {Hanwell). —Female: Edith E. Brazier.

Chester. —Male: Walter Griffiths. Females: Melinda Dilworth, Elizabeth
Roberts, Polly Jones, Nellie Rea.

Derby County. —Males: George Hough, William Lockett, George Henry Bourne.
Female: Beatrice A. Whiles.

Hants County. —Males: Andrew J. Pharaoh, William H. Moss, Albert E.
Bower, Walter T. Vine, Francis J. Smith, John Hill, James Randell, William

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674 NOTES AND NEWS. [July,

George Forder, Percy A. Hocking, George Elford, Albert E. Green. Females
Catherine Hill, Rose Stunt, Charlotte Boast.

Essex County. —Males: Christopher R. Stewart, Ernest A. Sutton. Females:
Mary M. Crew, Florence Holmes, Ethel F. Hamilton, Annie Althorpe.

Devon County. —Male: Harry Yolland. Females: Florence Hurford, Mary A.
Seaward, Emma Wensley, Josephine Wiscombe.

Herts County. —Males: Edward Dunnadge, William Alden, Thomas Burrow,
Henry G. Fassnedge, John Cunningham. Females: Nellie Bowers, Winifred
Porter, Nellie Lea, Mabel J. Parfitt, Ellen Legg, Lizzie Neve.

Kent County {Barming Heath). —Females: Clara E. Stephens, Elizabeth I.
Gray, Florence Probyn, Rose O’Brien.

Kent Countv ( Chartham ).—Females : Florence E. Blofield, Elizabeth Bowen.
Middlesex County {Napsbury). —Males: Thomas Adcock, Harry Higgerson,
Albert E. Crook. Female: Ada A. Hirst.

Middlesex County {Tooting). —Male: William J. Carver. Females: Agnes L
Sargeant, Agnes M. Pollard.

Lancaster County. —Males: Joseph Oakley, Richard S. Gardner, John W. Gold.
Females: Mary Raleigh, Sarah H. Turner, M. Alderson, May Huddleston, Elsie
Anderson, Catherine McLaughlin, Mary Allen, Margaret A. Tomlinson, Ellen
Molloy, Mary Eleanor Hill, Annie I. Atkinson, Sarah G. Jolly.

Norfolk County. —Males: John Seaman, Robert S. Howlett. Females: Ethel
A. H. May, Winifred G. Howard, Janet Purdy, Jeannie Dean, Annie G. Storey.

Lancaster {Preston). —Females: Annie Walsh, Martha Busby,Sarah Middleton,,
Mary Owen, Edith Young, Ida M. Walters, Elizabeth Williams.

Surrey County {Brookwood). —Males: Edward Wharf, Ernest Wm. Lovelock.
Females: Charlotte M. Palmer, Annie Phillips, Elizabeth Robinson.

Staffs County {Cheddleton). —Female: Edith M. Taverner.

Sussex County (Hellingly). —Males: George R. Martin, Charles Parsons, Thomas
W. W. Elliott, Horace R. Cox, Bert Cripps. Females: Amy M. Bruorton, Cathe¬
rine Holland, Lily H. Daniels, Lucy B. Martin, Beatrice M. Puddephatt.

Sussex County {Chichester). —Females: Nellie R. Bassett, Celia Anne Humphreys.
Warwick County {Hatton). —Females: Maggie Raphael, Sarah Jane Lenton,
Amy Annie Maguire, Lydia G. BofFy.

Yorks {Wadsley). —Males : Michael Minogue, Arthur E. Keenan, Albert Bell.
Yorks {Beverley). —Females : Edith A. Lambert, Maud Nurse, Lily Anderton.
Birmingham City {Rubery Hill). —Females: Mary Roberts, Florrie L. Stretton.
Birmingham City {Winson Green). —Males: William F. Palmer, Charles Cuttriss.
Females: Charlotte Williams, Florence Smith, Alice Lowe, Cissie Hartles, Edith
Williams.

Brighton Borough {Hayward's Heath). —Males: Thomas Gadsby, Francis W.
Osmond, Amos W. Newnham. Females: Lilian M. Dawe, Beatrice E. Hill,
Agnes E. Edwards, Annie A. Tate.

Bristol City. —Males: Alfred J. Pike, John O’Connor. Females: Charlotte
Blewitt, Margaret Lewis, Henrietta Gibbs.

Sunderland Borough. —Male: Francis Maekie. Females: Edith Hewlitt, Lily
Metcalfe, Alice M. M. Page.

Newcastle City. —Male: John Wm. Hornsby. Females: Catherine G. Newton,
Elizabeth Denham, Christina Bacon.

Leavesden. —Males: Alfred J. Ashby, Arthur E. Pinner, William G. Packer,
Charles H. Dear. Females: Lizzie Janes, Maud B. Jones, Ellen J. Mackintosh,
Lettice L. Jullian, Minnie Crawford, Mary J. A. Corcoran, Julia F. Corcoran.

Bethnall House. —Females: Lille M. Dann, Agnes Cottell, Elizabeth Cassidy,
Grace F. Campion.

Bethlem Hospital. —Male : Thomas J. Leary.

Camberwell House. —Female: Ellen A. Marshall.

Holloway Sanatorium. —Male: George H. Blaber. Females: Mabel E. Marks,
Blanche B. Kirby, Florence Blackman.

Moorcroft House. —Male : Frederick J. Green.

St. Luke's Hospital. —Male: George S. Putland.

Dartford. —Females: Florence Morris, Adeline M. Lindsay, May Clarke.
Storthes Hall. —Males: Archibald T. Black, Samuel Roberts. Females: Mary
J. Downes, Mary Jane Emmott, Annie McKenna, Edith Prince.

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NOTES AND NEWS.

675

1907 .]

The following is a list of the questions which appeared on the paper:

1. What is a vertebra? How many are there? Give their names and position.

2. Name the classes in which foods may be arranged, and give examples of
each.

3. Describe the circulation of the blood.

4. What is meant by “ varicose veins ” ? How should bleeding from a varicose
vein in the leg be dealt with P

5. What indications would suggest to you that a patient suffered from kidney
disease ?

6. How should a nurse act in regard to the delusions of a patient ?

7. What is dementia? Mention the mental features seen in patients suffering
from it.

8. How should homicidal impulse in a patient be guarded against ?

9. What would lead you to suspect that a patient was suicidal ?

10. A patient appears to faint; say generally what may have happened. What
would you do before the arrival of medical aid ?

NOTICES OF MEETINGS.

Medico-Psychological Association.

The sixty-sixth Annual Meeting of the Association will be held on Thursday
and Friday, 25th and 26th July, 1907, at the rooms of the Association, u,Chandos
Street, Cavendish Square, London, W., under the presidency of Dr. P. W.
MacDonald. There will be meetings of Committees as follows:—On Wednesday,
24th July, 1907, Parliamentary Committee at 2.30 p.m., Educational Committee at
3.30 p.m. The Council will meet at 9.30 a.m. on Thursday, 25th July.

The Annual Meeting will commence at 11 a.m. on Thursday, 25th July, when
the usual business of the Association will be transacted.

2 p.m.—The President’s address, after which Chas. C. Easterbrook, M.D.,
will read a paper entitled “ The Sanatorium Treatment of Active Insanity by
Rest in Bed in the Open Air.”

Friday, 26th July, at n a.m.—T. S. Clouston, M.D., F.R.C.P., will introduce a
discussion upon “ Psychiatry as a Part of Public Medicine.” Albert Wilson,
M.D., will give a Clinical Demonstration and read a paper on “ The Psycho¬
logy of Crime.” Henry Devine, M.B., M.R.C.P., ” A Case of Katatonia in
a Congenital Deaf Mute,” illustrated with lantern slides.

Afternoon, 2 p.m.—W. Ford Robertson, M.D., and G. Douglas McRae,
M.D., will communicate “ Observations on the Treatment of General Paralysis
and Tabes Dorsalis by Vaccines and Anti-sera.” Lewis C. Bruce, M.D.,
will read a paper entitled “ Clinical Observations on Certain Cases of Mental
Depression.”

The Annual Dinner will take place on Thursday, 25th July, at the Whitehall
Rooms, Hdtel Metropole, at 7.15 for 7.30 o'clock. (Tickets One Guinea, wines
included.)

Members are requested to notify their intention of dining to the General
Secretary.

South-Eastern Division. —The Autumn Meeting will be held, by the courtesy of
Dr. Reginald Stilwell, at Moorcroft, Hillingdon, on Tuesday, 8th October, 1907.

South-Western Division. —The Autumn Meeting will be held, by the courtesy of
Dr. Baskin, at Fisherton House, Salisbury, on Friday, 25th October, 1907.

Northern and Midland Division. —The Autumn Meeting will be held, by the
courtesy of Dr. Middlemass, at the Sunderland Borough Asylum, Ryhope, on
Thursday, 17th October, 1907.

Scottish Division. —The Autumn Meeting will be held on Friday, 22nd November,
1907.

Irish Division. —The Autumn Meeting will be held on Tuesday, 5th November,

1 9 ° 7 *

LIII. 47

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NOTES AND NEWS.

[July, 1907.

APPOINTMENTS.

Martin, Mary Edith, L.R.C.P.&S.Edin., L.F.P.S.Glasg., L.S.A.Lond., Assistant
Medical Officer to Fenstanton Licensed House, Christchurch Road, Streatham
Hill.

Mercier, Charles Arthur, M.D.Lond., F.R.C.P.Lond., appointed by the Home
Secretary as a Member of the Board of Visitors to the State Inebriate Reformatory
at Aylesbury.

Richards, John, M.B., F.R.C.S.Edin., Medical Superintendent of the Joint
Counties Asylum, Carmarthen.

Smith, Robert Percy, M.D.Lond., F.R.C.P.Lond., appointed by the Home
Secretary as a Member of the Board of Visitors to the State Inebriate Reformatory
at Aylesbury.

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THE

JOURNAL OF MENTAL SCIENCE

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

No. 224 OCTOBER, 1907. Vol. LIII.

Part I.—Original Articles.

Medico-Psychological Association of Great Britain and
Ireland. Presidential Address, delivered July 25 th,
1907. By P. W. MacDonald, M.D., Resident Physi¬
cian and Superintendent, County Asylum, Dorchester.

The honourable position, which, through your kindness, I
am privileged to occupy to-day, associates the occupant of this
chair with a long roll of distinguished predecessors, and unites
him as it were to a confraternity of honour which oversteps
time and unites generations. But whether the initial duty of
having to deliver an inaugural address is a wise one, I will not
venture to say; yet I do know that the consciousness of this
time-honoured custom neither tends to produce peaceful re¬
pose, nor happy thoughts during the year of probation. My
immediate predecessor, Dr. Robert Jones, having so diligently
covered the field of evolution, from the time of King Saul to
the latest conceptions of the London County Council, I have
experienced no little difficulty in finding a resting-place in any
of the ordinary fields of inquiry. Assuming that the members
of this Association would not expect anything new in what I
might say, I have speculated whether, perhaps in directions
which are not new, I might say anything which would suggest
useful thought to those interested in the aims and work of our
Association. On the very threshold of my task I was, as if
by chance, suddenly pulled up, and found written across my
path these words: “ I look into my glass.” Such is the title
LIII. 48

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678 PRESIDENTIAL ADDRESS, [Oct,

of the short address with which I purpose troubling you this
afternoon. Would that this glass were the simple artificial
mirror from off the reverse side of which you and I could re¬
move the silver coating and look into the fathomless abyss
beyond ; but no, the glass is the human mental mirror of which
all are possessed, some more, others less. If I propose to
you to look with me into this glass at the question of the
social aspect of insanity in a purely rural district, “ far from
the madding crowd,” and which has remained untouched from
the influence of large communities, it is not as a mere theoretical
exercise in race evolution, but because it contains within, a
further inquiry, which even in this the early part of the
twentieth century may be turned to profitable account in an
Association like this.

Allow me to digress for one moment while I recall to your
memories the blanks which have occurred in our ranks since
last annual meeting. I grieve to say the list is a heavy one,
and the profession and our Association are the poorer thereby.
From among our ordinary members we have lost a former Presi¬
dent, Oscar Woods, of Cork, whose geniality and sympathetic dis¬
position were as true a part of his sterling qualities as were his
large-heartedness and steadfast friendship. In England we
have to deplore the loss of three Medical Superintendents.
Frederick Hurst Craddock, of Gloucester; John Creig
MacDowall, of Menston, and Robert Sloss Stewart, of
Glamorgan, and in Scotland, Charles Angus, of Kingseat,
each one of whom has left indelible marks of devoted and honour¬
able services in their respective spheres of work. Dr. Dixon,
of Wye House, Buxton, was not only a successful director of a
private house, but an influential public man. In other branches
we have lost William Lloyd Andriezen and Robert A. L.
Graham, the former, one of our most distinguished workers, and
the latter, a promising son of an able father. We have also
lost three honorary members, who were not only distinguished
alienists and physicians in their own countries, but honoured
and revered members of our Association. I mean the late
Dr. A. E. MacDonald, of New York, Dr. Charles F 6 r 6 , of Paris,
and only a few weeks ago, Sir W. T. Gairdner, of Glasgow, a
past President of our Association, and of whom any apprecia¬
tion in words must fail which does not convey some impression
of the high moral dignity which was in Sir W. T. Gairdner

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1907 -]

BY P. W. MACDONALD, M.D.

679

associated with an intellectual power that placed him at the
head of his profession. The names of three former members
of this Association I may fittingly add to the already too long
list—the late Dr. Huxley, of Kent Asylum, the late Dr.
Toller, of Gloucester, and the late Dr. Schofield, of Camberwell
House. I think it was at the annual meeting of 1903 that a
distinguished member of our Association proposed a motion of
congratulation to a former Visiting Commissioner, on whom
His Majesty had conferred a distinguished honour, and I am
sure it will be with your concurrence that I should to-day
express from this chair the deep and great regret of the whole
Association on the death of the late Sir Charles Bagot, who
was one of out truest and best friends. Knowing, as I do, that
votes of sympathy and condolence have already been sent
to the sorrowing friends of our departed members, I will only
now say that in this long list there were gifted brains and
great reputations, and on behalf of this Association I express
the regret and grief with which we part with able, kind, and
noble associates.

Ratio of Insane to Population .

For the purposes of this address I have taken a period of
haif-a-century in the history of the county of Dorset, during
one-half of which I have been entrusted with the supervision
and administration of the county Asylum, and therefore have
had full opportunities of following and watching the changes
or otherwise occurring in the county and incidental to the
work of my life, and thus it is I am led to address you on the
subject of which I venture to think I know most. In order
the better to preserve continuity and to save you from the
infliction of an array of tabulated statistics, often so fallacious,
I have looked at the subject, I trust, without prejudice, and
hope to show how the swing of the pendulum has often been
affected, not in accordance with the teaching of Mother
Science, or the conclusions of those whose profound ignorance
of the disease led to the theory of its supernatural origin, but
by the hand of time and change and men and ways.
Scientific findings afford no data by which many of the varia¬
tions of this swing may be determined. At the commencement
of the period of this inquiry there was, according to authorised

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PRESIDENTIAL ADDRESS,

[Oct,

statistics (I do not mean lunacy blue books, but the statutory
registers), a ratio of i insane and defective person to every 307
of the population. Now if I were to argue from these figures
alone, and draw conclusions from a comparison with the
position of things at the present time, when on the same basis
there is a ratio of 1 to every 207 of the population in the
county, the outlook would indeed appear extremely black.
Let us look into this for one moment. In the fifties there
were in the county of Dorset scores and scores of feeble¬
minded persons of all ages, living free and simple existences
in the villages, unknown to blue-book statistics, and un¬
known to the lunacy laws. It may be that a percentage of these
—I do not mean the typical village “ fool,” for he exists now—
were not at all times kindly cared for, still they were not
reckoned or taken into account in working out the ratio of the
insane to the population. How then can arguments be built
or conclusions drawn from such a fallacious method of preparing
statistics. It is both wrong and misleading.

Since the seventies, and for reasons well known to all, the
weak, the defective, and the wreckage of human ruin and decay
have been gathered into the institutions of this country, until
the public have become alarmed, nay more, staggered, at the
annual cost or up-keep of these hordes of human beings, and
the perennial balloons of race degeneracy have been flying high
and far. We have recently been warned against hasty con¬
clusions based on general statistics, and a pious hope has been
expressed that local attempts would be made to deal with one
of the gravest problems for the future of this country. If we
take the period since 1875 we are on surer ground, not that I
wish you to believe or to think that I have pinned my faith on
this or any other source of information, based on figures alone.
In the last published volume of the Lunacy Blue Book, the
Commissioners state with a frankness worthy of emulation that
owing to the presence of foreign or out-county patients in many
asylums their statistics fall short of accuracy. Now in the case
under consideration no such inaccuracy can arise, as every foreign
element has been excluded, and thus we are left to deal with
the home-bred article. A quarter of a century ago first
admissions were in the ratio of 1 to 307 of the population, to¬
day the ratio is 1 to 207. Without further explanation these
figures appear as ominous as if we had dealt with the earlier

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1907.] BY P. W. MACDONALD, MJ). 68 I

part of the period, when, as we have already seen, the figures fell
very short of representing the true state of things. In all such
inquiries as the present the first and cardinal principle is to
throw your net as wide as possible, and for this purpose we
must look at the social conditions as represented by the birth¬
rate arid the important question of migration. During the
period since the census of 1851 the decline in the birth-rate
of the county, when corrected according to the methods now
most adopted, amounts to 30 per cent . This is in keeping
with what has been happening throughout the country as a
whole, but in a sparsely populated part like Dorset the conse¬
quences, as we shall presently see, are even more disastrous than
where the persons per acre are more numerous. A declining
birth-rate and steady flow of migration have resulted in a net
loss of 82,000 persons to the county during the period of fifty
years, which means that the stationary proportion of enumerated
natives is less than 65 per cent. Having arrived at this point,
we are now in a position to consider the relative value of the
ratio of first admissions to the population, and what, if any,
changes have taken place. In an earlier part of this address I
promised not to weary you with tabular statements, but you
must forgive me for introducing here what occurred during the
decade ending 1881. For this period the excess of births over
deaths was 22,564, yet there was at the end of the period a
fall of 4,028 in the population, which means that during these
ten years the county suffered a net loss of 26,500 persons by
migration, or at the rate of 2,500 per annum. From the start
to the finish it was a case of all loss and no gain.

I think it was Ruskin who said, “ In some far away and yet
undreamt of hour I can even imagine that England may cast
all thoughts of possessing wealth back to the nations among
whom they first arose.” May I venture to apply these senti¬
ments to the county of Dorset, of whom I may with truth say,
she has given much of her human peasant wealth to the un¬
grateful cities of England, there to be launched, not among the
submerged tenth, but on the flood-tide of the race for supremacy
in the eternal struggle for existence, while she has throughout
these fifty years struggled against the inevitable. When the
brain of the engineer and the hand of the mechanician began to
replace the village peasant, the results of which have been so
graphically portrayed in the history of Wessex, then there

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682 PRESIDENTIAL ADDRESS, [Oct,

followed the tide of village depopulation which has continued
to flow ever since, until the very foundations of the backbone of
this country are threatened. Provided the county had not
suffered such serious losses by migration, the ratio of first admis¬
sions to the population would stand at i to 282, as compared
with 1 to 307 in the seventies. This difference is easily accounted
for when the nature of the stock-producing article is considered,
and would have been wiped out had the normal birth-rate been
maintained. If I have succeeded in engaging your thoughts
to the thread of my argument, the simple truth amounts
to this: During the fifty years there has been a slight
increase in the ratio of first admissions to the population,
which is not surprising, and is what might be looked for when
we remember the destruction worked by the process of migra¬
tion, and, as will appear under the head of causation, the
enfeebled and tainted nature of many of the residue. There is
no need to argue this point further, but it should be said that
alarmists’ statements based on hastily prepared facts conceived
on a wrong issue are productive of much confusion, and, it may
be, national harm. While according to the Blue Book of 1906
Dorset is credited with the third highest ratio, viz. 3*6 of insane
to 1000 of the population, no mention is made of the conditions
which have resulted in this high proportion, nor of the changes
of a national character which may be reckoned as contributory
factors.

At the other end of the pole, and the one most in evidence,
is the accumulation of the chronic insane in our asylums, which
is out of all proportion to the population. One idea is that the
fault lies at the door of the 4s . grant, another that it is due to
the non-discharge of the 44 potential insane”, and yet another,
the failure to requisition the services of the general hospital and
poor-law physican in preference to the trained asylum physician
in the treatment of early or incipient insanity. 44 The ill-
informed public are apt to look upon a man who has a reputation
for skill in a particular class of disease as of necessity un¬
acquainted with all other diseases. We, on the other hand,
maintain that of him it should be said with truth, that he is one,
not who knows less of diseases in general, but who knows more
of the particular class of disease to which he has devoted most
time and special attention and study.” I do not think it is
necessary for me to enter into an argument with either school,

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1907.]

BY P. W. MACDONALD, M.D.

683

much as I should like to do so, but I venture to say, that while
a shadow of truth may attach to each, the real cause is the
unbounded confidence of the ratepayer of this country in the
administration of our public asylums, and while this is so the
trained and experienced asylum physician need not trouble to
warn either the neurologist, visiting-physician, or the Poor-Law
official off his preserves. To this confidence must be linked
the changed condition of things, at any rate in the country,
regarding the apparent reluctance on the part of the home
circle to care for their insane relative. Is this unreasonable or
unnatural ? There are desirable homes supported by the rates
where the patient can be nursed and cared for. At the same
time the relatives themselves have a greater struggle for exist¬
ence, and, therefore, through the mere force of circumstances
are not in as good a position as formerly to play the rdle of the
mental sick-nurse. Can you or I deny the force or truth of
this? No ; and while the reputed increase of the insane is
more associated with an increase in the number of the registered
mentally unsound than any increase in the prevalence of
insanity, let us not attempt to save or mould the future of our
race at the expense of the delightful personality so frequently
met with in institutions for the insane. Let me warn you
against beginning at the wrong end.

Type of Insanity .

Having thus far dealt with the human fabric in a limited
area, we may now turn our attention to the actual mental con¬
dition, and look into our glass from the clinician’s point of view.
Has the character of the cases remained the same, or have the
forms of mental disease under any of the many systems of
classification changed during these fifty years ? My initial
difficulty is to reconcile or bring into line the views and expe¬
rience of fifty years ago with the ripe experience of the present
day. Still, the difficulty is not so great after all, and he would
be a bold man who would question the diagnosis of a Pinel, a
Skae, a Tuke or a Bucknill. Perhaps they were not accustomed
to such borrowed terms as “ dementia praecox ” and “ manic
depressive,” but I venture to state that they were as competent
to diagnose a true case of mania, melancholia or any of the
dementias as the greatest Goliath of the present age. Under

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PRESIDENTIAL ADDRESS,

[Oct,

this head much interesting information may be gleaned from
the published experience of such men as Thurnam and Boyd,
and I am inclined to think that the registers of our public
asylums were as carefully and as accurately entered up fifty
years ago as at the present time. The types of insanity
exhibited by first admissions during the fifty years do not show
any very startling change, yet under certain heads the change
that has taken place is significant of what has been happening
in the county, and clearly adds soundly-welded links to the
chain I am humbly endeavouring to put together. With
reference to the groups of cases falling under the head “ mania,”

I find that the percentage has varied but little during the
period. In the first decade the percentage was 49, in the
last decade 48, of the total first admissions. These per¬
centages are curiously corroborative of the figures as given by
the Lunacy Commission, though not quite so high, and while
on the surface of no apparent moment, yet they have a
significance. Mania is the only type which does not show a
clear and ominous change. Now, without venturing on too
thin ice, is it not in accordance with experience, whether gained
in the laboratory or by the bedside, that this particular type is
less often associated with the wholly hopeless and incurable
than any of the other forms? It certainly is so in Dorset,
and in further support of this view I would here mention that
in the seventies, when agriculture was booming and the ordinary
or average population presumably engaged on their native soil,
the percentage of mania among the admissions was as high
as 65, so that while in a recently published tabular state¬
ment agricultural districts are credited with a high proportion
of mania among the admissions, it has to be borne in mind that,
notwithstanding the changed order of things, when individual
centres are closely scrutinised, the proportion remains about
stationary. Turning to melancholia, what do we find? An
advance from 18 per cent . in the fifties to 2 5 per cent . in the
nineties, a jump of 7 per cent ., and here is one of the striking
features in the changes that have occurred. The increase
of this type has been much more pronounced during the
decades ending 1896 and 1906 than formerly, and while the
loss by migration is an important factor, I am inclined to the
view that intoxicating physical causes have played a con¬
spicuous rdle if only by rendering the individual hyper-

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I907-]

BY P. W. MACDONALD, M.D.

68 s

susceptible to every extraneous influence. But the really
important point is the close association between the type of
melancholia as met with in Dorset and the absorbing question
of heredity. I do not intend to discuss this question
at present, as it more fittingly falls under the head of
“causation,” still I thought it desirable to refer to it, if
only to bring into evidence the variation between the two
main types of mental disease, mania and melancholia. The
dementias are not so easily dealt with, for while there has been
no great divergence of opinion respecting senile and secondary
dementia, nor have the use of these terms varied in their appli¬
cation during the period, ideas have not only changed, but the
whole aspect of things has altered in regard to the early
dementias. It has been stated that owing to the lack of brain
activity in rural communities senile dementia is thereby more
prevalent; but is this the only or real reason why there is such
a high proportion of senile cases among the admissions from
rural districts ? I do not think so. The proportion of this
type among the admissions has risen from 5*8 in the fifties to
8*8 at the present time—by no means an alarming increase.
But what about the residuum ? The quiet healthy life of a
Dorset peasant is as conducive to sound-minded longevity as
is the bustle of our large cities, and as the result of a patiently
conducted inquiry I am inclined to attribute the increase to
other causes than the lack of brain activity. I have already
stated that owing to the havoc wrought by the tide of migra¬
tion the humble home no longer harbours those who are able
and willing to act the part of the mental nurse. The poor-
law authorities in country districts fail to make provision
within their walls for the aged mentally sick, and by a process
of devolution the Lord Chancellor, through the Lunacy Acts,
ordains that his aged children shall be gathered into the fold
—into homes which were recently described as “ sepulchres of
living humanity, or tombs of the intellectually dead ” ; homes
where, through the instrumentality of the enlightened treatment
of mental disease, the ordinary span of life’s short journey has
been considerably lengthened. The aged are interesting, both
on account of the lessons we may learn from them, as well as
the reverence with which we in all humility should address
them ; but when we come to consider the position of the early
dement we are met with a totally different condition of things.

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PRESIDENTIAL ADDRESS,

[Oct,

The dementia praecox school ridicules the homely terms
“primary” or “early dementia,” and there are those who adopt
“adolescent insanity” in preference to either. I am anxious to
make my position clear in this matter, not only because I have
experienced some difficulty owing to the accepted views of
decades ago, but also because the question of primary or
early dementia bristles with the deepest interest in any
attempt to study the phases of mental disease as exhibited by
the admissions from the district now under consideration. It
is possible that in the fifties and sixties this particular type of
patient was not so thoroughly sifted from the others as at the
present time, still, if time and thought are not at a premium, a
few months’ careful study of our old case books will lay bare
their presence in no inconsiderable number. From the
seventies onwards we have been more familiar with this class
of case, and I find that in Dorset they have advanced from
I to 3 per cent . among the first admissions during the period
under review. This is, if we feel inclined to prophesy, an
alarming increase of a most hopeless type of mental disease.
Many and various are the opinions held and expressed in
explanation, but while the evils of educational pressure, un¬
healthy environment, a passionate indulgence in various
directions extending to abuses and other causes, are important
side issues, I have found, as I hope to show, that the increase
in this class of patient in Dorset is really grafted on an insta¬
bility associated with the scourge of heredity, or as Dr. John
Macpherson has put it, “ a predisposing cerebral weakness and
a physical intoxication.” This type has been of absorbing
interest to me for many years, and I am in sympathy with the
writer who reminds us of the danger of general statistics, and
warns us that of all classes of argument, statistical arguments
are the most open to misuse. Could there be a better illustra¬
tion of the truth of this than the published statement that the
proportion (per cent.) of primary dementia among the admis¬
sions in Dorset is somewhere about '5 per cent., whereas the true
proportion is, as I have said, 3 per cent ?

We have now to look into our glass at two types of a
wholly degenerative nature, viz., general paralysis and
epilepsy, associated with insanity. In the case of general
paralysis there has been an increase of 2 per cent., but as this
is not one of the common types of diseases in rural districts

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less interest attaches to it there than in other districts.
One curious fact has come to light in respect to the pro¬
portion of female general paralytics, which falls but little
short of the proportion in other centres, whereas in the case
of males it is only about one-half. If Dr. Mott could be
induced to devote a few months to the study of general
paralysis as met with in districts like Dorset, I am inclined
to think his impregnable fortress of “ no syphilis, no general
paralysis ” would shake still more, and I am assured on good
authority that the walls of his masterly-built edifice begin
to show fissures. The position of acquired epilepsy shows a
slight advance, about 1 per cent., which is entirely among the
men, for there is actually a falling off in the proportion of
female epileptics, but when we come to consider cases of
epilepsy, associated with congenital defect, there is need for
us to pause and think. It would serve no useful purpose
to make a separate group, and I have therefore considered
the whole class of congenitals under one head. The propor¬
tion per cent, of this class among the admissions has risen
from 47 to 8 per cent, during the fifty years—truly an
appalling state of things; and herein lies one of the problems
which has to be solved in any attempt to grapple with the
question of race degeneracy. I fancy I can hear whisperings
as to basing opinions on false premises, such as statistics,
accumulation, etc., but let me hasten to assure you that I have
been into the highways and byeways, the actual homes and the
village schools, for the facts on which I venture to express an
opinion. There is no denying, no getting away from the fact
of the alarming increase of congenitals among the annual admis¬
sions, and for an explanation we have not far to seek. It is ready
at hand, the deplorable state of things, easily recognised and
probed to the bottom in the social life of depopulated villages
and districts. Unwise marriages, no variation, an unhealthy,
nay more, unholy attachment to the native, has landed us on
the very brink of ruin and degeneracy. Having briefly looked
into the question of any variation or change in the type of mental
disease, we may summarise the matter thus : Melancholia, early
dementia and congenital defect, especially the last, have increased
beyond comparison with any increase in the admissions ; and the
gravamen of these changes lies deeply buried in the social life of
the people. Help, or relief, must come from the root; it is hope-

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less to attempt repairing the roof with new tiles while the walk
are so shaky and the decaying foundations are so rotten.

Occupations and Insanity .

I think it was the late Sir George Johnson who once said:
41 There is reason for the belief that the more thorough and
profound is the investigation of any disease or class of
diseases the more numerous and intimate will be found
to be the relationship with other morbid states.” Of no
disease more true than of mental disease, and with those
words clearly reflected in our mirror let us look at the
question of occupation in relation to the changes which
have occurred in certain types of insanity. It has been
thought that a consideration of “ how far the cause of an
attack of insanity is related to the occupation of the
patient might be a subject worthy of careful research” It
was, perhaps, with this object in view that I approached
the subject, and not without hope of some little reward, but
I fear the results have hardly justified my earlier conceptions.
Where the admissions are in numbers within the grasp of
easy and accurate classification, as in the case of Dorset,
we are not likely to have hurled at our heads the stock
phrases, “ inaccuracy,” “ borrowed information,” etc, and I
venture to say the facts as here given are accurate and
beyond dispute. Now what have we found? During the
fifty years the class from which the bulk of the cases are
drawn, vis., labourers of all kinds, but mainly agricultural,
has decreased by some 5 per cent, calculated on the annual
admissions. Will this occasion surprise? No, for we are
already familiar with the fact that the more intelligent
labourer has gone elsewhere. Therefore at this point there
is no apparent relationship between any increase among
the males and the main division under the head of occu¬
pations. The division of professions, artisans, etc., never a high
percentage, has also decreased, and while it would be sheer
waste of time and energy to sum up scattered occupation
fragments, I may at once come to the point and ask, if the
main groups have decreased, in what group or division
has the increase occurred? In that familiar group, “no
occupation,” which has advanced from 6 to 12 per cent..

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I think I ought to build a little wall of defence and beg
of you not to imagine that I have included in this division
cases where no information was forthcoming as to the occu¬
pation or how they gained a livelihood, for all such doubtful
factors have been excluded, and the group contains only those
who for a multitude of reasons never had and never could
have any occupation. I desire to treat this curious and
interesting fact as a matter of the greatest importance, and
therefore let us for a few moments look at the position of occu¬
pation in relation to the female admissions. As might be guessed
from previous observations, the wives of labourers and artisans
have decreased though there has been an increase of 7 per
cent\ among the class of servants and other unmarried workers,
but the main increase has been, as in the case of the males,
under the head of “ no occupation,” the proportion rising from

II to 34 per cent It will be observed that the increase

is much more than in the case of the opposite sex, and

reveals to us the high proportion of that most hopeless class,
the “mental defectives.” Now while a study of occupations
in relation to insanity may have shown a striking increase in
the group “ no occupation,” it has not, as was foreshadowed,
established any clear connection between certain occupations
and special types of insanity, yet I hope to show that the

inquiry has not been altogether fruitless. Though I cannot,

as has been suggested, trace any clear connection between lack
of brain activity and senile dementia, which after all is but the
result of natural physiological changes, and strictly speaking
should not be classed among the insanities, there is an
interesting state of things in connection with occupation and
melancholia. The lack of interest and want of any direct
stimulus to activity or change of thought in large numbers of
the peasant homes in Dorset, mainly through the forces follow¬
ing in the wake of migration, have resulted in a state of gloom
and despondency likely to be followed by one of the many
phases of melancholia, especially in the case of the predisposed
and badly nourished. In so far as the occupation of manual
labour is concerned the relationship results from enforced dis¬
placement and not because the labourer is not worthy of his
hire. A further illustration is to be found in the case of the
unmarried woman, who formerly had ample employment in
home laundry and dairy work. Most of this is now carried

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on by steam laundries and butter factories, and the simple
peasant is driven to eke out an existence in a multitude of
ways not always conducive to either mental or physical health.
In centres where the multitudes collect I can easily understand
a different state of things, and that results of a more definite
character may be arrived at, but where you have such disorganisa¬
tion of normal or ordinary life and occupation, as has happened in
Dorset, the chances are against any pronounced relationship
between occupation and insanity. Admitting that the Dorset
labourer lacks in initiative and responsiveness, I do not think the
increase of insanity, in so far as this may be proved or accepted,
has any direct connection with the ordinary avocations, and
therefore I have a difficulty in making any definite pronounce¬
ment on a subject which has not the value I was inclined to
attach to it. However, the consciousness of greater difficulties
ought to recall to our minds this fact, that if the field of inquiry
be narrow it can be dug deeply, and in psychological medicine
as in other departments, if only a very narrow shaft be carried
deep enough we may reach the richest stores of wealth and find
use for all the appliances of scientific thought

Causation .

"Now in every search for truth we can not only exercise
curiosity and have the delight, the really elemental happiness,
of watching the unveiling of a mystery, but on the way to truth,
if we look well around us, we shall see that we are passing
among wonders more than the eye or mind can fully com¬
prehend.” In this frame of mind, and remembering the words,
44 He shall be as a god to me who can rightly divide and define,”
I have to ask you to look with me for a few moments into the
question, which of all others is of greatest and deepest interest
to the student who, however imperfectly, attempts to trace an
association between insanity and any of the numerous influences
and factors at work. Dr. John Macpherson says : 44 Insanity
not being one disease, but a heterogeneous group of many
diseases, we cannot speak correctly of its cause, and, further, as
our knowledge of the fundamental facts of insanity is as yet
only fragmentary, our opinions regarding its causation are still
necessarily crude and imperfect” If we accept this position it
is clearly necessary, if we have a desire to get anywhere near

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the truth, to take nothing for granted unless we can satisfy
ourselves that truth is on our side, and that our conclusions are
not based on figures alone. If it has been necessary to devote
so much time and thought to the preparation of corrected birth¬
rates, how much more necessary must it be in the case of the
question now before us, and into which I venture to think more
errors are likely to creep than into any branch in the whole
domain of psychological medicine. I would here clear the
ground by one observation. Do not imagine that I propose
taking you through any tabulated list of causes. We are asked
to believe that one of the great factors in the production of
insanity is associated with the distiller's and brewer's produc¬
tions, and I think it was Dr. Hyslop who last year warned the
public against the evils likely to accrue from the disturbed
slumbers of London's rising generation by the nocturnal concerts
of love-sick tom-cats, and, again, Sir James Crichton Browne has
called attention to the dangers likely to follow in the wake of
the motor-car. Now all these influences may, and no doubt do,
play a part, but in the case of Dorset the real factors at work
are of a different nature, and I feel sure no one would more
readily admit than Sir James that good might come from the
increasing prevalence of motor-cars in a district where the
stagnation of ideas may have become rife and life's dull journey
not too exciting. The condition of things in a district where
migration has played a conspicuous r6le must be wholly different
to what is met with in centres or districts where the opposite
state of things exists. I cannot accept a grouping of causes
from different districts void of common ties as anywhere near
the truth. It may be our habit to speak of the causes in one
district as the equivalent of those in another, but is this always
right ? Acting in unison they might be allied forces, carrying
into effect a common condition, but acting apart from each other
they might be like foes upon common ground. In considering
the factors which have been at work I have not been content
with ordinary methods of inquiry, but have looked for facts of
corroboration, explanation, or otherwise, as are only to be
observed in the cottage, village school, harvest-field, etc.

If I take, first and foremost, intemperance, I do not wish you
to infer that I am thinking of alcohol only, as I think it is
generally recognised that intemperance in other ways may
prove deleterious to the nervous system, and I would suggest

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that the total abstinence school should considerably enlarge
its list, so as to include such baneful decoctions as black tea
and the pocket phial. As regards the question of alcohol, I, in
all sincerity, accept the position that, when abused or even in
many cases used in moderation, the poisonous effects on the
nervous system and the future of the race are fraught with the
gravest consequences ; but if you ask me to accept the view
that alcohol is the great cause, or even one of the greatest
causes, of insanity, then we must part company, for facts and
experience have taught me a different lesson. For many years
I have asserted, and I do so again, that drink, or intemperance
in alcohol, cannot be proved to account for more than 3 to 5
per cent, of all cases of insanity in the county of Dorset 1
admit there are no large towns, yet there are seaport towns
where it is generally supposed the sin or curse of drink is
prevalent, and I think those who know the Wessex country
will admit that the Dorset peasant is as fond of his glass of
cider or ale as is the Lancashire miner or the Shoreditch docker.
I am not aware of any authenticated opinion or explanation of
what must strike the reader as somewhat curious, viz., that while
the position occupied by the county of Dorset as regards the
ratio of insanity to the population is one of the highest, it is
also the fact that it is one of the lowest in regard to alcohol as
a factor in the production of insanity. Reasons may be assigned,
such as the greater purity of cider and beer compared with the
raw, adulterated and poisonous spirits so largely consumed in
cities; or, again, the lethargic and stolid character of the Dorset
labourer as compared to the more highly strung urban workman;
or, again, errors or differences in methods and ways of collecting
and arranging facts, and it is notorious how wholly unreliable
is the information as supplied by the statement of particulars;
but these and many other reasons which might be mentioned
are quite inadequate to explain away the difference between a
5 per cent, in Dorset and a 30 per cent, in Northumberland. As
Lamb observes, “ it leads the reader to frame further questions
on his own account to which no reply is forthcoming.” I am
tempted, but converging forces restrain me, to step on soil
which great and experienced minds have hesitated to tread, and
yet the question is of absorbing interest I am conscious of the
readiness with which the lay press and others pick up and shape
to their own liking every expression or statement on the subject

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1907 .]

from members of the profession, still I say frankly that the
prevalent notion that alcohol fills our asylums, that drink is the
greatest cause of insanity, or that the medical profession has
denounced alcohol as wholly unnecessary, has not been proved,
and, as regards Dorset, we must tap another source to account
for the high ratio of insanity. Has not the Chancellor of the
Exchequer solemnly prayed for further assistance from his
declining excise duties, while the ratepayer grows sleepless
under the increasing burden of insanity ? Was there ever such
a commentary on the intemperate statements, it may be, of well-
intentioned but misguided persons. All sound-thinking people
are alive to the evils of intemperance, whether in drink or other
directions, and it is well known that the mentally defective, the
epileptic, and the highly neurotic are more easily affected than
the mentally sound. Again, the number of alcoholics are far
more among re-admissions than first admissions, which fact
alone shows with what care we should approach the subject, lest
we fall into the error of tabulating as a cause what was clearly
a symptom of loss of control. I would therefore ask for a
stricter observance of the real facts and a truer regard for utility
and charity when considering the personal equation, which enters
so largely into every inquiry.

It might be thought I had run away from the question of
intemperance in other beverages, but this is not so, and while I
had not originally intended bringing up the subject of food at
this particular point, I think it will be better to do so and thus
save repetition as well as maintain a gradual ascent to the one
great factor. At a time when so much attention is being given
to the better housing of the poor, which means a gradual improve¬
ment in the environment, the question of how, if at all, the high
ratio of insanity may be associated with the ordinary diet of the
Dorset peasant cannot be left out of consideration. Now let
us first look at the difficulties so frequently experienced by the
cottage community as regards that most necessary article of diet,
milk, which, as Professor Osier reminds us, was the original food
of man. There would seem to be an inherent notion that poor
people in the country can always obtain milk. It is a fallacy.
The ordinary cottage family in the country has great difficulty in
obtaining even a partial supply of milk, and when extra is re¬
quired it is not to be had. This is not due to poverty, but
to the iniquitous system of tied dairies, small as well as large.

LIII. 49

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Further, the supply is not only short, but the quality of the
poorest, and “ the mere citation of this fact proves the primary
urgency of the milk supply and the binding obligation of pro¬
tecting its purity.” The evils do not stop here, for since milk
is short, something else must take its place, and everyone
knows what is meant by the black tea-pot, which is always
to be found on the hearth-stone. The father, mother, son,
daughter, and even the suckled infant, all share alike from the
ordinary fare of black tea, bread and cheese, morning, noon,
and night. This is no coloured picture, it is the simple truth.
If the beverage tea were properly prepared, and not indulged
in too freely, no harm would be likely to accrue; but what
will be said of the ordinary labourer who consumes daily two
to three quarts of black tea thus prepared. A brew is made
between 5 and 6 a.m., and this same pot continues in use by
being added to from time to time during the working day,
until at last it is little else than rank poison. The fact that
this tea is without either sugar or milk, being what is
familiarly known in Dorset as “ stark naked,” makes things
worse, and I am convinced is in many cases the cause of
insanity among the labouring class. I am not decrying tea in
its proper place, but the evils of tea-drinking among the
working classes have to be reckoned with in any attempt to
probe deeply the causes of insanity. As a nation we consume
six times as much tea per head as any other European country.
This innutritious diet must lead to impaired nutrition of the
nervous system, and as has been pointed out by the Irish
Board of Lunacy, “ when acting over many generations may
have developed those neuropathic and psychopathic tendencies
which are the precursors of insanity.” Facts of this nature may
lend colour for the demand for free breakfasts to certain classes
of school-children, and whoever has visited the typical village
or town school could not have failed to observe the number of
dull, stunted and neurotic children. In the course of my
inquiries I found as many as 15 per cent . of non-educable
children in village schools, and the percentage of dull and back¬
ward ran as high as 35 percent. Well might the author of
Physical Efficiency say : “ The towns will soon call in vain; for
in place of being robust and healthy, the children of the rural
districts will often be found to be stunted and in a worse
plight than the city children.” With these evidences of brain

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BY P. W MACDONALD, M.D.

695

poverty and physical defects looming large before us we might
be tempted to agree with the learned professor when he advises
us to throw beer, spirits, tobacco, tea, and coffee into the
Atlantic as unnecessary and that the race would be the better
for it. Whether this advice will ultimately prove to be a
panacea time alone will show, but it would certainly solve
many of the problems with which philanthropists, physicians,
and politicians have to deal.

Heredity .

In the Sixtieth Report of the English Lunacy Commission ,
issued last July, which is one of the most interesting and
valuable reports ever issued from that office, the county of
Dorset is credited with the highest percentage of heredity as a
factor in the production of insanity. The information therein
given does not reveal the whole truth, and, as in the case of the
birth-rate, so with the ratio of heredity, it has to be corrected.
I do not intend to wade through the mazes of the latest theories
on the subject as propounded by Beard, Ford Robertson,
Archdall Reid, and others, but, in the words of Dr. Clouston,
will content myself by accepting the theory that ill-nourished
and degenerative parents are likely to produce between them
bad progeny, and even if not ill-nourished a strong heredi¬
tary predisposition will far out-weigh the influence of good
environment. The author of Clinical Studies of Psychiatry
says: “ Whatever the exciting causes of insanity may be, the
chief predisposing factor is hereditary predisposition,” and Dr.
Mott, as the result of a vast experience, states, “ that the large
majority of the insane are hereditarily predisposed.” In dis¬
cussing a question of this magnitude it is as necessary to avoid
being too narrow as it is desirable to guard against collateral
errors, and as “ the inheritance of both mental and physical
characters hardly admits to-day of dispute, it is only the
manner or intensity of inheritance which calls for discussion.”
I have carefully looked into this question as regards the insane
and mentally defective in the county of Dorset during the fifty
years under review, and the position of heredity as being the
main predisposing cause is proved beyond dispute. While the
percentage of heredity among first admissions may have varied
during the five decades, there has been a progressive advance

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in the numbers admitted among whom a definite history of
inheritance could be traced, until at the present time it is some¬
where between 50 and 60 per cent. As stated in an earlier
part of this address, I have taken first admissions so as to avoid
any risk of false deductions which must inevitably arise if you
do not exclude the danger of reckoning the same person more
than once. In the course of this inquiry I have been more
than ordinarily careful to exclude all possible cross currents,
and this is why I elected not to deal with the question of
heredity on the total admissions. Considering the present
position of heredity as an all-important factor in the production
of insanity, it is well, perhaps, in passing to consider the views
of those able and distinguished members of our profession who,
while admitting the importance of heredity in relation to mental
disease, ask for statistical proof of a like inheritance among
the sane members of the community. Now a demand of this
nature must inevitably be characterised as of an inquisitorial
character, and as I think we all know how difficult it is to
obtain even a modicum of the truth in regard to recognised
cases of mental disease, how much more difficult, then, if not
well-nigh impossible, must it be to obtain information about
those who, though presumably sane, may be predisposed. Far
be it from me to even appear to throw dust on the brilliant
horizons of those who aim at such a goal, but it does not appear
clear how any inquiry would affect the case of heredity in
relation to insanity, for since heredity is equally established in
other allied neuroses such as epilepsy, alcohol, chorea, phthisis,
it would be necessary, in order to arrive at the truth, to trace each
variation to its ultimate end, and while I commend the subject
to race enthusiasts, I feel that it is quite outside the scope of this
address. It has been pointed out that you cannot stop at a
predisposition to one neurosis, for it is quite possible that the
variation may be as true an inheritance as the original neurosis,
so that the subject is one of many parts and great difficulties.
For our present purpose it is sufficient to deal with heredity as
related to insanity and mental defect, and since a predisposition
has been traced in over 50 per cent . of first admissions, it may
with some plea of justification be asked, is there any possibility
or even probability of accounting for or explaining this high
percentage of heredity among the insane in Dorset ? At this
point I am haunted by the words of the late Sir William Bowman,

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BY P. W. MACDONALD, M.D.

697

who said: “ Never till the present moment have I had so much
cause to lament my many deficiencies, since now they must of
necessity affect others more than myself” It is an easy task
to build an edifice in the matter of theories, but the cement has
to be of the best, and therefore the more special is any depart¬
ment of medicine the greater is the need to recur often to general
principles, and to bear in mind that so close is the solidarity of
the animal organism that there is a literal and physiological
truth in the apostolic statement, “If one member suffer, all the
members suffer with it.” It would be idle to attempt to throw
any doubt on the importance or position of heredity as a pre¬
disposing factor in every phase of mental defect and mental
disease in the county of Dorset. The field simply bristles with
evidence and proofs which even the most ardent advocate among
the opposition will find it hard to explain away. Admitting
that the scientific and reasoning mind can best sift the problems
of heredity to the bottom, the general question of predisposition
is so closely allied with the social and racial atmosphere that
one has to start from humble ground in the hope of building
up a passable conception of human stability, for, as Burke once
said, “ I am aware that the age is not what we all wish, but I
am sure that the only means to check its degeneracy is
heartily to concur in whatever is best in our times.” My
one desire in this inquiry is to seek out the truth, and since
experience has taught us that this can only be accomplished
by a true regard for the correlation of facts, I will not attempt
idealistic colourings, or ambiguous phraseology, but humbly
endeavour to delineate an unbroken sequence of events.

To begin with, there has been throughout the fifty years a
steady decline in the birth-rate, and while I shrink from entering
the raging field of newspaper warfare, I must take exception to
the statement that there has been a greater fall in the urban
birth-rate than in the rural. In Dorset the corrected birth-rate
shows the alarming decline of 30 per cent . during the period of
fifty years. The seriousness of this fact grows in volume
and importance as we link it with the question of migration,
for while the one may be the accredited result of studied
temperance, the other is the dire consequence of the social
upheaval in rural districts. The process of depopulation,
which has resulted in such a serious loss of persons to the
county during the five decades, whose places have not been

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led by a fresh population, simply means that the weak, the
insane, and the diseased were left behind—not a happy or
robust combination to continue the propagation of the species.
The unexplained attachment of the sexes among certain groups
of allied neuroses, such as insanity, phthisis, epilepsy, etc, may
be examples of natural selection, but not with a view to the
survival of the fittest, and reminds us of Dr. Clouston's pregnant
phrase: “To observe the way marriages are sometimes arranged
is almost to lose hope for the future of our race” In the
county of Dorset there are parishes which for obvious reasons
must remain unnamed, where the conservative principles of
matrimonial unions were so notorious that the choice of a
partner in wedlock was by local laws ordained, and whoever
dared to transgress might prepare to pack his goods and
chattels as one of the excommunicated. This was not a
custom of a day nor a year, but extending over generations, the
result of which has been an almost unparalleled condition of
things as regards the evils of unwise marriages. If we are to
accept Mr. Heron's proposition that 2 5 per cent, of the married
population produces 50 per cent . of the next generation, and
that the thrifty, the cultured and well-to-do, fail to produce their
due proportion, how appalling must be the outlook when the
weak and the feeble inter-marry and when the introduction of
fresh blood, which is most likely to check the neurosis, is as a
red rag to a bull. “ I should be loath to say that everyone
whose mind has once been temporarily unhinged by grief,
anxiety, or physical pain is therefore doomed to celibacy, that
man or maid whose father or mother’s mental health once broke
down, should never marry. But at least the risks should be
better known than they are at present, and some restrictions
might be put on the marriage of those whose record of mental
health is so bad as to promise a heritage of insanity to their
children.” To these facts, in the face of which it is useless to
attempt to speculate, there has to be added the far-reaching
effects of an innutritious diet, the consequences of which may
ultimately prove to be of even greater importance for the future
of the race than all the coloured pictures of the evils of bad
environment

It is commonplace that “ truth is stranger than fiction,” and
it is equally true that neither science nor the legislature will
materially affect the question of insanity before the lay public

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BY P. W. MACDONALD, M.D.

699

have awoke to the fact that there is still reason to believe in
the wisdom of the old adage, “ prevention is better than cure/'
It is no part of my task to enter the field of controversy in
relation to the present and future treatment of mental disease,
which has been flamed into prominence by the anonymous
expositions of those who guilelessly pretend to have an apostolic
benediction for the purity of their statements, but I may be
excused for briefly referring to some of the views and ideas
which have recently been put before the public. It would
appear as if a good cause were in danger of suffering, not from
want of kind intentions, but from a plethora of conflicting
ideas. Now as in the case of the causation of mental disease,
so in the case of the means to be provided for its treatment
districts differ, must differ, and will differ solely and simply
because the numbers which have to be dealt with vary to such
an extent. In the case of Dorset I am afraid that Drs.
Carswell and Toogood would not have much opportunity of
carrying out their methods, where, as all know, there is but a
scattered population and only the ordinary workhouse to deal
with. In large centres such as London, Liverpool and
Glasgow, where a high proportion of temporary cases are
met with, the conditions are wholly different to those in
country districts. It has to be stated, and with satisfaction,
that in several of the large centres the Poor-Law infirmaries
have done excellent work. To take but one example. Dr.
Toogood says there passed through his hands in 1905, 7,322
cases of supposed insanity, and he tells us that of this number
he discharged 2,877 as cured, and sent 3,583 to the asylums.
Now, what I would like to know is this. How many of the
2,877 discharged as cured were certifiable, and what proportion
of the total number sent to the infirmary should really have
been classed as of unsound mind ? Until we know this we are
not in a position to make comparisons or draw conclusions,
and the stigma of being sent to the workhouse is as much to be
resented as that of the certification bogey.

For some considerable time there has been much talk as well
as voluminous writing on what is familiarly known as incipient
insanity, by which, I presume, is meant the early symptoms of
mental perversion. Now, somehow or other many of the
expressions which have appeared in print would lead the
unwary and ignorant to believe that at the present time there

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700 PRESIDENTIAL ADDRESS, [Oct,

is some law or hindrance to the treatment of early symptoms.
Is this so ? I am not aware of any hindrance to the ordinary
medical attendant treating these early symptoms, and I think
it is generally known that many do so most successfully, and
with even better results than are often met with in the privacy
(its only advantage) of single care. In connection with this
question the suggestion or proposal as at present put before us
would only benefit those who are in a position to pay for the
consultant and single-care home, so that the vast majority of
the incipient class would derive no benefit. Will anyone say
that legislation of this kind can or could be considered satis¬
factory. The poor servant girl or the mechanic’s wife should
have equal opportunities of receiving benefit with the
millionaire’s daughter. I think it is much and greatly to be
regretted that members of our profession should continue to
harp upon the stigma of certification, which, after all, is senti¬
mental, and I would venture to throw out a word of warning
lest the proposed notification may not soon be surrounded
by similar sentimental objections. The clause in the Scotch
Act requires no notification, and because such a clause exists
across the border, where it is only taken advantage of by the
few and seldom by the general practitioner, do not let us
persuade ourselves into believing that its adoption in this
country would either reduce the ratio of insane to the popula¬
tion or raise the recovery rate. It is time to have done
with all this cant about the stigma of certification and to ask for
the removal of what produces the stigma. We are constantly
being told that it is not the question of the disease that is the
stigma, but the means whereby the disease is enabled to be
treated where it ought to be treated, in the homes and institu¬
tions provided for the purpose. This view of the position of
things reveals a veiled truth which is ruthlessly exposed by
Professor Clifford Allbutt’s solemn words: “ The stigma, if such
there be—I rather resent the phrase—lies in the misfortune
itself, and not in the red tape of the proceedings.”

There is a further proposal which, perhaps after all, is the
most interesting, as leading us rather nearer to the solution of
the difficulty. With regret it has to be admitted that the
inauguration of out-patient departments in connection with the
asylums of this country has proved a failure, and the question
here raised is this : What can be done to enable the poor of

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701

this country to obtain advice and guidance from the medical
profession in the early stages of mental disease ? It has been
suggested that public hospitals should open their doors and
establish mental departments. This is no new proposal. The
good work done at St. Thomas’s for many years by Dr.
Rayner and his successor Dr. Percy Smith, and at Charing
Cross by Dr. Mercier, must be known to all, and this very year
we have the splendid example of the Western Infirmary,
Glasgow, where a new mental department has been inaugurated
and placed under the guidance of Dr. Oswald. I venture to
think that if this were done all over the country no member of
this Association nor any member of the medical profession
would raise a dissentient note, but since the public hospitals of
this country are supported by voluntary contributions, is this
proposal feasible, and are not the difficulties insuperable?
Here again a simple question of numbers. What is practicable
in large cities ends in dreamland in country districts. There
is one suggestion I would make, viz ., that if city, county, and
cottage hospitals were to open their doors, and if it were
proved that thereby a number of cases were helped and
treated to recovery, county and other central authorities
should have the power to contribute a like amount to the
hospitals for the cases treated there, as they do to the existing
institutions.

The question of receiving houses for the care and reception
of cases previous to certification is being taken up in various
parts of the country. In large centres and populous districts
the proposal should prove a valuable one, but I fear the same
cannot be said of sparsely populated country districts. Again,
would these receiving houses be any improvement on the Poor-
Law infirmaries and would they not be surrounded with the same
atmosphere of suspicion, and although it is proposed that there
shall be no certification would there not be the same sentimental
stigma as attaches to the house or institution for the treatment
of mental disease ? Surely it would be a simpler, more
effective and better way to meet all these difficulties by asking
the legislature to free the institutions of this country from
oppressive laws and the stigma of lunacy, and to allow them to
open their doors to all, incipient or certified, as in the case of
ordinary hospitals, and then there would be an equality of
treatment, then there would be a chance of the early sym-

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PRESIDENTIAL ADDRESS,

[Oct.,

ptoms of mental disease being treated by those who, from
experience, are most competent to do so, and who have the
ways and means at their disposal. There are two phrases
which from time immemorial have been looked upon with sus¬
picion and disfavour. The phrases are 14 administrative duties”
and “ certification.” I have already touched on the latter, and
who among us will not admit that administrative duties are often
our only recreation, a safety valve, an outlet from the maze of
psychological cobwebs, a hobby if you like it commensurate with
the golf ball and the fisherman's tackle. No, where M there's a will
there's a way” and it is nothing less than a species of idle criticism
to talk about asylum medical officers having no time for scientific
research because of their administrative duties. Those who
have done the great and good work in the specialty have not
been those who have leisure but the busy, the willing, and the
determined. One does not care to be accused of hypersensi¬
tiveness, but I feel bound to say that the sweeping references
to asylum medical officers from the pen of an anonymous
correspondent of the Times are as unworthy as unjust, and of
this writer I might say what Shiel said of O'Connell: “ He
flung a brood of sturdy ideas on the world without a rag to
cover them.” By all means let the great metropolis of London
institute and endow an experimental school of research for
the study and treatment of mental diseases. All will welcome
such a school, but its establishment will be no answer to the
crying question of the day since it could but cover a limited
field, and all will agree with Professor Clifford Allbutt when he
asks that any such school of research should be officered by
trained men and not by the visiting physician, who, though we
all admire him and recognise him in his own department as a
distinguished specialist, does not pretend to have any special
acquaintance with the causes, symptoms and treatment of mental
disease. What did the late Sir James Paget once say ? “ In truth
the fault of specialism is not in narrowness but in the
shallowness and the belief in self-sufficiency with which it is
apt to be associated.” I think it will be admitted that
there is no scarcity of up-to-date or modem institu¬
tions, both public and private, for the treatment of mental
disease, and is it to be supposed that the ratepayers of any
county or city would quietly agree to the establishment of
other institutions which would seem to be wholly unnecessary

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BY P. W. MACDONALD, M.D.

703

and presumably for no better reason than to witness the
reincarnation of visiting physicians? It is possible that “by
the teaching of a higher and better system of life ” beneficial
changes may be carried into effect, and that the time may
come when different views will prevail, and when parliament
will consider it one of its first and most binding duties to
encourage the diffusion of knowledge of the conditions upon
which the health of the nation ultimately depends. I would
here recall to your minds the words of a great Russian physi¬
cian who on a memorable occasion said : “ If living individuals
may not be praised institutions may ”; and I think of the
British institutions for the insane it may truly be said that
they are worthy of the great country which has given them
birth and the great people by which they are governed and
supported, and of the great profession which has brought them
to their present admirable state of development. I would
emphasise the fact that the improvement of the natural gifts
of future generations of the human race is largely though
indirectly under our control. We may not be able to originate
but we can guide. The processes of evolution are in constant
and spontaneous activity, some pushing towards the bad, some
towards the good. Whatever may be the outcome of the
future it is clear that some sort of state interference is a neces¬
sity, for the influence of custom, law and tradition surrounds
and presses upon us like a social atmosphere. Let us guard
against any association with those vampires whose only busi¬
ness with the medical art is to drain its life blood for their own
particular use and advantage ; and whose complacent ignorance
of the bearings of medical science fails to recognise the pro¬
cesses of disease to be one and the same in kind, whether
they issue in the spoiling of a function or an organ. If through
circumstances in the nature of the work itself the care and
treatment of the insane may have assumed the character of a
specialism, let us fight strenuously against any tendency towards
the divorce of medical science and medical art from every act
and every thought throughout the hours of our life’s daily
work.

I fear I have trespassed too long, and I feel I have
treated an interesting subject in a broken and feeble manner.
I must trust to your scientific habits of thought to take up the
few mere hints which I have thrown out—for I have hardly

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704 PSYCHIATRY AS A PART OF PUBLIC MEDICINE, [Oct,

been able to do more than this within the time allotted to
me—and to judge of their value after your own reflections
as to what further may be said either for or against them.
May we work onwards and work upwards so that it may
not be said of us in the times that are to come that we
failed to do our duty. If under the strain of official work
and the full blaze of public criticism we can individually add
even a colouring of science and art—especially our own science
and art—to the many brilliant achievements annually accom¬
plished within our ranks, much as the waters of some noble
river gather their colourings from the soils through which
they pass, I have no shadow of doubt our labours will be
crowned with reward. To this great end we may all do some¬
thing, but labour as we may our task will never be finished,
for not once in a hundred years, as runs the fable of the
Arabian bird, but every day and all day long the process
goes on, a death of error, a development of truth. “Truth,”
said Plato, “ is the body of God and light is His shadow”
Let our aim be to hold fast and care well for the old
truths, in our love for the new science to care well for the old art
“ For in autumn the leaves fade and fall first from the youngest
branches ; they linger longest on the old wood. Let us graft
our new truths on the old stock ; so will they live longest and
flourish most.” Thus shall we help on in some measure the
great objects for which as a profession we are ultimately
striving, and do our part in contributing to the general well¬
being of the human race.

“Our remedies oft in ourselves do lie
Which we ascribe to heaven: the fated sky
Give us free scope, only doth backward pull
Our slow designs when we ourselves are dull.”

Psychiatry as a Part of Public Medicine . A Discussion
opened by T. S. CLOUSTON, M.D.

Dr. Clouston : Mr. Chairman and Gentlemen,—We all
know that preventive medicine—public medicine—is now that
branch of our profession which is in the ascendant, and which
is most looked to for the future. In short, medicine is called

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BY T. S. CL0UST0N, M.D.

705

on not only to aid the individual, but also to help the community
in regard to every matter concerning its health, its happiness,
and its longevity so far as these depend on bodily conditions.
Science can do a great deal for human life, and naturally the
community asks science to do so. The gist of what I am about
to say is this: Does our department in medicine—call it
psychiatry for short—do for the community in an organised
way what it might ? And if it does not, has not the time
arrived at which psychiatry should claim to become a part of
public medicine ? Should not it take its place with chemistry,
with biology, the study of infectious diseases of all sorts, the
study of air and water, and all those things which conduce to
human life and health ? Is it not time, sir, that the department
of medicine which studies the mind and its disorders particularly
should step in and say: “ We are now prepared to help as a
branch of preventive medicine ” ? You know that each man in
his private capacity, and especially those of us who hold public
appointments, has, by his annual reports, by means of papers
to medical societies, by means of the various efforts of this
Association, helped to spread the knowledge of psychiatry, and
has thus helped the community. Most of us are already public
servants, receiving public money, and therefore with a duty to
discharge to the public. It would seem very natural that
psychiatry should, in an organised way, claim to be a part of
public general preventive medicine. Let any person in this
room take half a dozen of the recognised text-books on “ Public
and Preventive Medicine,” and turn up the words “ mind,’
u brain/’ “ mental health,” and, indeed, anything which relates
to our department, and he may do so without finding a single
reference in any of those books to the mental condition of the
community as requiring the attention of the public health officer
or any other man engaged in connection with preventive medi¬
cine. The whole matter is conspicuous by its absence from such
works. Is this right, or is it wrong ? If it is right, I had better
sit down. If it is wrong, then I expect you gentlemen to take
part in this discussion, and to express your opinions as to why
it is so, and how it can be amended. Our opportunities are
very considerable. As public servants we have virtual charge
of the mental wrecks of the community, and we have the
means, in many cases, of telling why they have become mental
wrecks, as you, Mr. President, so vividly endeavoured to do in

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706 psychiatry as a part of public medicine, [Oct.,

regard to the county of Dorset yesterday. There is no doubt
that the community in general have not realised what this
department of medicine might possibly do to help them. I do
not claim, sir, for a moment that our data are as exact and
intelligible as the data of chemistry and bacteriology and some
other branches of public health are ; but I maintain, without
fear of contradiction, that we have relevant facts and data, and
that an organised effort might make those facts and data
available for the public benefit. In short, I would ask, Can
mental medicine, mental hygiene, be made a part of public
medicine, so that the authoritative writers of text-books on
public medicine shall not utterly neglect this subject for the
future ? If so, how is this to be done ? Like everything else,
it will be partly individual and partly by the organisation of
individuals. If we have facts, then those facts can be used, and
for the effective use of them I take it that an Association of
this kind can help enormously. In addition to impressing the
writers of text-books could we not also so impress our subject on
the minds of the profession and of the public that it might
become the duty of the medical officer of health seriously to take
into consideration the mental health, the mental condition, the
brain risks of the community that he serves, in addition to ques¬
tions of drainage and water supply, and infectious diseases and
adulteration of foods, and the housing question ? Does this
idea, which I feel I am but poorly expressing, seem to you and
to other members of the Association to have anything in it of
practical usefulness or not ? Is the medical officer of health
prepared to study the mental effects of environment in our
population ? Is he prepared to widen his view to such an
extent as to look at the social customs of the community that
he serves as affecting their mental condition ? Is he prepared
to look, say, at our drinking customs, at our marriage customs ?
Is he prepared to take up and consider not only the question of
the clothes of the tramp, but also the mental condition of the
tramp who is circulating as a bane of the community in our
midst? Then, again, the potential criminal, does he not
affect the mental life of the community in many places ? If
so, why should not the medical officer of health take cognisance
of these matters as well as the policeman and the lawyer ? And
will the ideal medical officer, trained in medical psychology,
will he, after ascertaining his facts, marshall them, and be the

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19 07 .] by t. s. clouston, M.D.. 707

means of directing the attention of the community to them, so
that they may realise them, and may look to the medical officer
of health, associated, perhaps, with the county asylum doctor,
for certain preventive measures ? Is that a counsel of perfec¬
tion, or is it not ? That is one of my questions. Then if the
medical officer of health takes it up, naturally and necessarily
the Local Government Board would have to extend the sphere
of its supervision and of its inquiries, it would have to go
beyond matters of drainage and smallpox, into matters mental.
Are we not a sufficiently organic part of medicine to claim that
this should be so in the not distant future ? We all know that
our annual reports give some of us a good deal of trouble in the
getting of them up. I have always professed to my medical
brethren and to the public that it was part of my duty, as the
doctor of an institution in my district, to educate my masters,
and to educate them in the mind specialty. I have never
hesitated to speak of these matters, and I am always pleased
when my annual reports have been published and commented
on in the local newspapers. If we come to take up this public
health idea our reports will undoubtedly need to be somewhat
enlarged and widened in their scope; and we shall have to bear
in our minds this definite idea of the medical officer of health
and the Local Government Board, in addition to our own
committees and the Commissioners in Lunacy, as our audience
to whom we speak, and whom we intend to benefit. We all
know how valuable the reports of the Commissioners in Lunacy
are for all three divisions of the Kingdom. To fit into the new
scheme they also would require to undergo a certain change in
character—a widening in scope, and a more conscious effort to
benefit the community in regard to its mental health. A blue-
book may be made, as we know some of them have been, of
intense interest and of great importance to the community, and
I am quite sure that the Commissioners in all three divisions of
the Kingdom would, if there is anything in this idea, consciously
endeavour so to frame their reports as to fit into the general
scheme. It is no secret in Scotland that though we have a
Local Government Board and we have a Lunacy Board—each
very effective, each doing its very best for the community—no
inter-communication had taken place between those two public
bodies, established for the public benefit up to two or three
years ago. It was only when Dr. Carswell’s wards were got

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708 psychiatry as a part of public medicine, [Oct,

up by the Glasgow Parish Council that there was any organised
arrangement between the Scotch Local Government Board and
the Scotch Lunacy Board for the benefit of the community,
Surely this was a scientific departure. If this idea is ever
carried out there will have to be a basis of co-operation for
public health purposes between the asylum doctor and the
medical officer of health, the Commissioners in Lunacy, and
the Local Government Board, as well as with the general
medical practitioner. General ideas, general principles, as we
know, do not commend themselves to everybody. But every
great reform must be founded on some general principle; and
it does not seem to me that this general principle that I have
laid down is an unattainable ideal to be looked forward to in
the future.

Can we increase the psychiatric modes of looking at things
in relation to the universal medical inspection of schools, which
is coming in the near future—and I may say it was this which
originally put this idea in my mind when our secretary did me
the honour of asking me to open this discussion? Here we are
to have a new Education Bill, the chief provision of which,
from our medical point of view, will be an universal, thorough,
and effective medical inspection of schools. Is it to be a
really efficient inspection ? Is it to take into account the
whole of the powers and faculties of the children, or is it only
to refer to their eyes, and their ears, and their clothing, their
height, and the gross physical characteristics of each child?
Can any man with any physiological or psychological know¬
ledge, thinking about this subject, doubt that the future
inspector of schools should be a man capable of a psychiatric
mode of looking at things, able to carry out his work on
those full and broad lines ? I say, sir, that this is extremely
important, and probably some member of this Association who
is better at this kind of thing than I am will think of some
effective method of bringing in our influence, so that when this
question comes to be discussed in Parliament and the rules have
to be laid down by the Education Department, a mental
examination shall be carried out, as well as a physical examina¬
tion. It is marvellous how little effect those extensive investi¬
gations made by Dr. Warner have as yet had on the lives of
the school community. His exact observations and records
seem to have “ been writ in water ” so far as the community is

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BY T. S. CLOUSTON, M.D.

709

1907.]

concerned. I think this Association could, in the work
which Dr. Warner has initiated, have concrete facts with which
to approach the Education Board and the medical profession.
That, I think, is far and away the most important part of this
discussion for our consideration to-day. Let us cut in now
and impress ourselves on the new medical inspector of
schools. He is* quite certain to come. He is at the door, and
he will be inside the room shortly. Let us have him properly
educated before he comes in. The schoolmaster, of course,
will have to be educated to a certain extent, and that would
follow naturally through the new medical school inspector.
There is such a thing as the relation of psychiatry to the law¬
breaker, and that has been already a good deal in the air. Dr.
Mercier can speak more effectively on that subject than I can.
But there is no doubt whatever that we ought to be able to use
in a far more definite and more organised and satisfactory way
the knowledge of our department for carrying out the law than
hitherto has been done. We know it could be done in various
ways, eg., as assessors to judges, or as experts selected whom
the judges must consult in certain cases, or in other ways.
At the same time tl^s would be part of public medicine, which
included psychiatry, if the question were looked at from a
philosophical and really scientific point of view. We would
thereby greatly benefit the community with our special know¬
ledge, looking at it from that point of view alone. And by way of
raising certain points I put down certain questions. At all events
they will probably help to excite discussion. Firstly, the occur¬
rence of hot-beds of insanitation, dirt, neglect of the decencies of
life, and of immorality in families, and the coteries of people
in large cities who are manifestly degenerate in mind—so
degenerate that those practices are quite natural to them, just
as the practice of eating his fellow man is natural to the
cannibal. If they have been submerged through real mental
deficiency caused by environment, cannot the medical officer of
health lay hold on them and do something for them from that
point of view, not from the moral, not from the law point of
view, but from the psychiatric, preventive point of view ?

Then, secondly, what are the effects of our present school
education and its methods on certain children ? To take
strong cases, let us say the children of the insane. Insane
people, and those predisposed to insanity, procreate lots of

LIII. SO

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710 PSYCHIATRY AS A PART OF PUBLIC MEDICINE, [Oct,

children. Neurotic people procreate them in large numbers,
and these children have to go to school. It is easy to find a
mentally deficient girl with many illegitimate children.
Habitual criminals have children, and many of them are
bright, excitable, imitative, very educable, but do they not
need special modes of education, special environment, special
treatment because they are the children of the insane, the
neurotic and the criminal ? This at present is not thought of
by the schoolmaster or, practically, by anybody else, except
those children are manifestly and grossly deficient.

Thirdly, there are kinds of brain and mind in which excessive
drinking and the drink craving are symptoms or consequences,
rather than causes, of social and mental defect and disease.
And then there is the tremendous question—and we are not
satisfied nowadays until we ask it—how does insanity arise ?
what are its prodromata in a community ? why should not the
medical officer of health hunt down the case of melancholia
as he does now the case of smallpox ? Is there any valid
reason against it ? If so, let those who think so speak out as
part of this discussion. How can the general public be educated
into that most momentous of questions, the making inquiry
into the mental health, the nervous health of the families into
which they and their sons and daughters propose to marry ?
I have been very much impressed of late years with the way in
which this subject is taking possession of intelligent people, by
the number of times one is consulted by young men and young
women proposing to marry, or by their fathers or mothers. I
used to have the feeling in the back of my mind when I was
consulted that it did not matter what I said, it would not make
any difference. But it is making a difference ; and I and
others could tell of scores of marriages which were put off in
consequence of psychiatric medical advice.

The President said the Association had had what it expected
to have, something clear and concise, something worth listening
to. He hoped many of those present would discuss the subject,
because he felt, with Dr. Clouston, that prevention was the
crying question of the day.

Dr. Hurd said he thought that all present would be persuaded
that the course recommended by Dr. Clouston was an extremely
desirable one ; that they, as medical men and as men interested
in mental medicine, should bring their knowledge to the use of

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BY A. R. URQUHART, M.D.

711

the community, so that they might assist in guiding the
community wisely in all matters in which they had special
knowledge. Unfortunately, however—at least if things in
England were like what they were in America—it was very easy
to point out the difficulties, but very difficult to suggest the
remedies. Dr. Clouston had referred to the fact of his having
been asked to give advice in reference to the marriage of
people who were unfit. He remembered scores of instances in
which he had been consulted as to the advisability of marriage
between neurotic persons, but he did not recollect a single
case where his advice was taken. It was given honestly and
judiciously, and sometimes at great length, as well as at great
personal discomfort to himself, but it was not taken. The
same was true of advice which he had given in reference to
neurotic children—children who should not be forced at school,
whose hours of study should be very carefully considered ; and
in many instances such advice had been disregarded by the
parents—parents who were aware that their children were
precocious, and had a nervous organisation. They were
rather pleased to have them advanced and stimulated in
school, instead of restrained. The advice of the medical man
was not always taken in reference to the treatment of the
criminal, as to the establishment of special schools for back¬
ward children, and for those who required special instruction.
The problem before medical men was how to make the know¬
ledge they possessed effective in the community. Dr. Clouston
had pointed out one method, and in looking back over a con¬
nection with the speciality for many years he thought he could
say it was the only means by which he had ever succeeded
in attaining any results, namely, through the published reports,
and through work which was brought before the public in some
general way. He thought it would be necessary for doctors to
sow the seed for a long time and wait very patiently for the
harvest.

Dr. Urquhart said that Dr. Clouston was always a little
ahead of the rest of the specialty, and was spurring them on to
fresh adventures in the working of the Association. And if
what Dr. Clouston said that day bore no immediate fruit,
he might well console himself with the reflection that it was
a considerable number of years after he addressed the Associa¬
tion on the question of the training of nurses and attendants

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712 PSYCHIATRY AS A PART OF PUBLIC MEDICINE, [Oct,

that the Association took it up and made it the success it
had proved to be. He had no doubt that what Dr. Clouston
now said would bear fruit; and he felt with Dr. Hurd that
what should be done in the meantime was to continue sowing
the seed, each one in his own sphere of usefulness, and endeavour
to do what he could, as the President had done in elucidating
problems of insanity relative to the county to which he had
devoted so many years of his life. Dr. Urquhart had had
occasion lately, for other purposes, to inspect school children in
Perth, numbering some 7,000, in the elementary schools, of course
from the psychiatric point of view, though he had also to take
into consideration their physical imperfections and necessities.
To examine those children properly, of course, took a long time,
but it was a work of the intensest interest to him. And when
the School Board heard of it they demanded a report, which it
was of still greater interest to him to produce. The consequence
of that was that a medical officer had been appointed for the
examination of the children in the Perth schools, on the under¬
standing that in regard to the feeble-minded and backward
children he was to be consulted in every case. He thought it was
by such means, by informing and enlightening reports, by the
spread of their opinions and their technical knowledge in the
Press, and in scientific societies, that they could come nearer
their goal. It must be remembered that this was not a new
question for the Association. Some years ago, he believed it
was under the auspices of Dr. Yellowlees, the Association
summed up the matter in a long series of articles which w r ere
largely circulated among the county councils of the country.
When an association promulgated its beliefs there was always
a difficulty, because what came very tersely from one person
had to be so watered down and amended as to become in a
great degree ineffective. And he did not know that the
Association was in a position to repeat its experiment of
informing the public as an Association. He certainly thought
that what Dr. Clouston had said that day was an indication of
the proper means of approaching the matter. Of course, the
various members did not necessarily agree on all points.
Nothing could be more repugnant to him than the idea of a
medical assessor being appointed to guide a judge in his
decision. Such an idea was quite subversive of the very
foundation of legal procedure in this country, and he hoped

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BY C. A. MERCIER, M.ET.

713

1907.]

such a thing would never happen. He had only to say, in
conclusion, what a pleasure it had been to him to hear Dr.
Clouston as eager to-day to press on the work of the Association
as he was so many years ago.

Dr. Mercier said that he had listened to Dr. Clouston’s
address—as he listened to everything which came from him—
with the most eager attention; and he waited for the first
definite and concrete and practical proposal which should be
made; but he did not get it. The author stirred his hearers
up to urge upon the public, and upon the medical officer of
health, that they should do vague things. He, Dr. Mercier,
could not make out what it was the medical officer had to do
in order to assist in the diminution of mental disease among
the people, except that he was to hunt down a case of melan¬
cholia as he would hunt down a case of smallpox. But he
would point out that a case of smallpox was hunted down in
order that the contacts might be discovered, and so that the
case might be isolated from the rest of the community, and
thus that the spread of the disease to other people might be
prevented. But supposing a case of melancholia was hunted
down—and it usually was hunted down sooner or later by the
relieving officer—what then ? It was isolated always; at all
events, it was separated from the rest of the community, not
for the purpose of preventing spread, nor could they discover,
as a rule, the contact from which that particular case had been
infected. So that he failed to see what the practical value
of such a proposition was. He did not say there were not
things which they could very well recommend to the State—
improvements in the general mode of dealing with the feeble¬
minded. And he thought there were ways in which the general
treatment of people could be very much ameliorated ; but he
did not see how it could be done through the medical officer of
health, nor exactly what it had to do with drainage, the water
supply, and the other matters to which Dr. Clouston had so
eloquently referred. He would indicate one way in which
members of the Association might be of service, if they were
to urge upon the authorities a greater co-ordination of effort in
dealing with defective-minded persons. At present there were
at least six central bodies sitting in London all of whom had
to deal with feeble-minded persons, or persons with defective
brain, and all of whom were isolated from each other. First,

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714 PSYCHIATRY AS A PART OF PUBLIC MEDICINE, [Oct,

there were the Commissioners in Lunacy, who<iad to deal
with certain classes of the defective in mind. There were the
Lord Chancellor’s Visitors, who had to do with a portion of
the same classes as those dealt with by the Commissioners.
There were Masters in Lunacy, and they, again, had to do
with the same class. There was the Home Office, which, by
means of its Prison Commissioners, dealt with the criminally
insane. Then there was the Local Government Board, which
dealt with lunatics in workhouses ; and there was the Educa¬
tion Office, which dealt with feeble-minded children. All
those different offices had authority over some section of the
unsound in mind, yet not one of them had any communication
with any other office, so that their efforts were unconnected.
Thus a person might pass from the workhouse to the streets,
from the streets to the gaol; from the gaol to the streets again,
from the streets to the lunatic asylum, and from the lunatic
asylum once more to the streets, and then to an inebriate
retreat—another department of the Home Office—and when
a person got into any one of those institutions there was no
official knowledge and no means of obtaining official know¬
ledge of his previous career, or of the institutions which
he had been in before. Nor was there, in many cases, any
machinery by which a person could be transferred from
one to another. All that seemed to him to show that the
administration of those matters was very defective, showing a
want of organisation and a waste of power which was discredit¬
able to our civilisation. What he would suggest—and what
he had suggested to the Feeble-minded Commission—was that
there should be one central body which should deal with all
cases of defective mind, so that the feeble-minded child which
had been educated in a special school, instead of being, as
now, at the age of sixteen turned into the streets, should be
detained beyond the age of sixteen and not automatically
discharged. In the case of the female child, in a very
large number of cases it reappeared within a year in the
asylums and in the lying-in wards of the workhouses. Those
children were prolific mothers of many more or less feeble¬
minded children. That work could be done in one central
office, so that when the feeble-minded child was sixteen years
of age it could be drafted off at once without having a chance
of being at liberty and degenerating into a wastrel. It should be

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drafted into a labour colony, or a lunatic asylum, or whatever
special institution would be more appropriate for it. Then
there was the borderline case ; the case which was constantly
toppling over the edge of insanity in one direction or
another; the man who was now an inebriate, now an inmate of
a lunatic asylum, now in the workhouse, and now, again, in
goal. Such a man should have his dossier in the central office,
and should never be discharged from any one of those institu¬
tions without a very good reason, and without the question
being considered whether he should be transferred to another.
So instead of alternating his periods of detention with periods
of complete liberty in the streets, during which he was doing
incalculable mischief, he would be detained in one particular
institution, or transferred from class to class, as his case
demanded. In that way a continuous record would be kept of
him throughout his life, and the time would come in the lives of
each of those persons when the central authority would consider
the case and say that particular person had had trial enough ; it
was evident he was a person who would never be anything
but a charge upon society; that it was of no use to give him any
further liberty or trial, and therefore an order must be made
for his permanent detention, whether he was an inebriate
or a criminal, or a lunatic, or a feeble-minded person, or a
wastrel, so that for the rest of his life he would be prevented
from being a burden and mischief to society. That was a
direction in which he thought the Association might fairly
make representations. But there were other propositions made
by Dr. Clouston which he very much regretted to differ about,
and he never differed from Dr. Clouston without having an
uneasy feeling that he might be wrong. That gentleman had
said that owing to his advice some scores of marriages had
been prevented, the marriage of couples, one of whom was, at
any rate, if not of unsound mind—and the question could not
have arisen if they had been insane—the subject of mental
deficiency or mental instability. He wondered whether Dr.
Clouston, as he neared the close of a career which all hoped
would be very much prolonged, would not look back with much
regret and remorse on the recommendations which he had
made; for he, Dr. Mercier, thought that if all the marriages of
persons into families in which there was mental instability were
prevented, in the first place the marriage rate would sink to an

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716 psychiatry as a part of public medicine, [Oct,

alarming degree, and in the second place the result would be that
the next generation would be at a level of uniform mediocrity.
It was true they might then save themselves from having to
maintain a certain number of persons of unsound mind; but,
on the other hand, who knew how many brilliant geniuses
society would be deprived of, and who knew that Dr. Clouston
was not responsible for the absence from their midst of a person
who might, before now, have solved the question of aerial navi¬
gation, and discovered the origin and cure of cancer, and even
of insanity itself? It seemed, therefore, that the Association
had no cause to thank Dr. Clouston for his prevention of
disease in that way. If they were to start on the path of
education he thought they should begin with their own pro¬
fession. He thought they would be doing a very good and use¬
ful work if they were to educate certain medical men, to whom
so many cases of mental disease went in the first instance, not
to send cases of incipient melancholia on a sea voyage; if they
were to educate them not to send cases of early acute insanity
into nursing homes, to be placed in solitude and be massaged.
Those were lines on which he thought they might very fairly
launch out with some prospect of doing good. But if they were to
recommend that cases of melancholia should be notified to the
central authority, and if they were to recommend that persons in
whose families there was any taint of mental instability should
not marry, he feared that, after all, they would do more harm
than good.

Dr. Carswell said he was sure all present felt that day what
he had himself always felt when listening to Dr. Clouston, that
had that gentleman chosen to follow the career of a picture-
painter—an artist in colour instead of, as he was, an artist
in the work of medicine—he would have been an impressionist.
He thought Dr. Clouston’s contributions had always the
characteristic about them that they were vivid, they were
colour impressions, they suggested more than they stated.
And he ventured to say that Dr. Mercier, when he called
his own contribution a discordant note, misnamed it. In
his view Dr. Mercier simply came in to supply the draftsman¬
ship which was lacking in the original colour picture. He
thought Dr. Clouston's picture would not bear the criticism of
the draftsman at all, and it was not intended that it should be
subjected to that kind of criticism. He thought most good

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1907 .] BY JOHN CARSWELL, L.R.C.P. 7 17

would be derived from the contribution by looking upon it as a
suggestion of things which ought to be, and which are to be.
He did not know whether he would be trespassing beyond the
scope of the address if he said that Dr. Clouston was also a
prophet; at any rate his contribution that day appeared to
indicate that: that however valuable blue-books were, they had
created in Dr. Clouston’s mind, as they had in many other
minds, the feeling that, having had lunacy blue-books for the
last fifty years something further was now required; it was
necessary to get the lunacy blue-books and lunacy statistics
brought into line with the vital statistics which they had been
accustomed to, and which had yielded such brilliant results
and suggestions towards medical and social effort in sanitary
science. Dr. Clouston expressed the hope that medical officers
of health, if they had their attention directed to questions of
mental health, would begin to think seriously of such questions
as the drinking habits of the community, and of the marriages
of drunkards and the unfit. Surely those officers were long
enough under the impression that tuberculosis, for example,
was an inheritable disease; yet one found no prominence given
to the question of marriage relationships in the reports of medical
officers of health during the last thirty or forty years. And surely
the alcohol question had been as present to medical officers of
health as to psychologists. It was known that although alcohol
exhibited its immediate physiological effects on the brain, yet
it caused more disastrous results on the kidneys and the liver and
the arteries. Medical officers of health were well aware of that,
and yet we did not find either of those questions bulking
with the prominence which Dr. Clouston desired, and which he
apparently believed would be seen if those officers were to direct
their attention to mental medicine in their work and in their
reports. That he regarded as a most significant fact; and it
was worth while to inquire why medical officers of health had
apparently attached less importance to heredity and alcoholism
than Dr. Clouston suggested they should have done. Medical
officers of health had contributed towards the reduction of the
death rate from phthisis long before they knew that phthisis was
not so pronouncedly due to a faulty inheritance as they now knew.
In the course of thirty years the death rate from phthisis had
fallen 50 per cent . Why ? Because medical officers of health and
sanitary inspectors and local government authorities had directed

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7 18 PSYCHIATRY AS A PART OF PUBLIC MEDICINE, [Oct.,

their attention to the removal of faulty conditions of living.
And who could deny that the same efforts would help to reduce
insanity ? The real position seemed to be just the opposite of that
suggested by Dr. Clouston, and was, in effect, that the medico-
psychologist should follow the same line of effort and adopt a
similar attitude of mind towards the problems involved in the
prevention of mental diseases that the medical officers of health
introduced into their work. He thought it was not a great
stretch of the imagination to hope to see a lunacy blue-book
which would be as interesting in regard to lunacy as Dr.
Branthwaite’s reports were in regard to inebriety. He thought
the blue-book should contain more than the number of people
in different asylums, and the percentage they bore to the general
population; that it should correlate the lunacy rate with the
other returns relating to public health. He, Dr. Carswell, did
not know anything about Dorset and other large English
counties, but he knew that if one took the general death rate and
the lunacy rate of a city like Glasgow, and attempted to compare
them in the mass, they would go astray. They must take the
lunacy rates of certain districts and compare them with other
districts. There was a whole field of effort lying ready to
hand, and, as Dr. Clouston had said, all they required to do
was to organise effort towards doing it. In Scotland there was
not too large an area in the whole country to expect that the
general Board of Lunacy might take up that work; and he
thought it was one of the happiest omens that the Local
Government Board of Scotland and the Board of Lunacy for
Scotland had got into close and intimate relationship. Dr.
Clouston’s reference to their relationships seemed hardly quite
correct. The connection between those two Boards really
began with the abolition of what was called the Board of
Supervision, which had been irreverently called the “ Board of
Superstition,” and the substitution of the Local Government
Board, specially through the efforts of Dr. Leslie Mackenzie.
He hoped and believed that the work which Dr. Clouston so
eloquently and picturesquely pleaded for would be undertaken
in Scotland.

Dr. Hayes Newington said he would like to interject a few
remarks from the philistinic point of view of a public health
committee. Looking at the proposition from the layman’s
position, the first idea was that it was going to cost money in

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1907.] BY CONOLLY NORMAN, M.D. 719

order to do the thing well. Merely general opinions did not
go very far. There was already an enormous difficulty in
getting accurate and reliable information on medical matters,
if money had to be expended in the process. But if an
absolutely good cause for spending money was shown, then, he
felt sure, the money would be forthcoming. With regard to
the prevention of insanity by the work of medical officers of
health, might it not be said that as the physical basis of mind
was an accepted belief, much was already done in present
sanitary work for the mind by regulating the physical factors
mentioned by Dr. Clouston ? With regard to another point,
that of education, Dr. Clouston struck a right nail on the head.
There was much scope for such work as he desired on the
Education Committee, and there was more hope of good being
effected by the help of the last Education Act. Many objected
to that Act for many reasons, political and otherwise, but there
was no question that the introduction of education Acts enabling
the primary education to be varied, adjusted, to be judiciously
extended in suitable cases into the secondary, was a help from
a psychiatric point of view. He would point to London as an
example of action. London appointed Dr. Shuttleworth, an
esteemed colleague, to go systematically through all the children,
and with very good results, and he thought the same practice
was likely to spread through all education committees now.
Men of common sense had studied the matter, and acknowledged
that one could not give the same education to A as to B, and
that if an attempt be made to give the same education to all
there would be disaster from one side or the other. In that
relation he thought Dr. Clouston’s recommendation would be
of the greatest value. If they could get the bodies who were
ultimately responsible for education to see the possibilities for
either good or bad so much good would result. The marriage
question was a very different matter, and a difficult one. His
own feeling was that they might do a large amount of mischief
by incomplete work; it would be far better not to interfere at
all.

Dr. Conolly Norman said the subject was so large and so
discursive that it was impossible for any speaker to deal with
more than a few points here and there. Dr. Clouston had said
that it might be objected to the scheme he had shadowed forth
that the data on which they were to work were at present

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720 PSYCHIATRY AS A PART OF PUBLIC MEDICINE, [Oct,

insufficient or deficient. But Dr. Norman did not think that
was much of an objection, because the data on which all the
ancillary sciences of medicine started as separate branches of
human endeavour were very deficient at the beginning; and
they had attained their present position only by differentiation
and prolonged work. As far as he could gather, and he
endeavoured to follow Dr. Clouston closely, the idea was that
the attention to the mental health of the community generally,
not of the particular fraction which was under the care
of members of the Association, should be handed over to
medical officers of health. And the author had said that that
was not a counsel of perfection, in which Dr. Norman agreed
with him, thinking that it was a counsel of imperfection. At
the present time medical officers of health said they had more
to do than they could accomplish; they were persons who
were not specialists, they had not made a particular study of
mental conditions, and he thought it would be a retrograde
step to hand over to such folk the work which it was required
to have done. What appeared to Dr. Norman to be needed
was a general co-ordinating centre, which would take account
of the health of the community, both mental and physical, on
large lines. Professor Clifford Allbutt, at the dinner the
previous evening, referred to the establishment of a ministry of
public health. That was what was required; and, as a portion
of that, and co-ordinated with the general working, should be a
department which would look after mental health. But he did
not think it should be an addendum to the work of the present
medical officer of health. Such a course was practically impos¬
sible, and he regarded it as distinctly retrograde. Dr. Mercier
had somewhat anticipated him in speaking of co-ordination
when he referred to the inco-ordinate condition of the various
lunacy departments in this country. Dr. Mercier enumerated
six, and mentioned seven; and Dr. Norman thought, with
all respect to Dr. Mercier, that there were eight bodies which
looked after lunatics, or potential lunatics; and their lack of
combined working led to the bad results which Dr. Mercier
had described, such results as he had painful experience of a
few weeks ago, when a man was sent from prison to Dr.
Norman’s asylum with an intimation that he was a drinker;
and that was all he heard about him. He began to improve
very rapidly and, in consequence of Dr. Norman not having

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I 9 ° 7 *]

BY CONOLLY NORMAN, M.D.

721

been informed by the prison authorities that he was a most
accomplished and expert burglar, in the period of comparative
liberty to which he very soon attained he “ burgled ” the
residence of one of the officers and stole £50 worth of jewellery,
on the proceeds of which he believed he had disported himself
in New York. A great many subjects had been dwelt upon,
medical pedagogy among the number. That was a distinct
branch of medical endeavour in several Continental countries,
and of late years he thought we were at least approaching in
England to ripe practice in this subject. Dr. Clouston went a
little out of his way to talk about the advice which members of
the speciality were asked for, and which was occasionally acted
on in reference to marriage. But all of them had insane
relations—even every one of those present to-day. If a man
had no insane relations in his family tree it was because he
had no family tree. In the country in which he lived statis¬
ticians had discovered—whether rightly or wrongly he did not
pretend to say—that there was one lunatic to every 178 of the
whole population. But fortunately in the human race from
its commencement, whether in Adam or the ape, there was a
tremendous tendency, if the stream was diverted a little, to
resume its course; and the whole current of the human race
was towards sanity. Therefore the insane died out and the
stock returned to the normal. Thus he did not regard the
marriage of persons who were supposed to suffer from some
hereditary tendency—as all did—as being so dangerous as
had been supposed. Dr. Norman would point out that Dr.
Clouston's suggestions, if he had lived 130 years ago, would have
prevented the procreation of that ornament of English literature
and of the human race, Charles Lamb, whose family on all
sides was saturated with insanity. Someone had spoken of
“ intermingling,” which Dr. Norman regarded as a bad phrase
when applied to the various bodies responsible for the depart¬
ments of public health. He did not think there should be an
intermingling, but a co-ordination of all departments of public
health, mental and physical; that all should be brought under
one head, and placed, probably, under one minister, who he
thought would be one of the most important ministers in the
cabinet.

Dr. Drapes said he would like to suggest one or two matters
which had not yet been mentioned in the discussion. Much

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722 PSYCHIATRY AS A PART OF PUBLIC MEDICINE. [Oct,

stress had been laid on the education of their profession. If
they desired to have that subject brought home strenuously
and effectively to the general public it must be the general
practitioner who should be thoroughly grounded in mental
hygiene. He thought sufficient attention was not paid to that
in medical schools, and it should be more insisted upon in the
future that the medical student should be thoroughly educated
in the principals of neurology and psychology if he meant to
effectually set a stop to the alarming increase of insanity which
had been going on continuously, and he feared would go on
still. So he thought, to use an Irishism, they might go lower
still than the bottom suggested by Dr. Mercier, namely, to the
school-children. He did not think the instruction in the
principles of physiology was at all sufficiently insisted upon in
schools. It was of great importance to take special care-
differential care—of the education of the feeble-minded, but he
thought it was of far more importance to take care of the
education of the sound children, to bring them up to be
thoroughly instructed in a knowledge of their own bodies and
minds, and the dangers which would ensue from their deviating
from the normal principles of hygiene and health. While they
admitted that the entire functions of the whole body were
absolutely dependent for their efficient working on the brain and
upon its healthy action, the mental functions seemed to be the
only ones which were left out of our systems of education.

Dr. Yellowlees said he felt that the valuable discussion
which had taken place, and the very opportune and important
remarks of Professor Clifford Allbutt at the dinner as to the
appointment of a minister of health, made it essential that the
annual meeting of the Association should not separate without
doing something in the direction of giving effect to those
earnest and very practical suggestions. His own feeling was
very strong that all Dr. Clouston had urged that morning
would remain unattainable—the co-ordination and co-operation
of many medical and quasi-medical bodies—unless they were
all ranged under one head, and were all parts of one great
supreme department, and unless the head of that department
were to have a place in the House of Commons, and a position
which would imply that his advice was listened to by the
House. He was sure the profession had greatly suffered from
want of due representation. He asked his hearers to think of

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1907-] SANATORIUM TREATMENT OF ACTIVE INSANITY. 723

the number of lawyers in the House of Commons in com¬
parison with the number of doctors. Lawyers got whatever
they wanted; doctors made vain attempts, and got nothing.
He thought that the present Government should be approached
in this matter by all the medical associations.

Dr. Yellowlees then moved the following resolution:
** That it be remitted by the annual meeting of the Medico-
Psychological Association to the Parliamentary Committee of
the Association to co-operate with the British Medical Associa¬
tion, or with any committee of other Medical Associations, with
a view to securing the appointment of a minister of health,
with a seat in the House of Commons, or to initiate such pro¬
ceedings.” This was seconded by Dr. Hayes Newington and
carried unanimously.

The Sanatorium Treatment of Active Insanity by Rest
in Bed in the Open Air . By C. C. Easterbrook,

M.A., M.D., F.R.C.P., Medical Superintendent, Ayr Dis¬
trict Asylum, Ayr.

During the past year I have systematically employed rest in
bed in the open air as a special method in the treatment of all
patients newly admitted to the Ayr District Asylum; and
during the past six months I have carried out the same method
in the treatment of all resident patients exhibiting relapses or
phases of active insanity, the latter including the most difficult
and most dangerous cases in the institution. At present, there¬
fore, all patients in Ayr Asylum who manifest their insanity in
such active forms as marked morbid excitement, exaltation or
depression, distinct delirium, confusion or stupor, vivid hallu¬
cination and delusion, active homicidal or suicidal tendency,
impulsiveness and the like, are being treated by the method of
rest in bed in the open air, a method which may be conve¬
niently termed the sanatorium or open-air rest treatment of
active insanity. Although it is yet too soon to speak as to the
ultimate therapeutic value of this system, and several years

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724 SANATORIUM TREATMENT OF ACTIVE INSANITY, [Oct,

must necessarily elapse before its effect on the recovery rate in
insanity can be definitely ascertained, even a short experience
has sufficed to demonstrate the immediate benefits and strong
points of the system, and to show that it is a more satisfactory
method of treating those who are actively insane than either
the outdoor exercise or indoor rest procedures hitherto in vogue,
and that, indeed, it secures the advantages without the dis¬
advantages of the exercise and rest systems combined. The
particular combination of rest in the recumbent position and
in the fresh air of the open would indeed seem to be Nature’s
specific for at least the alleviation if not the cure of an attack
of insanity; and the method is not only based on sound
physiology and correct pathology, but it is so easily carried out
in practice, it so obviously benefits the health of the patients—
not to mention also that of their nurses—and withal it is so
pleasant a remedy both in the receiving and the giving, that
even a comparatively short experience of its employment has
convinced me that the systematic open-air rest treatment of
active insanity has come to stay, and that at no distant date it
will secure a wide sphere of application in asylum practice, and in
the treatment of the psychoses and neuroses outside of asylums.
Before describing the sanatorium treatment of active insanity
I wish to put before you the stages in its development, and to
show how, after an apprenticeship in the exercise system of
treating active insanity, I came to adopt the rest method, and
by allying the latter with the open-air cure, as suggested by the
modern treatment of pulmonary tubercle, I arrived at the com¬
bined method of rest in bed in the open air, which has been in
vogue at Ayr Asylum during the past year.

(i) The Asylum or Outdoor Exercise Treatment of Active

Insanity .

From 1894 to 1902 I followed the exercise system of asylum
practice which has prevailed since the dawn of modern
psychiatry, and still has many advocates as a treatment of
active insanity. By this system, if a newly admitted patient
appears to be in fair physical condition and to have no
important complication of heart, lungs, kidneys, and the like,
if, in short, he seems to be sufficiently strong and healthy, he is

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BY C. C. EASTERBR 00 K, M.D.

725

sent to a ward of asylum dayroom or parlour type, placed for a
time under special observation by himself, or in a group with
others, and prescribed a course of treatment, an essential
feature of which is a certain amount of outdoor exercise
daily. If, however, his physical condition, general or local, is
such as to indicate confinement to bed, he is sent to the
hospital department and treated in bed until it is thought that
he is sufficiently able physically to be out of bed and to take
exercise daily. The foregoing procedure may be conveniently
distinguished as the asylum or outdoor exercise treatment of
active insanity. In my experience the intrinsic advantage of
this system is the more or less rapid physical improvement of
the patient, that is to say, an early improvement in the
appearance and condition of the skin, in the condition of the
muscles, in the state of the tongue, appetite and digestion, in
the action of the bowels, liver and kidneys, in the quality of
the blood and circulation, and sooner or later in the weight.
The physical improvement is followed by the improvement in
the sleep and mental condition in the great majority of cases;
that is to say, the improvement in the condition of the general
bodily organs usually precedes the improvement in the state of
the cerebral cortex and lower nervous centres. This retarda¬
tion of the mental improvement, in my experience, constitutes
the weak point of the outdoor exercise method in the treat¬
ment of active insanity, and is due, apart from the factor of the
inherent powers of recuperation of the nerve centres them¬
selves, not to the fact of the patient being out of doors,
but to the effect of exercise in keeping up an excitation of
the disordered nervous centres, and thus in tending to con¬
sume unduly their diminishing chromatic substance and store
of energy. The treatment of active insanity by exercise has,
I think, arisen from the idea that what is good for the muscles
and bodily organs generally is likewise good for the disordered
brain and nerve centres. There are, however, good reasons
for believing that there is an essential difference between the
metabolism of the muscles and body generally and that of the
nervous system. Thus the observations of Voit and many
others (Schafer’s Text-Book of Physiology) show that starving
men and animals live at the expense of their fat, muscles and
glandular organs, and that in fatal cases the fat and muscles
suffer the greatest relative loss in weight, whereas the central
liii. 51

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726 SANATORIUM TREATMENT OF ACTIVE INSANITY, [Oct,

nervous system suffers the least. Then, again, as F. Gotch
{op. cit.) has pointed out, whereas during muscular activity,
mechanical, electrical, chemical and thermal changes occur,
during nervous activity, electrical changes alone are readily
demonstrable, chemical changes are very slight, and thermal
changes have as yet not been observed. As Gotch remarks,
“ the negative character of the evidence of (nervous) metabolism
is an important circumstance in connection with the rationale
of nerve phenomena, and such positive data as exist support
the conclusion that nerve metabolism must be very small in
amount.” Lastly, Atwater’s famous experiment (f/.SJ.
Department of Agriculture , Bulletin No. 44, 1897) was per¬
haps the first experimental demonstration of the essential
difference between nervous and muscular metabolism. He
placed a man, kept for the time on a fixed diet and under
the other necessary conditions of the experiment, in a respira¬
tion calorimeter for twelve days, divided into five successive
periods, of rest (ij days), severe mental work (3 days), absolute
rest (3 days), severe muscular work (3 days), and rest (i| days),
and he found that during the period of severe mental work the
temperature of the air in the chamber and the amount of
carbonic acid given off remained the same as during the
days at rest, and that during the period of hard muscular work
the temperature distinctly rose and the amount of carbonic
acid given off was very conspicuously increased. While,
therefore, the metabolism of the nervous centres, as judged
by chemical, thermal and mechanical effects, is small in amount
in comparison to that of the muscles, electrical phenomena
during nervous activity are characteristic features, and indeed
the central nervous system may, with a considerable approxima¬
tion to the truth, be regarded in the light of a battery, which
during life is more or less constantly engendering energy from
its stores of chromatic or other substance, and therefore tends
to become exhausted or fatigued, specially in those diseases, as
the psychoses and neuroses, in which chromatolysis is well
recognised as an outstanding feature.

As is well known, outdoor exercise, if unskilfully employed in
the treatment of neuroses and psychoses, leads to the evils of
fatigue, such as bodily and mental exhaustion, ready exhausti-
bility, insomnia, and specific sensory and motor symptoms of
fatigue (as pains in the head, back or limbs, tenderness over the

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1907.] by C. C. EASTERBROOK, M.D. 727

spine or in other areas, fine intention tremors and local twitch-
ings of muscles, increased tendon reflexes and the like), also
such effects as impairment of appetite and digestion, and loss in
weight. The later researches on the subject by Mosso, of Turin
( Fatigue: Swan, Sonnenschein & Co., London, 1904), and others,
show that fatigue, however produced, whether by muscle work
or by brain work, is essentially a nervous phenomenon, an
exhaustion and poisoning of the nerve centres, and consequently
the idea that exercise in the treatment of active insanity serves
as a safety-valve for getting rid of superfluous energy has become
more or less exploded. Systematic outdoor exercise is therefore
of doubtful utility in the treatment of active insanity, in which
the finer symptoms of nervous irritation and exhaustion are so
common. Occasional mild exercise is allowable for the benefit
of the muscles and non-nervous organs of the body, provided
that it does not give rise to symptoms of exhaustion; and even
this amount of exercise is contra-indicated if the patient happens
to already exhibit the finer signs of fatigue. But just as rest
and exercise are both necessary to the preservation of health,
so are they the complement of one another in the treatment of
disease, and carefully regulated outdoor exercise is specially
useful during convalescence from active insanity. It is, of
course, hardly necessary to refer here to the value of regular
outdoor exercise in the hygiene of the chronic insane. Not
being satisfied with the suitability of the outdoor exercise
system for the treatment and observation of newly admitted
and actively insane patients, I ceased to employ it in this con¬
nection in 1902.

(2) The Hospital or Indoor Rest Treatment of Active Insanity .

Since the summer of 1902 it has been my regular practice to
receive all patients admitted to Ayr Asylum into wards of hospital
type, and to prescribe a preliminary course of bed treatment,
during which regular observations are made of the temperature,
pulse, respiration, action of the bowels, state of the urine, amount
of sleep, weight, mental condition, and any other changes of
note, physical and psychical, these observations, and also the
dietary and medicines prescribed, being recorded on charts, of
which the accompanying is a specimen (see facsimile of Ayr
District Asylum chart). These charts, which are ruled on the

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728 SANATORIUM TREATMENT OF ACTIVE INSANITY, [Oct,

back for notes on progress, are the same size (foolscap) as the
pages of the case-books, into which they are finally collected
from the wards, and pasted in their proper places following the
records of the history and condition on admission of the various
patients. It will be seen that the above procedure is simply an
application of general hospital methods to the case of the newly
admitted insane, both those obviously suggesting and those
apparently not requiring treatment in hospital; and as its dis¬
tinctive feature is the preliminary course of rest in bed in a ward
of hospital type, the method may be conveniently distinguished
as the hospital or indoor rest treatment of active insanity.
Having thus had considerable experience of both the outdoor
exercise and indoor rest systems in the observation and treatment
of actively insane persons, I have no hesitation in recommending,
on both clinical and therapeutical grounds, the system of placing
all newly admitted insane patients in bed amidst hospital sur¬
roundings for at least an initial period of observation and treat¬
ment. It may seem strange at this time of day to have to put
in a plea for the systematic bed-side or clinical observation and
treatment of those whose insanity is sufficiently active to cause
them to be sent into asylums, especially when we remember
that psychiatrists are constantly preaching the fact that the
insane man is a sick man, and that insanity is a disease—a
disease of the brain, nervous system and body in general. The
fact, however, that the older asylum or ambulatory method of
treating and observing those who are actively insane is still
largely followed in asylums, is a sufficient reason, and calls for
a statement of the advantages which in my experience attach
to the system of placing all newly admitted patients in bed
amid hospital surroundings for at least a preliminary period of
observation and treatment. This period need not exceed two
to three days in a small proportion of cases, in which the morbid
mental and nervous condition is quiescent and the bodily health
is fair; but even this short period in such cases suffices to secure
the advantages of the hospital system, which are chiefly as
follows:

Firstly , it is a good procedure from the point of view of the
physician , inasmuch as it enables him to make a more satisfactory
examination of the patient’s physical and mental condition from
day to day. All the bodily functions, discharges and symptoms
of the patient, his dieting and feeding, medication, etc., being

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TEMPERATURE FAHRENHEIT^ SCALE.

1907.]

BY C. C. EASTERBROOK, M.D.

729

Chart.

A. D. A. CHART. WARD_

Date L DIET AND EXTRAS Dai- REMARKS Dale MEDICINES

Weight

.... . lKf

do_

Ibl

Aa _ rr —

__lb*

One side of chart reproduced.

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730 SANATORIUM TREATMENT OF ACTIVE INSANITY, [Oct,

under constant bedside observation, and the facts being recorded
on the clinical chart, any changes which occur are not so likely
to escape notice, and so the physician feels that he has a more
satisfactory clinical grasp of his patient, and can observe his
progress from day to day with greater precision and care.

Secondly , it is a good procedure from the point of view of the
nurse for sundry reasons, chiefly that it enables the nurse like¬
wise to carry out with greater satisfaction to himself or herself
the recognised duties of the vocation of nursing; for the patient
being under constant supervision in bed has his various require¬
ments more readily observed and more readily attended to.
Further, patients who are actively insane, in my experience, are
more contented and more manageable in bed than on their feet,
and less apt to be dangerous to themselves or others, if so
inclined, with the result that the chances of undesirable accidents
are considerably reduced ; and, consequently, the bed treatment
of the actively insane makes the difficult and often trying work
of the mental nurse safer, easier, and more pleasant to all con¬
cerned. Again, the regular practice of treating all newly
admitted insane patients in bed amid hospital surroundings is
more effective than all the preaching in making the probationer
nurse realise the cardinal fact that insanity is an illness, dis¬
order, or disease of the body corporeal.

Thirdly and chiefly , the hospital system is a good procedure
from the point of view of the patient , partly as the result of the
preceding factors—the more satisfactory attendance by physician
and nurse—and partly for other reasons. Thus, it is well known
that those newly admitted insane patients who are sufficiently
in their senses to realise their surroundings often keenly resent
being sent to an asylum, regarding it more or less in the light
of a degradation and something to be ashamed of, with conse¬
quent wounding of the amour propre , and the arousal of an
attitude of mind which is unfortunate at the outset of treatment
and is not conducive to recovery. If such a patient on admission
is placed in bed amid hospital surroundings and treated as a
sick man, as he really is, he from the outset comes to regard
himself as a sick man and not as an injured man, as he is more
apt to do if received straightway into the less familiar but
readily recognised environment of the ordinary asylum day-
room or parlour. And further, the more able-bodied the patient
appears to be, the more likely is he, as a rule, to resent his con-

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BY C. C. EASTERBROOK, M.D.

731

finement, and therefore the more reason for placing this type of
new arrival for a time in bed amid hospital surroundings; for,
under the circumstances, it is better that his mind should be
occupied with the suggestion that he has been and is ill, than
that it should become the seat of those more turbulent feelings
of injured self-esteem, indignation, and the like, which effectually
banish for the time all sense of peace and contentment. Lastly,
by placing the new arrival in a comfortable bed, we are employ¬
ing the most familiar means at once of suggesting and of
securing bodily and mental rest. And this raises the important
question of the value of systematic indoor rest in the treatment
of active insanity, a system which is becoming more prevalent
in asylums as a result of the more general adoption of hospital
methods during recent years, and which, as is well known, dates
from the teaching of Weir Mitchell, of Philadelphia, in 1875
and onwards, as to the value of rest in the treatment of neuras¬
thenia and hysteria. In my experience the intrinsic value of
indoor rest in the treatment of the insanities is the more or less
rapid improvement in the mental and nervous condition of the
patient, evidenced by an early diminution of the intensity of
the mental symptoms, resulting in their abatement or dis¬
appearance, and by an early diminution of restlessness and of
insomnia: in other words, there is characteristically a more or
less rapid induction of mental and bodily repose, and of the
return of sleep. Following, as a rule, the subsidence of the
active cerebral symptoms is a gradual improvement in the
physical appearance and condition, nutrition and weight of the
patient. During the continuous indoor rest treatment, therefore,
the mental improvement commonly precedes the physical. The
retardation of the improvement in the physical condition,
general metabolism and functional activity of the non-nervous
organs is the weak point of the system; and, as is well known,
if the indoor rest method is unduly pushed, it leads to the
evils attributed to prolonged bodily inactivity, such as sluggish
action of the skin, bowels, liver and kidneys, defective meta¬
bolism and flaccidity of the muscles, and weakening of the heart
and circulation, evils, however, which Weir Mitchell and his
followers showed could be obviated in the prolonged rest treat¬
ment of neurasthenia by such measures as massage, passive and
active movements, baths, electricity, and the like. In my
experience, however, of indoor rest in the insanities, in the

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732 SANATORIUM TREATMENT OF ACTIVE INSANITY, [Oct,

great majority of cases it is not necessary to keep the patient in
bed for the long period of two, three or more months advocated
by the Philadelphian School in the rest treatment of mania,
melancholia, neurasthenia, etc., for, as a rule, shorter periods of
indoor rest suffice to bring about the characteristic subsidence
of the active mental symptoms. For this special therapeutical
effect, therefore, of the employment of rest in bed, as well as for
the other advantages which attach to the practice of indoor bed
treatment on hospital lines from the points of view of the
patient, nurse and physician alike, the hospital or indoor rest
system is much to be preferred to the older asylum or outdoor
exercise method, for purposes both of observation and treatment,
and in the case both of newly admitted patients, and of more or
less confirmed residents during their relapses and phases of
active insanity.

The reason why rest in bed is beneficial in active insanity is
fairly obvious in cases of morbid excitement and exaltation,
delirium and confusion, vivid hallucinatory and delusional
states and impulsiveness. The very fact of being in bed sug¬
gests to the patient the calm and rest and induces the sleep
which are so desirable for him; and the inactivity of the
recumbent attitude, by diminishing the inflow of afferent
impressions from the muscles to the sensorium, and therefore
the outflow of impulses from the motor and psycho-motor
areas to the muscles, leads to a physiological reduction of
restlessness. The rationale of rest in morbidly depressed,
stuporose, and catatonic cases, in which muscular passivity,
resistiveness, and even paresis are often prominent features, is
at first sight not so evident. S. J. Franz and G. V. Hamilton
(Anur.Journ. Insan., October, 1905), indeed, recently advocated
exercise in melancholia, basing this practice on experimental
investigations of the mental reaction-time of melancholiacs.
They observed that these mental reactions, which are usually
retarded, were quickened in the afternoons following morning
exercise; also, however, in the morning following a restless or
sleepless night. They read the quicker reactions as meaning
mental improvement, considered that melancholiacs required
“ keying up,” and concluded that in melancholia there was a
condition of lowered irritability, which it was desirable to raise
to a normal level by systematic exercise. Franz, however,
from later experiments (A fner. Journ. Psychol., January, 1906)

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1907]

BY C. C. EASTERBR00K, M.D.

733

admits that there is no satisfactory evidence to show that the
retardation in melancholia is due to lowered irritability, and
states that while systematic exercise may lessen the mental
retardation and change a habit of slowness into one of quick¬
ness, it does not cure the depression. It will be readily agreed
that melancholiacs are none the better for restless or sleepless
nights, and the conclusion that one comes to is that quicker
reactions produced in melancholiacs by the “ keying up” pro¬
cess, in the form of systematic exercise or otherwise, are a
fictitious sign of mental improvement, being attributable to the
irritability of a fatigued, poisoned, or morbidly disordered
nervous system. At the same time, owing to the passivity of
the musculature and body generally in melancholia, stupor and
catatonia, and consequently an earlier tendency to the metabolic
and other bodily troubles of prolonged bodily inactivity, the
treatment by indoor rest cannot be pushed so freely as in
mania without recourse to accompanying measures of actual
or modified exercise for the benefit of the muscles and non-
nervous organs generally. Apart from this consideration, how¬
ever, the central fact remains that the actively insane man is a
sick man, and urgently sick as regards his nervous system; for
whatever views we may hold as to the etiology and pathology
of insanity, all are agreed that it is the brain which is proxi-
mately affected and is the immediate seat of the mental and
nervous symptoms characteristic of insanity. In active insanity,
therefore, the brain diseased calls for ease or rest, and on
psychologic, physiologic, etiologic, and pathologic grounds
brain-rest is more or less effectually secured by absolute rest
for the time of the body in bed amid surroundings which are
congenial and suggestive of cure.

(3) The Sanatorium or Outdoor Rest Treatment of Active

Insanity .

The sanatorium or outdoor rest treatment of active insanity
is simply the hospital treatment by rest in bed carried out daily
in the open air in verandahs, attached to the wards, instead of
inside the wards and their bed-rooms as formerly. I had been
much impressed by the improvement exhibited by tuberculous
patients, sane and insane, undergoing the open-air treatment. I
also recalled certain sun-bathed days in summer at Morningside
when all the sick, infirm and bed-ridden patients in the women’s

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734 SANATORIUM TREATMENT OF ACTIVE INSANITY, [Oct.,

hospital at West House were turned out of doors, in beds,
hammocks and chairs, and given an annual outing in the fresh
air and sunshine; and I retained vivid impressions of the sun¬
burnt faces, healthier bodies, and more contented minds as the
result thereof. Having become convinced from my own ex¬
perience of the exercise and rest methods that the principle of
rest was the correct one in the treatment of the active stages
and phases of insanity, I accordingly decided to combine the
“ rest cure ” with the “ open-air cure ” as a systematic treat¬
ment for those acutely and actively insane, and made provision
for this purpose in the design, in 1903, of the new hospital at
Ayr, with the opening of which, in 1906, the regular practice of
the sanatorium treatment of active insanity was commenced.
The daily practice of outdoor rest in the case of the newly
admitted patients at the reception wards of the hospital proved
so successful that I decided to extend its application to all other
actively insane patients in the institution, namely, to residents
• of longer or shorter standing during their relapses or phases of
active insanity, including the most difficult and dangerous cases
in the asylum. Two large vqfandahs at the main buildings
were accordingly utilised for this purpose at the commencement
of the present year, and these patients also soon began to show
the special benefits of outdoor rest as compared with those of
outdoor exercise or indoor rest and isolation formerly practised
in their case. Owing to the common feature of noisy excitement
among such cases, and the tendency of one excitable patient to
disturb or to be disturbed by others in the vicinity, I found it
advisable to have the beds in these verandahs isolated from one
another by means of wooden partitions, thus adding the valuable
factor of isolation to the open-air rest treatment. Isolation is
also secured at the hospital verandahs by the use of temporary
screens between the beds, if necessary, or at times by the use of
the smaller verandahs at the hospital which are ordinarily
occupied by phthisical patients requiring confinement to bed.
The accompanying photographs show the system being carried
out in the association and isolation verandahs at the hospital
and main buildings of the asylum (see photographs of verandahs
for sanatorium treatment). They illustrate the operation in
combination of two, and sometimes three, potent agents for the
amelioration and cure of those actively insane, namely, open air,
rest in bed, and isolation if necessary. Experience has already

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JOURNAL OF MENTAL SCIENCE, OCTOBER, 1907.

lSulr mul LhtnielbxOH, I.Ul.

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. A. Hospital. Women’s Large Verandah.
To illustrate Dr. Easterbrook’s paper.

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♦ V •

JOURNAL OF MENTAL SCIENCE, OCTOBER, 1907.

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.. D. A. Main Buildings. Women’s Isolation Verandah.
To illustrate Dr. Easterbrook’s paper.

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1907]

BY C. C. EASTERBR00K, M.D.

735

shown that the verandah accommodation at the hospital could
have been increased with advantage, so as to enable all patients
in that building who are confined to bed, not only the new and
actively insane, but also the sick and infirm—with the exception,
obviously, of the excessively weak and moribund—to be exposed
daily to the beneficial action of open air. And further, even
the more or less able-bodied and quiescent insane, who do not
require bed-treatment, and whom we treat in asylums with
regular forenoon and afternoon outdoor exercise in walking
parties and the like, have likewise benefited from systematic
daily exposure to the open air so distinctly as to convince me
that this class of patient in asylums does not get a sufficiency
of fresh air. The general conclusion I have come to, and the
standard to be aimed at in the medical administration of an
asylum or similar institution, the primary object of which is to
secure the best mental and bodily health attainable for the total
population, is to carry out a continuous open-air rcgitnc during
daylight hours, from, approximately, seven in the morning to
seven in the evening, throughout as much of the year as possible,
for all patients, both those requiring rest or bed-treatment, the
only exceptions being the excessively weak, and also those not
confined to bed, the only exceptions being those who are
engaged in necessary indoor work in wards, dormitories, kitchen,
laundry and workshops, the exception in their case, however,
taking effect only at the times at which such work is being done.
Given suitably sheltered verandahs, even meals can be com¬
fortably taken out of doors during most of the year, and the
large central dining-hall of asylums, which is already disappear¬
ing with the coming of the villa system, will become a thing of
the past. To prevent the good effects of the exposure to the
open air during the day from being counteracted during the
night, when confinement indoors is obviously necessary for the
great majority of the insane in asylums, the essential importance
of sufficient air-space and ample ventilation in bedrooms and
dormitories cannot be too strongly insisted upon. Under such
conditions not only does the asylum population become more
healthy and contented, but in time the mortality from tubercle,
which is three or four times greater amongst the insane than
the sane, should markedly diminish, notwithstanding that the
insane are specially susceptible to this disease, as is shown by
its frequency among them, and also in my experience amongst

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736 SANATORIUM TREATMENT OF ACTIVE INSANITY, [Oct.,

their near relatives. C. J. Shaw (Journal of Menial Science ,
July, 1907) has recently shown that the tuberculo-opsonic index
is subject to greater daily variations, and is on the average
lower in the non-tuberculous insane than in healthy sane
individuals, and finds that the average index is lower in the
acute than in the chronic insane, in adolescents than in adults,
in melancholiacs than in maniacs, and is specially low in general
paralytics.

As regards the sanatorium treatment of the actively insane at
Ayr, all newly admitted patients are, after examination, and
unless too weak ’physically to be carried or moved about,
placed straightway in the verandahs attached to the reception
wards of the hospital, and treated with rest in bed in the
open air during daylight hours. The hospital verandahs face
the south and have pleasant views of the hospital garden,
asylum estate and country beyond. They are sheltered from
the north, east and west by the adjoining buildings, and
their roof is of rippled glass, which is painted in summer for
extra protection from the sun. They are sufficiently deep
(9 feet) to project well beyond the foot of the beds, but could
with advantage have been made deeper to prevent access
of rain when the wind is in the south, a difficulty, however,
which is met by means of waterproof sheeting spread over the
beds. Unusually strong southerly winds with rain, or specially
raw and inclement days, are the only weather conditions which
hitherto have caused an occasional day’s interruption of the
treatment. The beds, which are strong, light and portable and
were specially made for the purpose, are carried to and fro
between the verandahs and the reception wards as required. The
amount of bed and personal clothing worn naturally varies with
the season, weather, and out-door temperature mainly. The
patients are in the verandahs daily from 7 a.m. to 7.30 p.m.
during the spring and summer months, when they receive all
their meals out of doors. During the months of November,
December and January they are taken out to the verandahs in
the mornings at half-past eight o’clock, just after breakfast,
and during the months September to March they are brought
in from the verandahs in the evenings at 5 o'clock, just
before the tea-time (5.30 p.m.) of the day staff. Those patients
who are sufficiently strong and exhibit no obvious or fine
symptoms of fatigue, are allowed to walk to and from the

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BY C. C. EASTERBROOK, M.D.

737

I 907 .]

verandahs when the beds are being moved in the morning
and evening, and to and from the ward lavatory as required
during the day; but apart from this, such patients take no
exercise during the period of rest in bed. Patients exhibiting
signs of fatigue, weaker and easily exhausted patients, are
wheeled or carried to and fro as required, and are allowed no
exercise at all to begin with. Extreme physical weakness, for
obvious reasons, contra-indicates the treatment. The severity
of the mental symptoms is no contra-indication, and even in
the worst cases does not prevent the treatment from being
carried out straightway on admission with safety and propriety
to all concerned, given plenty of nursing assistance, a sufficiency
of bed and personal clothing for the patient, and an isolation
verandah; for even such cases respond satisfactorily to the
treatment by rest in bed in the open air, and for the reason of
its direct and specific beneficial effects. Even in those com¬
paratively rare cases of intense or fulminant excitement, in
which instant action'is necessary, in which outdoor exercise is
impracticable and in addition harmful from the extra exhaustion
induced, in which hot packs and the continuous warm bath are
likewise objectionable and not devoid of danger, and in which
as a rule the only thing to be done at the time is to isolate the
patient in bed with as many nurses as are required, and to
administer hypodermics of hyoscine or morphine or other
sedatives and hypnotics until the critical excitement subsides,
I find that if this bed treatment and isolation with the nurses
is conducted out of doors instead of indoors, aided if necessary
by the temporary administration of sedatives, the patient gets
over the crisis more quickly and looks better at the end of it
than by the other procedures, and is able to continue the
open-air rest treatment without further difficulty.

What, then, are the effects of rest in bed in the open air in
the case of newly admitted and actively insane patients, and
wherein do the effects of outdoor rest differ from those of out¬
door exercise or indoor rest ? First and foremost , there is a rapid
subsidence of the active mental and nervous symptoms. This,
as already mentioned, is the special feature of treatment by in¬
door rest as compared with outdoor exercise, but it is still
more pronounced in rapidity and degree when the rest in bed is
conducted in the open air. Thus, there is a rapid amelioration
of mania, melancholia, delirium, confusion, stupor, vivid

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738 SANATORIUM TREATMENT OF ACTIVE INSANITY, [Oct.,

hallucinatory and delusional manifestations, impulsivenesss
and mental excitement of all kinds, also of restlessness and of
insomnia. The general effect is that the large majority of
newly admitted patients show distinct improvement of their
various morbid mental states, become less restless, more
manageable and more contented, and regain their sleep with
greater rapidity than with any other method that I know of.
This amelioration of the mental condition occurs after one, two,
or three days of outdoor rest in quite a fair proportion of cases,
but commonly takes one, two, or three weeks, and in a minority
of cases longer. The improvement in the sleep is striking, and
in most cases is distinct within a week, the sleep being increased
by one, two, or more hours at nights, in addition to occasional
light slumbers during the day. Secondly , there is a rapid
improvement in the physical condition. This, as pointed out
before, is the characteristic feature of treatment by outdoor exer¬
cise as compared with indoor rest, but is quite as marked and, in
some respects, more rapid than with outdoor exercise. Thus,
from the first there is a noticeable improvement in the appear¬
ance and condition of the skin, which takes on a better colour,
becomes clearer, and functionates more satisfactorily. From the
first, also, the improvement of the appetite is striking, the
patients, in the majority of cases, readily taking their mealsthem-
selves and not requiring to be spoon-fed, as is so commonly the
case with new patients at first, whether treated by indoor rest or
outdoor exercise. Again, there is an early and distinct improve¬
ment in the state of the tongue, and of gastric digestion if
previously impaired; and actively insane patients with gastric
atony and catarrh and coated tongue do specially well with
open-air rest. As regards the state of the intestines, it is my
practice to secure a preliminary evacuation in all new cases,
usually by five grains of calomel on the evening of admission,
followed by a tablespoonful of Epsom salts next morning, and if
this fails by a copious simple enema the following evening.
Apart from this preliminary measure, with open-air rest, the
bowels, if previously constipated, become regular in action
without the aid of laxatives in the great majority of cases, the
exceptions being patients who are specially the subjects of
habitual constipation, and who, like similar sane individuals,
require to take aperients regularly. Open-air rest does not
benefit catarrh of the intestine to the same extent as that of the

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stomach, additional local treatment being necessary. Again,
distinct improvement occurs in the quality of the blood and
circulation, anaemia being markedly benefited by open-air rest,
as also conditions of debility and atony of the heart and
arteries. The muscles of the limbs become similarly toned up
and firmer. And, finally, fat is laid on, and the improvement in
general nutrition, once established, is soon marked by a satis¬
factory increase in weight. This increase in weight commonly
amounts to five, six, or seven pounds during the first two to
three weeks, on a moderately abundant simple diet consisting
largely of milk and milk puddings to begin with, and in my
experience the gain in weight sets in earlier with open-air rest
than with outdoor exercise. To sum up, in newly admitted
cases, with open-air rest, there is a rapid and simultaneous
improvement of both the mental and the physical condition of the
patients; there is not the retardation of the mental improve¬
ment which occurs with treatment by outdoor exercise, nor the
retardation of the physical improvement which occurs with
treatment by indoor rest.

As to the effects of open-air rest and isolation in the case of
the resident and more or less chronic patients during their
relapses or phases of active insanity. Such patients in the past
were chained in fetters or manacles, at a later date restrained
in straight-jackets or locked up in miserable dens, and nowa¬
days are taken out regularly for exercise two or three times a
day; or, if exercise fails, as it does in a certain percentage of
cases in which it cannot be carried out with safety or pro¬
priety, they are treated, as many a chronic invalid at home is
treated, with more or less prolonged confinement to bed and
bedroom under the observation of a nurse or nurses, sedatives
being administed if they cannot be avoided. It may be said
that outdoor exercise and indoor rest with isolation are at the
present time the common and most hygienic procedures for deal¬
ing with this class of patients. All such cases at Ayr are now
treated with open-air rest and isolation during the same hours
of daylight as the newly admitted patients, namely, 7 a.m. to
7.30 p.m. during spring and summer, and shorter periods
during other months ; and consequently, indoor isolation during
the daytime for active insanity has to all intents and purposes
been abolished, like its predecessor, locked indoor isolation or
seclusion.

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740 SANATORIUM TREATMENT OF ACTIVE INSANITY, [Oct,

What, then, are the changes noticeable, more particularly in
such chronic cases undergoing open-air rest and isolation in
place of indoor rest and isolation as formerly, changes which,
therefore, must be due largely, if not entirely, to the prolonged
daily exposure to the open air ? Firstly , the patients are un¬
doubtedly improved mentally—that is, they become less ex¬
cited, less noisy, less restless, and, as their attendants and
nurses say, they become more manageable and more contented
than formerly. Further, they sleep distinctly better at night
and are less noisy at night. This mental and nervous improve¬
ment in consequence necessitates the use of still fewer sedatives
and hypnotics than formerly. Secondly , they are distinctly

improved physically; their skin is healthier, their appetite is
better, and their bowels become more regular—a very interest¬
ing effect of fresh air. Both in the case of newly admitted and
chronic patients undergoing verandah treatment the administra¬
tion of laxatives has distinctly diminished. The preceding
observations apply also to the other patients in the wards of
the main buildings who are not undergoing bed treatment in
the verandahs, but now, like the verandah patients, spend the
day in the open air, occupying the courts on to which the
verandahs look, except at walking hours and meantime at meals.
The verandah patients, however, receive their meals outside,
and as the verandahs at the main buildings are specially well
sheltered, verandah treatment of the chronically excited patients
is carried out in all weathers. The interesting fact has, there¬
fore, been demonstrated that those resident patients who
formerly went out for the customary forenoon and afternoon
exercise, as in all similar institutions, now, since being exposed
regularly to open air during most of the day, are improved
physically and mentally, have a healthier appearance, sleep
better and are less noisy at nights; and further, in the case of
those patients who are subject to distinctly recurrent attacks
of active insanity, it is already noticeable that the attacks are
becoming less frequent, and when treated with rest and isolation
in the open air are less severe and last a shorter time than
formerly. At present nearly io per cent . of the population at
Ayr asylum is being treated for active insanity by the method
of open-air rest.

Comparing, then, the general therapeutical effects in active
insanity of outdoor exercise, indoor rest, and outdoor rest, I

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find that outdoor exercise benefits primarily the physical con¬
dition but may retard the mental improvement; that indoor rest
benefits primarily the mental condition but may retard the
physical improvement, and that outdoor rest benefits from the
first both the mental and the physical condition. Outdoor
rest thus from the outset promotes both mental and physical
improvement and so retards neither; further, it avoids the risk
of undue exhaustion which attaches to the method of exercise;
and lastly, it obviates the evils of bodily inactivity and sluggish
metabolism which attach to prolonged indoor rest. Further,
my observations show, firstly, that the advantages which
have hitherto been attributed to the exercise treatment of active
insanity are due, not to the exercise, but to the fact of the
patient being out of doors; for regular exposure of the patient
to the open air during most of the day without exercise secures
the characteristic physical improvement, and more readily if
combined with rest in bed. And secondly, that the dis¬
advantages which have hitherto been attributed to the prolonged
treatment of the neuroses and psychoses by the indoor rest or
Weir Mitchell method are due not so much to the factor of
rest as to the confinement indoors; for the sanatorium treatment
by rest in bed in the open air not only prevents the evils of
sluggish metabolism and the like, but remedies them if present,
securing an all-round physical improvement; and in my experi¬
ence, the open-air rest treatment may with benefit and safety
be continued for months if necessary without recourse to
massage, active movements, movements with resistance, electro¬
therapy and the like, it being, however, advisable in such cases
to permit the daily walk to and from the verandahs morning
and evening, and every now and again to allow the patient to
sit up in a chair in the open air for a day or perhaps more,
this being done chiefly with the object of ascertaining whether
the change will be beneficial, apart from the reason that it
introduces in such cases the desirable element of variety in the
routine of the treatment. Such variations in prolonged severe
cases, however, are not permissible if distinct symptoms of
fatigue are present, for continuous absolute rest is the best safe¬
guard against the special risk of fatal exhaustion in such cases.

The duration of the sanatorium treatment in the case of new
patients naturally varies. In a small proportion of cases, in
which the bodily health is fair and the mental and nervous

LIII. 52

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742 SANATORIUM TREATMENT OF ACTIVE INSANITY, [Oct,

condition is quiescent, the period need not exceed two to three
days, which I regard as the minimum, and desirable even in
such cases, for the purpose partly of the more satisfactory
clinical observation thereby secured, and partly for the psycho¬
logic and other therapeutic advantages which attach to the
system of an initial period of rest in bed for newly admitted
patients, as already explained under the hospital system-
Commonly a period of one, two, three or four weeks of sana¬
torium treatment suffices, and so in the great majority of cases
the period of rest in bed in the open air does not exceed one
month—a considerably shorter period than the two, three and
more months commonly employed by the chief advocates of
the rest treatment carried on as hitherto indoors. The mental
and bodily conditions each constitute the guide as to the
duration of the treatment, and it may be stated generally that
as soon as the active mental and nervous symptoms have
subsided, and physical improvement has become established, as
gauged specially by an increase in weight, the rest in bed
stage ceases; but the open-air treatment still goes on, the
patient being prescribed much sitting with occasional short
walks in the hospital garden, until convalescence is fully
established, when exercise and work may be pursued with more
freedom. During the after-treatment following the period of
rest in bed the gain in weight continues to increase satis¬
factorily. The dietary enjoined during the sanatorium treat¬
ment is a simple, digestible, and moderately abundant one,
comprising largely milk and milk puddings to begin with, and
sooner or later light ordinary diet with extra milk, eggs, and
the like, the chief guides being the particular taste of the
patient, and the state of the appetite, digestion and weight.
It may be mentioned here also that during the sanatorium
treatment of active insanity, as with other methods, any con¬
comitant bodily disorders present which specially call for
treatment, in addition to that supplied by the rest in bed and
the open air, are corrected so far as is possible. And further,
during verandah treatment, if the patient is sufficiently fit
mentally and physically, light reading, sewing, games of
draughts, dominoes, and the like, are enjoined, as they serve to
occupy the mind of the patient in healthy directions without
undue effort, and thereby to relieve any tedium arising out of
the treatment.

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743

From what has been said it will be gathered that the special
efficacy of the sanatorium method in the treatment of active
insanity is due to the action of rest in bed plus that of the open
air. The modus operandi of rest is comparatively simple, and
has already been referred to ; that of the open air is more com¬
plicated, and herein lies a wide and worthy sphere for the investi¬
gator—the pharmaco-dynamics of the fresh air of the open as a
remedy for the preservation of health and the cure of disease.
The fresh air has an undoubted soothing and soporific influence
on the nervous centres, and the cooler outdoor atmosphere
stimulates general bodily metabolism and appetite, both of
which effects render the open air of special value in the treat¬
ment of active insanity. But in the treatment of the insane,
and, indeed, of the sick in general, by exposure to the fresh air
of the open, we cannot overlook the concomitant operation of
such beneficent influences as the soothing action of soft breezes
playing over the features, the comforting effect of the pleasant
sounds and prospects of Nature and her surroundings, as
commonly associated with the life in the open, the cheerful
influence of sunshine, the health-giving action of the ozone and
oxygen and possibly other gases of the atmosphere, and the more
obscure influences of light, sound, electricity, heat and cold or
temperature, humidity, atmospheric pressure and the like.
Indeed, to arrive at the rationale of open air in the therapy of
disease, we must take into consideration the entire gamut of its
mechanical, chemical, and physical properties and conditions, as
regards the influence of which on the human organism for
good or the reverse there is now almost a pressing need for
further elucidation.

The great importance of an outdoor life in the management of
neurotic and insane patients has long been recognised. Largely,
no doubt, owing to our habit of associating health with the
outdoor life, and sickness with the bed of sickness and confine¬
ment to the sick-room, we have in the past come almost instinc¬
tively to regard the open air as the inseparable ally of exercise
in the treatment of disease, and consequently in practice to
confine its use to those conditions, and to those more or less con¬
valescent stages of disease in which it is considered that exercise
is suitable and beneficial. Consequently, before the advent of the
open-air cure of pulmonary tubercle, to have removed the sick
man on his bed of sickness out from the sanctuary of the sick-

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744 SANATORIUM TREATMENT OF ACTIVE INSANITY, [Oct.,

room into the exposure of the open would have been deemed
highly incongruous and even reprehensible by profession and
public alike. Thanks, however, to the efforts of the pioneers of
the open-air treatment of tubercle, which has assumed so great an
importance during the past decade, and has been associated with
the names of Hermann Brehmer on the continent, and Trudeau
in America, though Dr. Philip, of Edinburgh, tells me it was
practised by Bodington and M’Cormac in this country at the
middle of last century, the recognition of fresh air for its own
sake and not merely as the dormant partner of exercise has at
last come about, and the open air is now taking its proper place
as a potent prophylactic and curative agent at the disposal of
the physician, and promises to occupy as important a position
in the domain of medicine as Listerism in the realm of surgery;
and not even to stop here, with active schemes afloat for open-
air schools in London and elsewhere, hedge-schools in
Switzerland, and open-air nurseries and creches .

Since the advent of the open-air treatment of pulmonary
tubercle, which has now found its way into every well-equipped
asylum, doubtless many psychiatrists must have been adopting
the open-air principle more freely in the treatment of those
actively insane. Apart from a preliminary communication by
myself on the sanatorium treatment, contained in the article on
insanity in the Medical Annual for 1907, the only other contri¬
bution on the subject with which I am acquainted is a recent
paper entitled “ The Open-air Treatment in Psychiatry/* (New
York Med. Journ., February 9th, 1907) by W. Mabon, Medical
Superintendent of Manhattan State Hospital, Ward’s Island,
New York. According to Mabon, the late Dr. A. E. Macdonald
introduced tent life for the tuberculous insane at Ward’s Island
in 1901, and the late Dr. E. C. Dent extended the open-air treat¬
ment to the acute insane about 1904. Mabon has continued the
system and in the paper reported gives his experience of it. The
tents originally used, owing to obvious disadvantages in wet
and stormy weather and the difficulties of proper ventilation,
have been largely replaced by wood and glass pavilions termed
“ camps.” These are situated near the permanent reception
building, into which it would appear that the worst cases are
first admitted and frequently undergo, in delirious and similar
cases, treatment by warm packs and the continuous warm bath
for a week before being sent to the camps, one of which is

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BY C. C. EASTERBR00K, M.D.

745

reserved for bed cases. Mabon speaks very favourably of the
open-air method as carried out in the camps or pavilions and
tents. He obtains a recovery rate of 40 per cent., and has
“ found the open-air treatment particularly beneficial for the
following classes of the insane: (1) The tuberculous; (2) the
feeble and untidy; (3) the retarded convalescents; (4) the
acute insane, in whom the psychosis is associated with the
anaemic blood states, delirium and loss of sleep.”

In the sanatorium treatment at Ayr, which is carried out
straightway with all new patients, mild and severe cases alike,
it will have been seen that the essential feature is the combina¬
tion of rest in bed and the open air, the rest in bed being quite
as important as the open air. It seems strange indeed that the
combination of rest in bed and the open air as a distinct thera¬
peutic system has not hitherto been recognised in the treatment
of the neuroses and psychoses, in which rest and exercise have
each played, and still play, so prominent a part. And yet in
one of the latest and best expositions of the rest cure, by Dercum,
of Philadelphia {Cohen's System of Physiologic Therapeutics , vol.
viii, Rebman, London, 1903), emanating from the home and
fountain head of the Weir Mitchell treatment, there is from
cover to cover no suggestion of a possible alliance between rest
in bed and the open air, but throughout an estrangement, the
result of the tacit association of open air with the antagonistic
though complementary system of exercise. The rest in bed,
full rest, or strict rest treatment, which lasts for two, three or
more months, is always indoor rest, and is to be followed
sooner or later by exercise, exercise indoors, and ultimately
exercise in the open air; and this applies to the treatment of
neurasthenia, hysteria, hypochondria, melancholia, mania,
stupor, confusion, delirium, and other neuroses and psychoses.
Thus, speaking of the treatment of melancholia, Dercum says
(page 197): “ Whenever it is possible, other things being equal,
radical rest in bed should be carried out. This rest should
always be of many weeks’ duration, just as it is in the treat¬
ment of neurasthenia. Even in cases of melancholia in
which the duration of the disease is of unusual length, say
a year or more, the patient should, from time to time,
be submitted to periods of rest, these periods alternating,
according to circumstances, with other periods of open-
air and out-of-door life.” . . . Again (page 204): “ Even

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746 SANATORIUM TREATMENT OF ACTIVE INSANITY, [Oct,

when the patient is under rigid rest treatment it is a wise plan
to allow him to sit up or exercise about the room for a few
minutes twice daily.” . . . And again (page 205): “ Little

by little, as the case progresses, the patient should be permitted
to get out of bed ; little by little passive movements should be
added to the massage, and finally, movements with resistance
may be instituted. The time out of bed should gradually be
increased, and very soon the patient should be permitted to
exercise for short periods in the open air.”

From the foregoing description of the sanatorium treatment
of active insanity as practised at Ayr it will be seen that on
physiologic, psychologic, etiologic, and pathologic grounds the
combination of rest in bed and the fresh air of the open secures
in the most natural way the rest required for the nervous
centres during their critical experience in an attack of psychosis
or neurosis, and so places the patient in the best conditions
for recovery. And here it may be asked, What is the recovery
rate by the open-air rest treatment in active insanity, and how
does it compare with the results by the exercise and rest
methods respectively ? I have purposely refrained from giving
statistics on such points because of the inherent difficulties and
fallacies which beset such investigations, and further, because
it is too soon yet to speak definitely as to the recovery rate
by the open-air rest treatment. I may, however, state that
excluding transfers of all kinds, and including only those
patients who had not previously during the existing attack
been under treatment as certified insane persons, including the
good with the bad, the highly recoverable, and the congenital
imbeciles and idiots who came in with the others having
become certified as insane for the first time in their lives, I
obtained, in the case of 512 patients treated under the exercise
system, a recovery rate of 42 per cent . (the results being slightly
better with women than with men), and in the case of 511
patients treated under the rest system a recovery rate of 44 per
cent . (the results being slightly better with men than with
women). And I must merely content myself meantime with
the statement that a trial of the sanatorium system as described
in the foregoing has convinced me that it is a more satisfactory
method of treatment than either the exercise or the rest
method as hitherto practised, and that it should in due time
yield even more satisfactory results.

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747

Discussion

At the Annual Meeting held in London, July 25th, 1907.

The President said that the Association was very much indebted to Dr.
Easterbrook for his interesting paper, and those present must have been struck
by the efficient way in which he had carried out his ideas regarding sanatorium
treatment.

Dr. Yellowlees said that the Association was much indebted to Dr.
Easterbrook for his practical common-sense contribution. All his hearers would
be absolutely agreed as to the value of fresh air to everybody, whether sane or
insane. The method of converting his airing-courts into bedrooms had much in
its favour, and he had no doubt that in suitable cases it should be tested. The
old universal way of allowing excessive exercise in the open air was often bad
because it was so apt to be overdone. The swing of the pendulum, he believed,
had now gone rather too far in the other direction. There were certainly some
cases which did better with exercise in the open air than they did if sent to bed.
For instance, a full-blooded able-bodied adolescent he would not put to bed, but
would, if possible, set him to dig in the garden. On the other hand, he would like
to ask Dr. Easterbrook how the treatment he advocated answered with a case of
melancholia. His own experience was that melancholiacs who had been treated on
Weir-Mitchell lines had been injured thereby. In many asylums Dr. Easterbrook’s
plan would be difficult, because the verandahs were not suitable; but wherever it
could be tried it was worth trying.

Dr. Wilson said he was one of those who had the advantage of having seen
Dr. Easterbrook’s method in practice at Ayr. At that time all who saw it were
much struck by the completeness of his arrangements, and by the apparent ease
with which they were carried out. He confessed that the doubt to which Dr.
Yellowlees had given expression was left on his own mind as to whether Dr.
Easterbrook was right in assuming that his method of treatment was suitable
for all cases, especially for paranoic and melancholic cases, as well as for the more
restless ones. With regard to his own experience he had carried out the treat¬
ment almost invariably, but latterly his ideas had modified in two respects, and he
would like to hear whether Dr. Easterbrook thought the same. First of all he
came to modify the treatment largely in regard to the extent of the isolation. The
second modification concerned the amount of exercise. He had been of the opinion
of Dr. Yellowlees, and remained so, that the pendulum had swung too far in the
opposite direction. He had been in the habit of taking some of his patients out of
bed and sending them for a certain amount of exercise during the day, and then
putting them back to bed again. He would like to know whether the author had
found, as he had himself, that there was a class of patient for whom isolation
was bad, and also the class for whom a certain amount of exercise was good.

Dr. D. Thomson expressed his agreement with Dr. Yellowlees and subsequent
speakers when they spoke of the pleasure which Dr. Easterbrook’s paper had given
them. He agreed that the exercise method of treatment had been overdone, and
all his hearers must be aware of the wonderful improvement produced in anaemia
and chlorosis by simple rest in bed. But he, in common with Dr. Yellowlees, was
not at all sure that the rest treatment could not be overdone. The effect of work
upon the ordinary hysterical young woman was little short of magical. Cases of
melancholia had been mentioned, and he had had cases of hysteria, too, self-centred
people, generally in the female sex, who had received all the attention and devotion
possible at home. For them there was no treatment like that of the pail and the
scrubbing-brush. Women hated exercise, staff and patients alike, airing-court
duty as it was formerly called. That was the most distasteful work which they
could be set to do. Therefore he would be glad to hear from the author whether
his nurses liked that perpetual out-door method, and whether he experienced any
difficulty in getting them to undertake it. One striking point which the author
brought out was very different from what others had been led to believe in recent
years, when he mentioned that the mental improvement immediately preceded the
bodily. Surely it was the experience of most of those present that with other
methods of treatment, such as indoor rest, the bodily improvement always pre-

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748 SANATORIUM TREATMENT OF ACTIVE INSANITY, [Oct,

ceded the mental. He joined others in thanking Dr. Easterbrook for his paper,
which was a very suggestive one.

Dr. Clouston said that he most heartily joined in the thanks which had been
expressed in regard to the paper as a whole. On the other hand, he had now
lived to see a great many changes, from the nondescript system onwards, and he
had become a little more eclectic than he was as a young man. Having had a good
deal to do with private patients, with regard to the treatment of whom there was
little difficulty in providing a nurse for each patient, one could individualise
the patients. Having seen many so-called systems in use he could say that each
one of them had some good in it; but he had a note of doubt and criticism when
Dr. Easterbrook said he had a system which was applicable to all cases, that other
systems had been tried and failed, but that this was the one which produced the
greatest amount of good in every case. He had had an opportunity of seeing
Dr. Easterbrook’s new place and nis system carried into effect, and he was greatly
instructed and interested. He was certain that for many cases that system was a
very good one indeed. But if the author told him that he (Dr. Clouston) had been
entirely wrong when he had seen marked improvement when many patients were
put upon vigorous exercise, that he had been wrong when he said he had seen a case
of melancholia get absolutely well from being put in a quiet workroom and not pat in
bed, and that he had been wrong when he had seen another case simply sent out to
work on the farm get better, then he felt he must beg to differ from Dr. Easterbrook.
He agreed with almost all that Dr. Yellowlees had said. That gentleman said be
never saw melancholiacs benefited by the Weir-Mitchell treatment. He (Dr.
Clouston) thought very many melancholiacs were badly injured by the Weir-
Mitchell treatment, but he had also seen cases in which there was a combination of
melancholia and neurasthenia very much improved by that treatment. In short,
people like Dr. Yellowlees, Dr. Thomson, and himself looked with admiration,
with respect, and with great approbation on a man like Dr. Easterbrook coming
and telling them about a new system, and thereby laying psychiatry under a special
indebtedness to his efforts ; but the author must not be offended if they said that
they did not believe in its universal applicability.

Dr. Goodall said that when he was a student at Bethlem Hospital, many years
ago, many of the acute cases were allowed on swings and see-saws, and encouraged
to take all the exercise they could. The recovery rate was then 50 to 60 per cent.
He believed that now the reverse order of things prevailed at Bethlem, and, as
Dr. Stoddart was present, he would perhaps say whether it were so. He believed
they kept acute cases in bed, according to the orthodox view, and he would be
glad to hear what was the present recovery rate, as they no doubt had the same sort
of cases there as formerly. He had been thinking of instituting a system of
continuous baths in an institution to which he had recently been appointed. If
the sort of patient under discussion did as well in bed in the open air as in baths,
the former plan was very much cheaper and was easier to carry out. He was glad
to say that at the institution at which he was now the architects had been
enlightened, and had provided verandahs, and the beds of patients could be rolled
out from the infirmary wards under them. He understood Dr. Easterbrook to
make his recommendations after a year’s experience. But the plan deserved more
trial than that, and no doubt the author meant to give it. It would be interesting
to compare the results with those achieved by prolonged baths. On the Continent
it was claimed that all recent cases should be either in bed or in a bath. If
Dr. Easterbrook’s system proved satisfactory for recent cases, the present too solid
asylum fabrics might melt and give place to lighter and much cheaper structures,
for no doubt such a system would be beneficial to the chronics and all the members
of the staff also.

Dr. Stoddart said he was already about to speak when Dr. Goodall rose, and there
was now an additional reason since he had asked him some questions. At Bethlem
they went in largely for bed treatment, and he believed that the method received a
great impetus after he had paid a visit to Professor Kraepelin,at Munich, and found
that he kept all his patients in bed for at least a considerable portion of each day.
Dr. Easterbrook had received some criticism, under the idea that he believed all
cases should be put to bed. But he imagined that the author did not mean that
he would put paranoiac (chronic delusional) cases to bed, because they had been
practically bora what they were, and nothing would alter them. But the manic-

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749

depressive cases, dementia praecox and the exhausted cases certainly seemed to
be improved by bed. He had noticed the exhaustion cases especially. They
improved up to a point, and they appeared to be well, and accordingly one
allowed them to get up. When they did get up and began to walk about, they
sank back again, and had to be put back to bed for perhaps a couple of months
more. He strongly supported Dr. Easterbrook’s contention that bed was the right
place and the right treatment. Alienists were apt to err on the wrong side in
getting patients up too soon. When a patient appeared to be well it was too soon
to get him up; he must still remain in bed each day until at least 12 o’clock. There
was some difficulty in keeping maniacal patients in bed. On the Continent, the
method was largely employed of using a prolonged bath, and that was sometimes
resorted to at Bethlem. The patient was simply put into the bath ; there was no
restraint, and the man stopped there, an attendant being put with him to encourage
him, and there was something for him to do in splashing the water, whereas he
would not stop in bed. Dr. Goodall’s suggestion of having several baths together
was a very good one. He had seen that carried out at Munich, where Professor
Kraepelin put four people in baths in the same room, and the patients were very
happy together. He saw one jump out of his bath and into the next one, to the
evident enjoyment of both patients. With regard to the recovery rate at Bethlem,
it had been up to 52 and 53 per cent., and sometimes it had gone as low as 40 per
cent., so that he could not say whether there was any improvement with the rest
treatment or not. The open air was the proper treatment, and it was much more
economical to have the patients in the open.

Dr. Hubert Bond said that Dr. Easterbrook had given a most stimulating and
fascinating paper, and it had given him very great pleasure to listen to it. Had
Dr. Easterbrook’s time been longer he would have asked him, with some insist¬
ence, to go and visit Bexley Asylum. He could there see that his scheme had
been largely in practice seven or eight years, both in regard to detached hospitals
for recent admissions and the cases in the infirmaries of the main asylum. He
was sure the author would see very much there which would interest him. He
was in close sympathy with most of what Dr. Easterbrook had said. Just as Dr.
Clouston had said, he did not believe in it as a panacea, but he did not suppose
that Dr. Easterbrook did either. When it was remembered that every twenty-four
hours one drew something like 26,000 breaths, one could not pass over the question
as to how many of those were drawn in the open and how many within closed
walls. He noticed that the author laid stress on the patients being in the open in
daylight hours. When Dr. Stoddart rose he had hoped to hear something from
him as to patients being out in the open during the whole of the twenty-four hours, a
suggestion that Dr. Hyslop had asked him to join with Bethlem in trying. At
the institution he had just left, the Epileptic Colony at Ewell, without any pre¬
tence of curative results, he did succeed in improving the condition of many
patients immensely, even those who had been in other institutions a long time.
He ventured to hope that it might be to some extent the result of his programme,
by which almost the whole of the male patients were seven and a half hours in the
open air every day of the year, commencing at 7.30 a.m. Dr. Goodall had referred
to the question of baths. He supposed most of them had seen the practice which
was so prevalent abroad; and if it were proved that there were great value both
in the use of the continued bath and in the verandah treatment, there was no
reason why baths should not be under the verandahs.

Dr. Easterbrook, in reply, thanked the President for his kind remarks about
the paper, and the meeting for their kind reception of it. As regards the isolation
of cases of melancholia, he carried that out only in the case of noisy patients. He
would remind those who were not in sympathy with indoor rest that outdoor rest
was quite a different thing, for by carrying out rest in the open air one avoided the
disadvantages attaching to indoor rest. The effect of the open air itself was to
promote the physical and mental improvement induced by the rest in bed. It was
very striking to see how new insane patients treated with open-air rest stayed in
bed; he believed it was the effect of rest plus the open air. In his experience a
certain amount of difficulty in carrying out the treatment with new admissions
occurred in only a small number of cases (less than 5 per cent.), and was but
temporary, these patients soon settling down and becoming contented. This was a
striking feature of the verandah treatment of those actively insane. The verandahs

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TREATMENT OF GENERAL PARALYSIS,

[Oct,

of the reception wards had, as a rule, seven or eight occupied beds, and one nurse
in charge was usually sufficient, though other nurses were available if required. It
was not intended that the sanatorium treatment was the panacea for all insane
persons in all their various morbid phases. But if, for example, a paranoiac was
admitted with morbid excitement, he was treated with open-air rest until the
excitement subsided, and then allowed to be out of bed. In deciding when the
bed stage should cease, one had to consider both the mental and the bodily con¬
dition, and specially the more obvious and the finer nervous symptoms of fatigue.

Observations on the Treatment of General Paralysis and
Tabes Dorsalis by Vaccines and Anti-sera. By W. Ford
Robertson, M.D., and Douglas McRae, M.B., C.M.,
M.R.C.P.Edin.

The investigations that have led us to employ specific
vaccines and anti-sera in the treatment of general paralysis and
tabes dorsalis have been the subject of several previous papers,
the last of which formed the basis of a discussion at a meeting
of this Association on May 16th. It is necessary, however, to
state here in a few words the more immediate reasons which
seemed to us some eighteen months ago to justify the under¬
taking of these experimental observations of therapeutic aim.
Prior to their initiation we had definitely ascertained that a
threading diphtheroid bacillus, isolated from the brain and the
bronchus of a rapidly progressing case of general paralysis, was
capable of producing a sub-acute disease in rats, in which the
symptoms were distinctly comparable to those of general
paralysis, that on post-mortem examination of the animals the
brain showed the characteristic changes of general paralysis, and
that there was also the characteristic invasion by the thread
form of the bacillus. It was thus evident that among the
various species of diphtheroid organisms that can be isolated
from a general paralytic there is at least one capable of pro¬
ducing the disease general paralysis. We had also ascertained
numerous facts which harmonised with this view. We had
obtained cultures of a diphtheroid bacillus from the brain of the
general paralytic in ten out of twenty-four cases ; and whilst
attempts to cultivate the organism from the blood and cerebro¬
spinal fluid of the living patient had, as in the experience of
most other observers, been in most instances entirely negative,
we had succeeded in obtaining pure growths from the blood in
four cases and from the cerebro-spinal fluid in two. We had also

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1907.] BY W. F. ROBERTSON, M.D., AND D. MCRAE, M.B. 75 I

ascertained that diphtheroid bacilli, in a more or less advanced
state of disintegration, are frequently recognisable in these
fluids, even when a culture cannot be obtained, and that such
altered bacilli are almost constantly present in the walls of the
inflamed vessels of the brain in cases dying in a congestive
attack. We had also evidence of the occurrence of a diphtheroid
cystitis in all of several cases of tabes dorsalis examined, and
of the existence of a high intra-corpuscular bacteriolytic index
to certain diphtheroid bacilli on the part of such patients and
of general paralytics, which we interpret as denoting that
they were defending themselves against the attack of an
organism of this kind.

With such and other evidence before us, and as our aim in
these researches was entirely a therapeutic one, we felt justified
in having recourse to specific vaccine and serum-therapeutic
measures. As there was reason to believe that the bacilli with
which we were concerned produced their toxic effects chiefly
by means of their endo-toxines, we decided in the first instance
to prepare an anti-bacterial serum, similar to that which
Wasserman prepared with the Klebs-Loeflfler bacillus in 1902.
After we had begun to immunise sheep, we ascertained, as the
result of the application of Gordon’s bio-chemical tests to various
strains of diphtheroids isolated from cases of general paralysis,
and through further experimental observations, that at least one
other species of diphtheroid bacillus is often virulent to mice
and rats and is capable of causing the symptoms and lesions
of general paralysis. We therefore employed both of these
two types of bacilli in our therapeutic experiments.

Both have a close morphological resemblance to the Klebs-
Loeffler bacillus. The first, which we have designated the
Bacillus paralyticans longus , differs from the bacillus of acute
diphtheria in producing no acid in the control broth in
Gordon’s bio-chemical tests, in being non-virulent to guinea-
pigs, but occasionally virulent to mice and rats, and in forming
threads under certain conditions of growth. The second,
which we have termed the Bacillus paralyticans brevis , is
distinguished especially by its bio-chemical reactions ; it
produces acid abundantly in saccharose and glucose broths,
but forms no acid in lactose, salicin, starch, dextrin, glycerine
and control broths ; it is not virulent to guinea-pigs, but is
often very virulent to mice and rats. We believe that these

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752 TREATMENT OF GENERAL PARALYSIS, [Oct,

are not the only species of diphtheroid bacilli that are
commonly concerned in the production of the toxaemia of
general paralysis and tabes dorsalis, but that, just as in the case
of the pathogenic streptococci, numerous different but closely-
allied species are capable of exercising a similar pathogenic
action.

Method of Vaccination .

The material employed was a suspension of a weighed
quantity (io—30 mgr.) of the bacilli in 2*5 c.c. of sterile saline
solution heated to 6o° C. for fifteen minutes.

The skin of the limb was cleansed by rubbing with a
I per cent . lysol solution and injections of the emulsion were
given hypodermically. Local effects varied from the merest
induration at the site of puncture to erythema and cedema of
the subcutaneous tissues.

The immediate general effects were the production of brief
pyrexia, flushing of face, headache and drowsiness, while
increase of tremors, ataxia and a return of lightning pains
occurred in some cases. Mentally, there were remarkable
changes in not a few of the cases.

Case i. —Female, a third-stage bed-ridden general paralytic,
with contractures and lightning pains of an intensely distressing
character. Three injections were given and the pains were
increased for a time after each. Three weeks after this she
began to make active efforts at dressing herself and walking
about with the aid of a chair, and was able to express herself
coherently, while the pains seldom recurred. Two months
later she was able to scrub floors and go about the wards with¬
out support. She was never able to stand erect, however, on
account of permanent flexion at the knees. This improvement
was maintained for a year, when the patient was removed from
the asylum.

Case 2.—Female,a third-stage general paralytic, very helpless
and intensely confused in mind. Three injections gave tempera¬
ture reactions of over ioo° F. each time. Increase of tremors and
grosser impairment of speech followed the first inoculation.
Shortly after the second the patient talked sensibly and with

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clear articulation, and she was able to go about. Two months
afterwards she relapsed into her former condition.

CASE 3. —Female, a stuporose general paralytic in second
stage. Three inoculations were followed by rises of temperature
to over ioo° F. and a temporary lucidity in the patients mental
state was noticed.

Case 4.—Female, a non-progressive general paralytic, the sub¬
ject of “ pains ” and “neuralgias/* had nausea and vomiting after
the first injection and became depressed in mind with exacerba¬
tions of pains after the second and third inoculations. Three
weeks later she became cheerful and employed herself in house¬
work for the first time since admission twelve months
previously. She relapsed, however, several weeks later.

Case 5.—Female, a depressed and confused tabo-paralytic,
became lucid and gave a correct account of her family history
after the first inoculation. After two more inoculations she
employed herself in the ward, but relapsed after three weeks to
her former state.

Case 6.—Female, was in third stage and bed-ridden for three
years, became excited and impulsive a few hours after injection.
She developed diarrhoea and had a marked exacerbation ot
leucorrhoea. No improvement was noticed.

Case 7.—Female, a confused general paralytic in the second
stage, had a return of pains and became flushed after inoculation
on three occasions. Her speech, at first more defective,
became for a time clearer than formerly.

Case 8.—Female, an early third-stage general paralytic,
became excited and violent after each injection and improved
considerably in bodily condition later.

Case 9 was that of a medical man who had been developing
symptoms of tabes for over two years. His reactions to inocula¬
tions of the toxins of a diphtheroid bacillus of the “ brevis **
type, isolated from his bladder, are interesting and significant.
The left arm was injected with 10 mgr. of dead bacilli, and the
patient in a few hours suffered from distinct malaise and had a
definite attack of lightning pains for twenty minutes. These
had not troubled him for a fortnight previously. There was no

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754 TREATMENT OF GENERAL PARALYSIS, [Oct.,

rise in leucocytes. Pains recurred on the second and third
day. Leucocytes remained about 9,000. The second injec¬
tion of 20 mgr. of bacilli a week later resulted in a rise of
temperature to 99 0 F. at 3 a.m. Next day there was marked
local reaction and he had considerable malaise. There was
slight recurrence of “ pains ” and the leucocytes were 16,000.
After the third injection he suffered from severe headache
and had return of lightning pains for half an hour, about
twelve hours from time of inoculation. Next day there was
a leucocyte count of 17,000.

On the whole the patient was better and had not the same
mental depression that accompanied his ailment prior to inocula¬
tions. A fourth injection caused very marked malaise, a tem¬
perature of ioo*2° F., and once more a return of the pains fora
short time. Subsequently he expressed himself as being better
in health, much longer free from pains, which, moreover, were
considerably diminished in severity.

The results of these observations would seem to show that
repeated vaccinations might prove a useful mode of treatment
in general paralysis and tabes. This belief is supported by the
results of the independent observations of O’Brien in America^ 1 )
who has recently reported that he has obtained considerable
success by such methods in cases of general paralysis.

That we have not pursued the method further is entirely on
account of the fact that our original object was to prepare a
specific anti-serum, and we merely temporised with vaccines
until the serum was ready for use.

In our opinion such vaccine treatment would have to be
carried out under the following three conditions: (1) The
bacillus ought to be one isolated from the patient; (2) there
should be evidence that it is exercising a pathogenic action
upon the patient; and (3) the injections should be carried out
under the guidance of the leucocyte count or the opsonic
index.

Preparation of the Anti-sera.

Sheep were selected as most convenient for our purpose,
and in March, 1906, two healthy animals were first of all
inoculated with dead cultures of bacilli of the Bacillus paralyti -
cans longus type, isolated from the brain of a case of general
paralysis.

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1907-] BY W. F. ROBERTSON, M.D., AND D. MCRAE, M.B. 755

Weighed quantities of the living bacilli were then injected once
a week, and the temperature of the sheep was taken twice daily.
The inoculations caused a local induration and tenderness at the
site of puncture, a rise of temperature of from one to two degrees
and a slightly torpid condition of the animal. After two
months, as the injections failed to cause any of these phenomena,
and as the intra-corpuscular bacteriolytic index had been
raised, it was decided to use the serum. We have now twelve
sheep immunised to various strains of virulent diphtheroid
organisms, six to the Bacillus paralyticans longus type, four to
the brevis type, and the remaining two animals to both types.

Obtaining the Serum.

The animal is lifted on to a specially contrived stool, the
front of the neck shaved and sterilised with 5 per cent lysol
and carbolic lotions. A large syringe needle with a bore of
2*2 mm. which has been sterilised in hot oil is grasped by
means of special forceps ; the thumb of the left hand, enveloped
in a carbolic swab, is pressed against the external jugular vein
low down in the neck, then the needle is plunged into the dis¬
tended vessel. The blood is collected in quantities of 40 c.c.
in 60 c.c. glass tubes, previously plugged and sterilised in a hot¬
air chamber. The serum separates out in twenty-four hours to
the amount of 20 c.c. in each tube, though it often takes forty-
eight hours to reach this quantity. It is now ready for injec¬
tion, though it may remain in contact with the clot for a
month or so, till required.

Mode of Administration.

The sera have been given by hypodermic injection, by the
mouth, through the nose, and, in one case, per rectum.

For hypodermic injection we use an all-metal serum syringe,
which has been thoroughly cleansed in carbolic lotion, and then
repeatedly filled and emptied with oil at a temperature of over
i6o°C., a method employed by Dr. Stenhouse Williams, of the
Runcorn Serum-Farm, Liverpool.

The skin of the abdomen is carefully cleansed with 1 percent.
lysol, and the injection is given with not too small a needle
(1 mm.). The skin at the site of puncture is pinched before

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756

TREATMENT OF GENERAL PARALYSIS, [Oct.,

and after removal of the needle, and held for half-a-minute in
order to seal the wound and prevent any escape. A piece of
fresh wool is placed on the spot and the fluid is left to be
absorbed.

Given by the mouth the serum is quite palatable if some
peppermint water or cassia is added. We also administer it by
means of an ordinary glass syringe through the nose, passing
I o cc. slowly along each nostril, directing the patient to retain
the fluid for a little time before swallowing.

Local Effects.

Given hypodermically, the serum may produce no local effects,
or merely a little induration with or without erythema, which in
a few cases may spread and give rise to oedema and brawny
swelling of a large area of the abdominal subcutaneous tissues.
This is readily subdued (in twenty-four to forty-eight hours)
by painting the skin with a solution of picric acid. Some cases
are more prone to this reaction than others, and it suggests the
local formation of toxins by destruction of bacilli in the tissues.
It has been found also that friction of the clothing during active
exercise is liable to cause a degree of inflammation if the patient
is not kept in bed for the day after injection. Serum urticaria
occurred in nearly every case.

When the serum was given by the mouth, local effects were
manifested by the development of nausea, vomiting and diarrhoea
in some cases, and the occurrence of a feeling of hunger in
nearly all cases.

General Effects .

These were chiefly drowsiness, diaphoresis, and malaise,
whilst polyuria and exacerbation of chronic leucorrhoea were
occasionally observed.

Immediately after injection, or in about half-an-hour in oral
administration, flushing often occurred ; some of the patients
complained of being giddy, with a “ tight feeling ” in the head
and a “ stiffness of the face.” Some experienced temporary loss
of vision. In one case the patient was blind in one eye for ten
minutes, nearly twenty-four hours after injection. Others asserted
they felt as if they were drunk. Vomiting occurred in some

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1907.] BY W. F. ROBERTSON, M.D., AND D. MCRAE, M.B. 75 7

cases after hypodermic injection. Mentally, many of the patients
became more confused ; most of them experienced an unusual
sense of well-being, and some were hilariously excited. The
speech, gait and co-ordination were for a time more impaired,
whilst the tremors were increased, and many of the patients
complained of shooting pains and sensations of numbness and
tingling, or feelings of “ pins and needles”

The temperature reaction is characteristic, and so far as our
experience goes it is diagnostic. It has for its features a rise
to ioo°F., or more, when the serum is given hypodermically,
and to 99° F., or more, when given by the mouth. This rise
occurs within twelve hours and is over in twenty-four, although
in the case of mouth administration it may be delayed till the
following day.

It has been observed that a temperature reaction may fail to
occur if the patient is in a state of remission, when the serum is
taken close upon the ingestion of food, or if diarrhoea occurs
immediately after its administration by the mouth.

The pulse-rate is usually increased, but on account of its
erratic character in cases of general paralysis and other forms of
mental disease (well seen in a study of the charts of these cases
kept for over a year), no useful data can be obtained.

The serum was tested originally in four cases of general
paralysis in the final stage of the disease. In addition to a
raising of temperature a few hours after the injection, a
remarkable lucidity of mind temporarily supervened in three
cases. One patient, who was in a congestive seizure and coma¬
tose, became quite conscious two hours after injection of 15 cc.
of serum, and the convulsions ceased and did not recur. She
remained conscious and lucid up till the time of her death,
fifteen days later. Recently another patient admitted to the
asylum while in a congestive attack, who rapidly developed
coma, became quite lucid within an hour of the administration
of the serum. The convulsions persisted, however, and she died
in two days, but maintained consciousness to the end.

The therapeutic effects on the mental and motor symptoms
of the patients treated can best be illustrated by a short
summary of a few cases.

Cases Treated .

Case 5.—C. S—, female, aet. 28, married. Admitted in
Lin. 53

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TREATMENT OF GENERAL PARALYSIS, [Oct,

July, 1906, in a confused apathetic mental state, being rather
fatuous and facile. There was general muscular enfeebleraent
with paresis and ataxia of gait, Rombergism, absence of knee-
jerks, considerable dysarthria and marked labial and lingual
tremors. The pupils were very irregular, unequal and sluggish
to light and accommodation.

In August she developed a congestive attack lasting twelve
days, during which she had ten severe epileptiform seizures
which left her with flaccid paralysis of the right arm and leg
for a few days. A month later she had a similar attack last¬
ing two days, during which a leucorrhoeal condition was
aggravated.

Serum treatment was begun on September 24th, and had
the usual effects. In January a sensation of “ pins and
needles,” lasting for twenty minutes, was all that occurred to
suggest an abortive congestive attack. In February she had
so far improved as to be able to attend the weekly dance.
Improvement continued up till the end of April, when it was
noticed that six consecutive doses of anti-serum gave no
temperature reactions. About this time she became markedly
constipated and developed a congestive seizure on May 2nd,
which caused a slight paresis of left side of face after twitchings
had occurred over both sides of face and in left arm. There
was no loss of consciousness, and, being perfectly lucid, the
patient was depressed on account of this return of the seizures.
On this occasion the temperature, which stood at ioi°F., was
raised to I03°F. after 20 c.c. of serum had been given by
mouth. Three days later she was out of bed and did a hard
day’s work at “ spring cleaning ” with no ill effects.

Her present condition (July, 1907) is one of almost complete
lucidity with normal articulation. The pupils react briskly,
though they are still unequal and irregular. The facies is
almost quite free from amimia and tremors, though the knee-
jerks remain absent and the tongue still shows fibrillar
twitchings.

CASE 6.—C. M—, female, aet 48, married. Admitted in
June, 1906, with obvious symptoms of general paralysis.
She became a confused, amnesic, bed-ridden paralytic who lay
huddled up in bed, unable to feed herself or have control of
the sphincters.

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1907-] BY W. F. ROBERTSON, M.D., AND D. MCRAE, M.B. 759

Serum treatment was begun in September. The usual
temperature and other phenomena were observed. Two
months later she was up, able to read a book and to converse
a little. In January she could knit and do light house-work,
recognised her relatives and appreciated their visits. This
improvement has been maintained.

Case 7.—Mrs. S—, female, aet. 24, married. Admitted in
September, 1906. Was a bed-ridden, rapidly progressive
general paralytic with large bed-sores. The knees were
acutely flexed, there were marked tremors, the speech was
Inarticulate and unintelligible, and there was complete absence
of intelligent response.

Injections were begun on September 24th, and were followed
by typical and well-marked reactions. Two months later the
bed-sores had healed and she was able to get up for a little.
Improvement has continued and she is now actively and
intelligently employed in the wards. Beyond a slight degree
of facility she betrays at present no mental symptoms of her
disease, and the motor signs are limited to fixed pupils and
abolition of knee-jerks.

Case 10.—J. H—, female, aet. 48. Intemperate and
dissolute for seven years after the death of her husband.
Admitted in July, 1906, in a state of excited melancholia with
symptoms suggesting peripheral neuritis. Six months later,
while in a state of sub-acute mania, she exhibited marked
unsteadiness of gait, and leant and lurched to the right side
while walking. The articulation became very defective. The
pupils were found to be unequal, very irregular in outline, and
sluggish, and limited in their movements both to light and
accommodation. Early in February she was put under serum
treatment and gave typical reactions. The day after the first
injection the patient expressed herself in a rational way for
the first time since her admission eight months previously.
She steadily improved and passed into a state of complete
remission and has technically recovered and been discharged
from the asylum. On the day she left the following motor
symptoms were noted to be present: The pupils were irregular,
the right particularly so ; both were limited in their range of
movement to accommodation, and the right was distinctly
sluggish and limited in its response to light; stumbling and

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TREATMENT OF GENERAL PARALYSIS, [Oct.

occasional slurring of speech, a slight tendency to lurch to one
or other side while walking, and tremors of facial and lingual
muscles were also to be observed.

CASE 12.— M. A. H. B—, female, aet 35, married. Admitted
in 1900. A case of dementia with the motor symptoms of
general paralysis, which had not cleared up under vigorous
anti-syphilitic treatment. She had passed gradually into the
third stage, had been bed-ridden, resistive, irritable and
absolutely mute for over a year. She was unable to feed her¬
self or attend to the calls of nature, and was extremely
emaciated. Serum treatment was begun in February of this
year and the usual reactions occurred. Within two months
she was able to walk in the garden, could feed herself and had
control of the bladder and bowels. She can now express
herself coherently, is delighted with her improvement and
proud of her ability to do light house-work. She is up and
goes about all day, takes an interest in her surroundings and
is sociable and amiable.

Time does not permit of a further individual survey of the
cases, but we may here summarise the results obtained up to
the present.

Altogether thirty-four cases of general paralysis have been
subjected to the anti-sera, and all of these have yielded a
positive result as regards temperature and other phenomena.
Two cases of tabes have also shown similar reactions. With
regard to the therapeutic results, out of twelve cases under our
own immediate supervision for over a period of three months
all have shown remarkable degrees of improvement Of nine
cases treated indirectly by us for a sufficiently long period to
obtain therapeutic results, four have improved up to the present,
and two have become well enough to leave hospital and to
enjoy ordinary social life, and are considered capable of taking
care of themselves. The remaining three have become pro¬
gressively worse in spite of vigorous application of the sera.
One of them was in a state of almost complete remission for a
time, but relapsed completely while absent from medical super¬
vision.

In the case of the medical man with tabes the employment
of an anti-serum prepared with his own particular u diphtheroid”
resulted in typical temperature reactions, considerable malaise

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1907 .] by W. F. ROBERTSON, M.D., AND D. MCRAE, M.B. 761

and an immediate return of lightning pains at first. He has
now been under serum treatment for five months. He is
satisfied that the severity of the pains is very greatly diminished,
while the duration of the periods of remission is increased, and
he no longer experiences unpleasant paresthetic sensations as
formerly. Similar improvement has occurred in another case
of tabes of over twelve years’ standing, which has been a
shorter time under serum treatment. The ataxia in his gait is
much less marked. He has regained his facial expression.
The pains, which occasionally return about six hours after
taking serum, are much less severe, and he has longer periods
of freedom from them than he ever had prior to serum
treatment.

Control Cases .

It may here be convenient to refer briefly to eleven cases
which were subjected to the anti-sera in order to control our
observations in the cases of general paralysis. Three were
cases of dementia precox, four of excited melancholia, two
were suffering from alcoholic dementia, one was an epileptic, and
another laboured under mania. They all had the anti-sera on
at least three occasions, two cases having them as often as eleven
and ten times respectively. In none of these did any specific
reaction occur after mouth administration, and any rise of
temperature subsequent to injection could readily be explained
by other factors.

Dr. Alex. Russell, at present assistant physician at Morning-
side Asylum, made daily observations over a period of four
months on the leucocytes of some of the cases treated by serum.
He found that in the cases of general paralysis there was no
material change in the numbers of leucocytes, or in the diffe¬
rential counts after injection of the anti-sera ; whereas in control
cases in most instances there was a decided rise in the number
of leucocytes, while the polymorphonuclear percentage showed a
tendency to rise.

Control Sera . •

Cases of general paralysis were also subjected to other sera
in order to test the specific character of our anti-sera.

Normal serum was obtained from each of the sheep prior to
the inoculations with bacilli, and this was injected in doses of

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TREATMENT OF GENERAL PARALYSIS, [Oct.,

20 c.c. into ten cases of general paralysis on more than one
occasion, without the slightest reaction.

Again, nine of the patients were injected each with 10 cc.
of polyvalent anti-streptococcic serum and no reaction traceable
to it followed.

The reactions resulting from the use of our anti-sera could
not be confounded with “serum disease,” since they do not
correspond to it, and they occurred only in the general paralytics.
Urticaria and occasionally accidental local inflammation at the
site of injection were the only reactions common to both the
general paralytics and the controls.

In conclusion we would say :

(1) That the anti-sera with which we have been working
produce reactions which are diagnostic of general paralysis or
tabes dorsalis ; they are probably due to the liberation of
endo-toxins.

(2) Cases of these diseases treated with the sera in most
instances undergo improvement.

(3) A polyvalent anti-bacterial serum is likely to be more

efficacious than either the mono- or bi-valent serum we have
hitherto used. #

(4) One of the chief obstacles in the way of obtaining a very
potent serum has been the loss of virulence in the strains of the
organisms used.

(5) There are grounds for believing that an anti-toxic serum
would be of use, especially for the immediate treatment of con¬
gestive seizures.

(6) Lastly, in view of the presence of dissolving bacilli in the
brain of the general paralytic, where in all probability they
produce extremely virulent endo-toxins, another aim should be
the production of a serum containing chiefly an anti-endo-toxin.

(*) Journ. Amer. Med . Assoc., June 29th, 1907.

Discussion,

At the Annual Meeting held in London, July 26th, 1907.

Dr. Clouston said he could speak of the clinical facts, and confirm Dr.
McRae’s results. He was for a long time a sceptic in regard to the cause of
general paralysis. He had run through the various views which were held during
the succession of the years, believing first that it was a progressive degeneration,
then that it was connected in some way with syphilis, as he believed still, and after
very great searchings of heart and observations of cases he came to the conclusion
that it undoubtedly was toxzmic in character, and that the toxaemia was bacterial
in origin. It was a very striking fact that in every case of general paralysis where

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1907-] BY W. F. ROBERTSON, M.D., AND D. MCRAE, M.B. 763

serum was used there was an effect, whereas in the control cases there was no
effect. Without being a bacteriologist he knew that was a clinical fact which
would require a good deal of explanation to dispose of. He understood Dr. Ford
Robertson and Dr. McRae were not in the position of imagining for a moment
that they had discovered all about general paralysis, but he believed they were
on the track of what might turn out to be a momentous discovery in regard to an
extraordinarily difficult disease. There was something dramatic in the very notion
that in studying this disease, in regard to which they had been hopeless from the
time it was discovered until now, at last a ray of light had risen above the
horizon. There was no doubt whatever as to the facts, and all would agree that
Dr. Ford Robertson and Dr. McRae had stated their case with manifest honesty,
with manifest care not to exceed the facts, and with a manifest feeling of responsi¬
bility as to what they were doing. And Dr. Robertson had been working at the
subject certainly for five or six years. Clinicians must leave a great part of the
subject to bacteriologists to decide. But the matter had a clinical side, and from
that side he was satisfied that a definite result had been attained by the serum
treatment; and there was every hope that further results would be got by the further
researches of Dr. Ford Robertson and Dr. McRae. There were considerable diffi¬
culties. It would not only have been dramatic, but miraculous, if they had
succeeded at once in curing general paralysis; but if they had established a
diagnostic method they had gone far in the study of the disease.

Dr. Mickle said he had not anything new to say on the subject. Reasoning on
the principles of serum therapeutics which had been for some years in vogue, he
devised a plan in his own mind, but owing to various causes, including illness, he
did not carry out anything in that direction. So he could only say it appeared to
him that serum therapeutics on general principles offered what might be expected
to be a reasonable ground of amelioration and of cure of that disease when it had
not gone too far. To cure an advanced case of general paralysis would be
impossible, because the brain and mind effects would remain when once the case
had advanced. A portion of brain once gone could not be fed, nourished, or
resume its function. He was only raising the question on the general principle of
serum therapeutics, which was applied successfully to other diseases.

Dr. Goodall said he had come for the purpose of hearing the contribution, not
to make any comment. He thought he understood Dr. McRae to say that the
injection of the serum into some patients who were not general paralytics caused
an increase in the polymorphonuclear leucocytes, and he had been wondering what
was the cause of that. The conditions described appeared to be remissions, and
even if they were prolonged remissions it was a considerable achievement, and
something to be thankful for. From the clinical point of view a strong case
seemed to have been made out, and he very heartily congratulated them on their
careful, conscientious, and honest work.

Dr. Dixon said he had heard that there were thirty or forty varieties of diph¬
theroid bacilli, and he would like to know whether cultivations of many or several
of those had been made. Also, whether any sheep had been immunised to other
diphtheroid bacilli than those referred to by the authors of the paper, and, if so, with
what results ?

Dr. Rows said he had had the pleasure several times of listening to demonstra¬
tions by the authors, and he had been glad to watch the gradual development of
their work which had been perceptible in the series of demonstrations. It seemed
to him that, in the case not only of general paralysis and tabes, but in the case of
various other diseases, they had been too prone to use the word “ toxic,” and to
rest satisfied there. He could appreciate the difficulty of the subject, but as the
toxin is of bacterial origin it must be appreciated that there must be some
focus in the body where the bacteria giving rise to that toxin were growing and
producing that poison. Dr. Ford Robertson had localised that organism in lesions
of the body and of the nervous system, and lesions had been found in sections of
the spinal cord corresponding to the organ in which the micro-organism was grow¬
ing. He thought there must be a close connection between the one and the
other; and he was very glad that by the production of that anti-serum Dr. Robertson
was obtaining a means by which the organism could be attacked in its focus.

Dr. Orr desired to add a word of congratulation to Dr. Robertson and Dr.
McRae regarding the results which they had already obtained. Some months ago,

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764

TREATMENT OF GENERAL PARALYSIS,

[Oct,

while he was in Edinburgh, the authors gave him the opportunity of observing
their cases, and he could endorse everything they had mentioned to-day. There
were remissions, and the condition markedly improved ; tremors of face, tongue,
and limbs decidedly less, and the pupillary symptoms improved also. He wished,
however, to point out one thing : that although there was a marked remission in
the symptoms it would be exceedingly interesting to observe how long that remis¬
sion lasted; because, as everyone was aware, remissions in cases of general
paralysis were very common events, and sometimes lasted a considerable time.
But Dr. Robertson and Dr. McRae would be able to apply that test and compare
their results with the natural remissions of general paralysis. Dr. McRae had just
stated that he had already sent some cases home. His own short experience was
that general paralytics who were sent home in a remission usually returned very
quickly, and in a very much worse condition than before. If the authors' cases
remained out a considerable time, and did not return in an acutely delirious con¬
dition, or in a markedly advanced state, they would have advanced considerable
additional proof in support of the idea that the remission was the result of their
injections, and that they were on the track of, at any rate, arresting the disease.

Dr. Mercier said that as he criticised Dr. Ford Robinson's work last time—
when he said he thought the verdict to be given was one of “ not proven ”—it was
only graceful that he should take the earliest opportunity of saying that the results
which had been brought forward that day rendered it necessary for him to re-con-
sider that opinion. Dr. Orr had spoken about the remissions in general paralysis.
Remissions did take place in general paralysis, but complete remissions, so far as
he knew, were confined to the very earliest stages of the disease. He had never
heard of or seen a complete remission occurring in so advanced a stage of the
disease as in some of the cases reported that day by the authors. And he could
not regard it as a mere coincidence that even partial remissions should have been
in the cases in which injections had been made. That a patient who had attained
to so advanced a stage in the disease that he or she had become bedridden, and the
knees contracted at an acute angle, that he had large bedsores, and that he should
then be so far improved as to get up and walk about, and go out into the garden,
and, after being mute for a year to be able to converse, was so extremely unusual
that it could scarcely be a coincidence that it occurred in a case in which injection
had been given, and it seemed to indicate that a real advance had been made in
the treatment of the disease. He wished to say that at once, because hitherto
he might have appeared to criticise somewhat ungraciously the very admirable
work which Dr. Ford Robertson had been doing, and that he had not appeared
to appreciate it at the value that he really did; because when there was a chorus
of praise it was natural to men to introduce a discordant note. But he thought
they could not resist the evidence which had just been brought forward.

Dr. Goodall desired to add a word to say that his experience in regard to
remissions in the disease did not accord with Dr. Mercier’s. He had seen cases in
a very advanced stage, in which cellulitis and sloughing had occurred, get up again
and be able to play at billiards, and walk about and generally exhibit a remarkable
return of motor power. Those cases were, he believed, as advanced as the ones
described by the authors, though in saying that he did not wish to detract from
the value of their results.

The President said he was sure he spoke not only for himself but for all those
who had attended that meeting when he expressed his gratitude to Drs. Ford
Robertson and McRae for their valuable work.

Dr. McRae, in replying on the discussion, said he would like to deal with one or
two points which had been raised. With regard to Dr. Mickle’s contention
as to the selection of advanced cases, it was necessary, in his opinion, to take
advanced cases because they must be genuine. If cure were pronounced in an
early case the obvious retort would be " the diagnosis was wrong.” It was true
that very advanced cases showed, post-mortem , such gross changes that regenera¬
tion was impossible. On the other hand, he knew it was a mistake to allow them¬
selves to form a judgment emphatically and everlastingly that all those changes
were irremovable; because often, in acute insanities, such as puerperal insanity,
one found post-mortem a degree of chromatolysis which was astonishing ,* and one
saw clinical cases which presumably had as much chromatolysis and yet they
recovered. They had no means of knowing for a certainty that the condition

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I9O7.] BY W. F. ROBERTSON, M.D., AND D. MCRAE, M.B. 765

under discussion was incurable. Dr. Goodall had asked why the leucocytes went
up in the control cases. If he (Dr. McRae) might put it reversely he would say
the leucocytes did not go up in general paralysis because one was putting some
substance into the patient’s blood which supplied something to the economy of
the leucocytes. On the other hand, in the case of control patients one was putting
foreign material into the blood, and presumably the leucocytosis occurred to get rid
of it. With regard to Dr. Dixon’s wish to know whether he and his colleague had
tried other diphtheroids in injecting sheep, he would say they could not go through
the group of diphtheroids in the short space of time during which they had been
working at them—twelve months. They had been using strains of bacilli which
had specific broth reactions, and they had used only bacilli which they had shown
by injection or by feeding to be toxic to rats and mice. It had been said that he
and his colleague were too ready to diagnose general paralysis at Morningside; but
he could say that anyone was welcome to see the cases at any time; there was more
than one member of the staff to examine the cases and Dr. Clouston confirmed the
diagnosis. Dr. Orr touched on what was, of course, the most important point in
the whole matter. Time alone would decide if they were to be successful in
pointing out the way to the cure of general paralysis. Dr. Bruce had asked him
to say that in the matter of control sera he had confirmed their observations. He
kindly gave anti-streptococcus serum, anti-coli serum, and anti-rheumatic serum
to cases of general paralysis, and none of them reacted. He wired to him (Dr.
McRae) for a couple of doses of anti-serum, which were sent, and both cases
reacted. He felt that Dr. Mercier had dealt most kindly with Dr. Robertson and
himself in his criticism. He trusted that the remissions which had occurred in
the cases would be prolonged. He was well aware of such remissions occurring,
even in so-called advanced cases of general paralysis.

Dr. Ford Robertson, in reply, said he desired to add one word. They
certainly wished that their results had been more successful than they were, but,
compared with the results of anti-serum treatment outside diphtheria, they showed
up very well. The author of a German paper the other day spoke with regret of
the small measure of success attending serum treatment outside anti-diptheritic.
They were only yet at the beginning of the anti-serum treatment. There were so
many things which there were still grounds for trying, and which they had reason
to hope would result in getting a more potent serum, that he thought they would,
in future years, revolutionise the anti-serum treatment. He thanked Dr. Mercier
for his appreciative remarks, and assured him he took his former criticisms as
kindly. He also thanked the President for his kind words, which would be a great
encouragement to Dr. McRae and himself in their future work. He drew attention
to the microscopical specimens on the table. In his Morison Lectures they asserted
positively that in the brain of the general paralytic, especially dying in a con¬
gestive attack, there were dead bacilli, which could not be grown, but which could
be seen by means of special staining methods. Formerly they used ordinary stain¬
ing methods, but now they had a special method, and found that in the dibris in
the cerebro-spinal fluid in a congestive attack there were myriads of dead bacilli.
If one took a sheep’s immune serum and digested in that some of the bacilli in
question they became altered, and had the same appearance as those bodies which
could be found in the centrifuged deposit of the cerebro-spinal fluid of the general
paralytic. They were finding brains in which those bacilli occurred in enormous
numbers. Two were under the microscope. For the demonstration of the dead
bacilli the metallic methods were useful. They had their own silver method, which
they regarded as an improvement. In the second specimen the platinum method
brought them out clearly as diphtheroid bacilli. If stained by the ordinary methods
one did not see them, because they were dead and no longer retained the stain.

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7t6 COAGULATION RATE OF BLOOD IN EPILEPTICS, [Oct,

The Coagulation Rate of the Blood in Epileptics . By
John Turner, M.B., Assistant Medical Officer, Essex
County Asylum.

The following is an account of a systematic examination of
the coagulation rate of the blood of nine female epileptics and
seven healthy women.

The great variability in the coagulation rate led me to
regard my former somewhat isolated observations (*) as by no
means conclusive in determining the relationship between
coagulation and epileptic fits. It is therefore satisfactory to
find that these results confirm my former conclusions, viz., that
in epilepsy there is a greater tendency for the blood to coagu¬
late and that this tendency is specially marked about the period
of fits.

The nine epileptics, with one exception, were chosen from
those who were, or had been, when not under the immediate
influence of their attacks, of average intelligence. Two of the
cases, although originally in this category, were now demented
from the long continuance of their disease. Eight were
healthy, one delicate and subject to bronchitis.

In five of the cases observations were made to test the
effects on coagulation of bromide of potassium, in three to
test the effects of citrates, and in three of a purin-free diet.

The method employed was that of Wright and Paramore (*),
but instead of taking up two or three samples of blood from
different pricks in the calibrated capillary tubes, putting them
all into the water heated to 37° C., and taking them out one
after another at different intervals to test for coagulation, I
have preferred the alternative method mentioned by them of
taking one sample at a time, and testing it at stated intervals,
e.g., the tubes were tested at 105, 120, and 135 seconds, and
if one was found to have coagulated at, say, 120 seconds, the
following would be tested at 115 seconds, and so on. On
account of the variability in the coagulation rate in the same
individual, I believe this latter method to be the more accurate.

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1 907-]

BY JOHN TURNER, M.B.

767

The method is one which requires considerable practice
before one can at all rely on the results, and this is a further
reason why I undertook a long series, during which many more
than a thousand samples were tested, to see how it would
compare with my earlier series.

Whatever may be the defects of the method, I believe the
results obtained, although they may not, strictly speaking,
represent the coagulation time of the blood within the living
subject, will at any rate be comparable, in as much as each
blood tested is exposed to similar sources of possible error.

As illustrating the very great variation in coagulation, it
may be stated that from three successive pricks in the same
individual on different fingers, the blood in both control and
epileptic cases often showed a difference in the time of over
two minutes, and in all my observations I only on three
occasions found the same coagulation rate in the blood from
three consecutive pricks.

Buckmaster (®) refers to the variability in coagulation rate,
and states that he is satisfied that on different days, at the same
temperature, it may, in the same individual, vary by at least five
to six minutes. The largest variation among my seven control
cases was two minutes twenty-five seconds.

The blood is not a simple solution, but contains multitudes
of organised elements which in all probability play an impor¬
tant part in the process of coagulation, so that according as
different samples contain more or less of these elements, so will
the rate be quicker or slower. On account of these variations,
to get a true mean I have examined the blood of each of my
subjects for at least fourteen consecutive days, taking on each
day three samples from three different fingers. The observa¬
tions were made between 11 a.m. and noon.

The systolic blood-pressure was taken in the sitting posture,
with Martin’s modification of the Riva-Rocci apparatus.

In the following table is given, both for the seven control
cases and the nine epileptics, the average for the fourteen days
of the samples which coagulated most quickly and most slowly.
Also the average blood-pressure and its greatest variations.

In all the charts the figures at the left hand side in the case
of the coagulation observations refer to seconds, in the case of the
blood-pressure to mm. of mercury. The continuous line repre¬
sents the coagulation rate, the broken line the blood-pressure.

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768 COAGULATION RATE OF BLOOD IN EPILEPTICS, [Oct.,

Controls.

Epileptics.

Coagulation time

Systolic blood-

Coagulation time

Systolic blood-

in seconds.

pressure in mm.Hg.

in seconds.

pressure in mm.Hg.

Average

quickest.

Average

slowest.

Average.

Varying

between.

Average

quickest.

Average

slowest-

Average.

Varying

between.

146

189

>33 I

148-118

2 l

>>7

160

102

99 - 1 "

147

178

116

> 34-105

120

160

102

90-115

l8l

1*1 I

136-IO4

127

>65

85-105

4 ,

148

>99

>>5 !

132->05

127

>55

102—122 ,

149

180

>42 ;

>56-125

> 3 *

162

IO8

92-120

>50

178

118

126-1IO

>35 ,

170

122

> 09-144

7 i

168

204

>>9

125-108

>36

170

III

90-123

5 .

> 5 >

185

117

102-129

1 '

>53

188

>47

I 25-I72

i ■

> 5 >

>33

1 This refers to the average of only nine days.

Three of the control cases were menstruating during the

Chart i.

Sho „ :he mean daily coagulation time in seconds of seven controls (upper

line) and seven epileptics (lower line).

period that their blood was being examined; in neither of them
did this seem to have any effect on coagulation.

The accompanying chart (No. i) shows very clearly the
greater rapidity of coagulation in the epileptics. On not one

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BY JOHN TURNER, M.B.

I907.]

769

of the fourteen days compared was the average rate in the con¬
trols so rapid as the average rate in the epileptics.

Further, the shortest period of coagulation recorded in the
controls in nearly 300 observations was 120 seconds, and this
only occurred on three occasions (once each in three different
nurses).

The shortest period recorded (from the finger) in seven epi¬
leptics was 105 seconds, whilst a rate of 120 seconds or less was
met with on thirty-three occasions (the number of observations
in the epileptics, from which this chart was constructed, being
the same as the number in the controls).

II.

Case i. —J. A. S—,aet. 27. Her fits date from early childhood;
she had, however, passed the sixth standard, and was two years
in one situation as a servant and five in another. When free
from fits she was a nice-looking, intelligent, well-dispositioned
girl, and her mental standard was above the average of her
class. From her own account she was at first subj'ect to
attacks both of the grand and petit mat type, but for the last
three or four years has had none of the latter. She says that
she used to feel worse after the attacks of petit mal than after
the attacks of grand mal . The number and order of fits
observed for the, nearly, four months that a record was kept,
viz., from December 30th, 1906, to April 15th, 1907, was as
follows:

January 5-6 . .5 fits.

„ 31-February 1

February 15
„ 20

„ 22-24 .

„ 28

March 6-7

„ 14

„ 21-22 .

April 7-9

1 fit.

2
2

2
7

fits.

fit.

fits.

fit.

fits.

During this period she had in all thirty-two attacks of
grand mal —eighteen when up, and fifteen when in bed.

Her bodily health was very good. She had a neurotic
palate. From December 30th, 1906, to January 12th, 1907,

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77 O COAGULATION RATE OF BLOOD IN EPILEPTICS, [Oct.,

daily observations were made on the coagulation rate of the
blood, the systolic blood-pressure, and pulse rate. She was
not taking, nor had she been taking, any drugs.

The average for the samples which on each day coagulated
the quickest was, for the fourteen days, 132 seconds, and for
the samples which were longest in coagulating the average
was 162 seconds.*

On January 5th she had four fits, the blood coagulated
quickly, and, although not so low as the day following, it
should be noted that there was a difference of only five seconds
between the slowest and quickest.

On January 12th she was ordered potassium bromide in
half drachm doses three times a day. On the 14th she had a fit,
and afterwards was sulky, irritable, depressed, and confused.
She had three fits on January 31st, and two on February 1st,
and showed profound and prolonged change in disposition.
The two following days she appeared like a drunken woman,
lying about on the floor with flaccid limbs and dilated pupils,
and spoke in a sulky, drowsy way. She then got a little better
and was able to do her work, but remained sulky, dull, and
sleepy. From February 1st to 12th inclusive her blood was
again tested. Coagulation was retarded but not to the same
extent as in some of the other cases; the minimum average
for the twelve days was 144 seconds. There was much greater
variation in the coagulation time of the different samples of each
day, so that the maximum average was 196 seconds. On February
12th, as she continued so much worse mentally and bodily, the
bromide was discontinued and she soon regained her natural
lively disposition and activity. A batch of fits succeeded the
discontinuance of the drug (see list). For seven days, from
February 25th to March 3rd, her blood was again tested, and
the coagulation rate had dropped to its normal figures, viz,,
minimum average 135 seconds, maximum average 167 seconds.
During this period, viz ., on February 28th, she had two
attacks of grand mat , one early in the morning at 1.50 a.m.,
the other in the evening at 8 p.m. and on that day there was
a marked quickening of coagulation (120 seconds) which was
maintained the next day, and then gradually became slower.

On March 4th she was put on a purin-free diet, consisting of
milk, eggs, cheese, butter, bread and rice pudding, with cab-

* Hereafter I shall call these two averages the maximum and minimum.

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1907-]

BY JOHN TURNER, M.B.

771

bages when served. She seemed brighter and better on this
diet, but there was no marked diminution in the number of fits,
although they did not seem to leave her so dazed afterwards.
She gained flesh, and was cheerful, active, and rational. Her
blood was tested again for the fourteen days ending April 13th
(the 10th omitted), and there was no marked retardation in its
coagulation; the minimum average was 139 seconds, the
maximum 171 seconds. On April 8th it was reported that she

had had three attacks of grand mal, the first at 4.45 a.m.,
the second at 5.45 a.m., and the third at 6.40 a.m., and whilst
her pressure was being taken she shot forward on to the floor,
upsetting the apparatus, and had a strong fit. So soon as
spasm had ceased her blood was tested; the first sample co¬
agulated in 105 seconds, the shortest time recorded in 141
occasions, the third in 135 seconds.

Her fits are all of this sudden character with no warning.
She falls as if shot. Such an absolutely sudden onset appears
to me difficult to reconcile with the idea of a toxin circulating

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772 COAGULATION RATE OF BLOOD IN EPILEPTICS, [Oct.,

in the blood as the immediate cause, but harmonises with a
thrombotic origin. The two ideas are not, however, neces¬
sarily antagonistic, for an effect of the toxin may be to render
the blood more liable to coagulate, in which case, although not
the immediate, it would be a co-efficient cause.

Blood-pressure for the first fourteen days (taking no drugs)
was on the whole rather low, its average being 108, only reach¬
ing 120 mm.Hg. on one occasion, and on one day falling to 95.
There was no appreciable effect on the pressure on the days
when she had fits, and on January 5th it was taken almost
immediately after one. During the period that her pressure
was taken whilst on potassium bromide there was on the whole
a slight tendency for it to rise. On February 1st the pressure
was taken whilst in a fit, before the convulsions had quite
ceased. Whilst on a purin-free diet the pressure, contrary to
my expectations, showed a slight upward tendency, and on four
occasions was above 120.

Pulse, as very generally found to be the case in these epi¬
leptics, was occasionally irregular. In the first period (no
drugs), it varied between 64 and 93, averaging for the fourteen
days 76. Whilst on bromide it varied between 70 and 98,
averaging 93, dropping to nearly the first average when the
drug was left off (79), and whilst on the purin-free diet again
slightly quickening, varying between 61 and 109, average 83.
On two occasions (January 4th and April 8th) it was counted
whilst in a fit, but just after spasm had ceased it was not
quickened (75) on one occasion, slightly quickened (99) on the
other.

In the chart, the upper dotted line shows the coagulation
time of that sample of the three taken daily, which coagulated
most slowly. It serves to show the very marked difference
found in successive samples of blood. I did not think it neces¬
sary to give this maximum period in the other charts.

Case 2.—F. N —, aet. 32. Her fits date from the age of fifteen
or sixteen, and are said to occur generally in the daytime, one
or two every week, and to be entirely of the petit mol variety.
Her eyes become fixed, she changes colour, clenches her teeth,
and dribbles saliva. They are over in a few seconds and she
never falls.

She was admitted in an acutely melancholic condition, with

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1907-]

BY JOHN TURNER, M.B.

773

a self-inflicted wound on the throat, which she did a week
previously because she “ felt so miserable.’* She is a delicate
woman subject to bronchitis, and has a very narrow and high
palate. Appears to be of quite average intellect, converses
rationally and sensibly, and tells me that after her attack she
generally feels relieved. Six days after admission had a strong
attack of grand mal 9 in which she fell down and bruised her
face. So far as can be ascertained this was the first attack of
grand mal she ever had.

From October 25th to December 1st she was taking £ drachm
doses of bromide of potassium, three times a day, and during
this period she had no attacks whatever, but continued in a
very depressed state.

On December 2nd, that is, immediately after a prolonged
course of bromide, observations were begun on the coagulability of
her blood and blood-pressure. The minimum average for fourteen
days was high, 156 seconds. During this period she had no defi¬
nite attacks of petit mal t but merely transitory sensations of
fulness across the nose, flickering at the heart, and a “ funny ”
smell (incomplete attacks). On December 16th she was put on
30 gr. doses of citrate of potash, three times a day, and on
December 30th the dose was increased to 1 drm. She had,
during this time, frequent attacks of petit mal. In spite of
the drug the coagulability of her blood was markedly quickened,
so that for the four days, from December 30th to January 3rd,
it averaged only 120 seconds.

On January 3rd she was again put on bromide of potassium,
30 gr. three times a day, and from this time the attacks were
much diminished in number. For the four days ending January
nth her blood was again tested, and still showed a short coagula¬
tion time, the average being only 115 seconds. The bromide
was continued, and when her blood was again tested for five
days, from January 24th to 28th, there was a marked retarda¬
tion in the coagulation time, the average being 161 seconds.

Her chart shows very strikingly not only that the bromide
markedly retards coagulation but also that this effect is lasting.
The first fourteen days represent the retarded coagulation,
which continued during the whole of this period, though she was
not then taking the drug, but had been for a long time previously.
Apparently the effects of the drug had worn off by the time the
second series of observations were made, for the fits had returned

li 11. 54

Digitized by v^ooQle

774 COAGULATION RATE OF BLOOD IN EPILEPTICS, [Oct,

in their usual, or even greater, frequency, and the coagulation
rate was much quicker. I believe that the reason why there
was no retardation of coagulation in the third series, after four
to five days’ administration of bromide, was because her system
was not saturated with the drug, for at a later period (fourth
series of observations) the retarding effect is again well marked.
Wright and Paramore ( 4 ) found that by the administration of

Chart 3.— F. N—.

citric acid, in three cases, it was possible within a week to very
materially retard the rate of coagulability of the blood, and to
keep it at this lower point for a month, but that after this time,
in spite of the continued exhibition of the drug, the coagulation
returned to its previous rate.

Hence I quite expected a marked retardation in the coagula¬
tion of her blood whilst taking the citrate, and gave it for that
purpose. This did not occur; in fact the rate was quickened,

Digitized by v^ooQle

1907.] by JOHN TURNER, M.B. 775

and during this period she was having many attacks of petit
mat.

List of fits during the time under observation :

1906, December 6.

„ 10.

„ 12.

14-

Aura (incomplete attack)

))

16.

2 attacks of petit mal.

17-

2 99

99 99

19.

3 »

99 99

21.

1 attack

99 99

28.

1 ,,

99 99

29.

2 attacks

99 99

30.

3 99

„ grand mal.

1907, January

1 attack

„ petit mal.

1 „

„ grand mal.

1 „

„ petit mal.

11.

1 „

99 99

23-

1 »

99 99

February

1 >,

99 99

15-

1 „

99 9

March

1 „

99 99

20.

1 „

„ grand mal.

April

1 „

„ petit mal.

No further attacks during April.

Blood-pressure was low and consistent, varying scarcely at
all for the first eleven days. It averaged 102 mm. for the first
period. Whilst on citrate of potash it was usually lower,
average 92, and again, when fully under the influence of
bromide, it returned to its former level, average 103.

Pulse was very irregular. Apparently the bromide tended to
quicken it, for it gradually slowed down in the first series
immediately after a course of bromide, and quickened again in
the fourth period when fully under the drug. A similar condi¬
tion was noticed in the previous case.

Case 3.—E. S—, a domestic servant. Her fits, entirely of the
petit mal variety, date from several years previous to her
admission here in 1904, when she would have been from nineteen
to twenty-three years of age. When first admitted was suffer-

Digitized by v^ooQle

776 COAGULATION RATE OF BLOOD IN EPILEPTICS, [Oct.,

ing from an attack of acute mania with auditory hallucinations;
this soon subsided and left her apathetic and lachrymose. She
has a typical epileptic disposition, disagreeable, quarrelsome and
religious, but is auseful worker in the ward, and of average intelli¬
gence. Has a neurotic palate. Has frequent attacks of petit
mal both day and night. Does not fall, but pulls things about in
an aimless fashion, e.g ., will pull off the cloth while having
dinner. On one occasion she spilled some water on the table¬
cloth (in an attack) and took soap out of her pocket and began
to wash the wet cloth. The following is the description of an
attack I witnessed: Said to me, “ I feel very funny,” and her
eyes became fixed; she was laid on the floor by the nurse and
there was a very slight, transient tonic spasm (?) of her arms.
After a few seconds she began to make clawing movements at
her dress, got up in a dazed fashion, picked up several objects
from the floor (some imaginary), rolled up some paper and
flung it into the fire, and brushed her dress down with her
hands. She did not micturate in this attack, although she
sometimes does.

At the time that her blood was being examined she was 29
years of age, in good health, and was taking no drugs. It coagu¬
lated slowly, the average for fourteen days being 153 seconds.
Nearly every day during this period she had at least one attack
of petit mal. It will be noticed that there was a gradual
quickening in the coagulation time from December 8th to nth,
on which day she had the maximum number of attacks (4), and
when her blood coagulated in 135 seconds, the quickest
recorded for this period.

On December 26th she began taking 40 gr. of potassium
citrate three times a day, which, four days later, was
raised to a drachm t.d.s. and continued daily until January
7th, 1907. While taking the drug she continued to have her
attacks much as usual. On January 4th, 5th, 6th, and 7th
her blood was again tested with the anticipation of finding a
retardation in its coagulability. This, however, was not found.
On no single day was it any higher than it had been when it
was tested formerly, and on one day it coagulated in 120 seconds
—a shorter period than had hitherto been recorded. The average
for the four days was 140 seconds. From January 7th to March
5th she was taking | drm. doses of potassium bromide t.d.s.,
and whilst taking the drug she had very few attacks of petit

Digitized by v^.ooQle

1907.] by JOHN TURNER, M.B. 777

mal of the usual description, but had frequent hysterical
attacks, when she would lie or fall down and scrape her feet up
and down on the linoleum and chatter her teeth, without any
loss of consciousness. She became very emotional and bad
tempered, listless and depressed, unable to do her work and
lost her appetite, so that the drug was discontinued. Her

Chart 4.— E. S—.

rt(i)4-^)>oNoo»-0 IT ST ~ ^ —

>4* L, vO r-

130

220

21 0

200

ISO

1 8 0

170

160

1 SO

1 a n

■

W&-

wmdm

■

*■

■

—

■

■■

■

■■

■

■11

■

□

■

■m

■

■u

■

■■

►1

■

■■

■

■■

■

□

■

iil

■■

■

»a

■

■■

■

■■

■

■■

1 *T v

1 3 0

1 20

110

■

>■

•

_L1

■

■tj

■

■■

■

ITift

■

□

Uft

■

■ft

■

■ft

PULSE

!2j

il«

il\1X

blood was tested on five days from January 27th to 31st, and
as usual the coagulation was retarded, in her case very
markedly, the average for these days being 185 seconds.

Blood-pressure .—This was the only case out of the nine
epileptics examined where the blood-pressure was distinctly
high ; its average was 147 mm. Hg. There did not seem to be
any definite relationship between its variations and the occur¬
rence of the attacks of petit \nal. Both during the adminis¬
tration of the citrate and bromide of potassium there was a
distinct lowering of the pressure.

Pulse was regular and quicker than normal. As in the case

Digitized by v^ooQle

778 COAGULATION RATE OF BLOOD IN EPILEPTICS, [Oct.,

of the blood-pressure it did not seem to vary with the attacks.
In her case there was not any acceleration of pulse-rate whilst
taking the bromide.

List of attacks of petit mal whilst under observation
(they occurred, with one or two exceptions, whilst she was up):
1906, December 3 .

»> 4 •

„ 6 .

» 7 •

„ 8 .

„ 9 •

» IO .

„ II .

„ 12 .

„ 14 •

„ 15 •

„ l6 .

M *9 •

„ 20 .

„ 22 .

>. 23 .

„ 27 .

,, 28 .

„ 30 •

„ 31 •

1907, January i .

„ 10 .

n 17 •

1907, February 5 .

No further attacks to March
discontinued.

1 attack.

1 „

4 attacks.

1 attack.

1 „

1 ,»

1 »

1 ,,

1 „

2 attacks.
1 attack.

1 > t

5th, when the bromide was

Case 4.—E. L—, was seven years old when she first had a fit.
When admitted twelve years ago was in good condition; a
nice-looking, bright girl, set. 17, with a kindly disposition,
not at all spiteful; in Standard III. She answered questions
readily, but her intelligence was that of an average child of ten
or eleven.

Said that she experienced a “ funny ” sensation in the chest
or a buzzing in the head immediately before a fit and then
lost consciousness. Said that her fits had been getting worse

Digitized by v^.ooQle

BY JOHN TURNER, M.B.

779

I907.]

lately, and that she felt very silly and lost after them. Neurotic
palate. Developed mild chorea from November, 1896, to March,
1897, but this disappeared, and her bodily condition greatly im¬
proved on cod-liver oil. In April, 1898, she menstruated for the first
time, and during that period had a series of attacks of grand
tttal. The post-epileptic condition was long and severe. She
laid on the floor of her room for days in a quite dazed and lost
condition. She continued to have series of fits at irregular

Chart 5. —E. L—.

■ ■

W»

©■

ift vo

■

'll

—

2.1 0

■

10 0

■

1 9 O

■

Eft

■

Kill

■

1 60

■

ft:

■

ft*

■

Fil

■

fro

! t

■

■ft

■

14. 0

■

130

■

1 4 0

■

1 00

■

■■

■

□

■

IBuSBi

l£l

[13

CBCII

tam

.am

LEC3K3

Lacrno;

The dotted line represents the coagulation time of blood from the ear.

intervals of a few months with similar prolonged post-epileptic
phenomena. When free from attacks was active, industrious,
and bright.

On January 13th, 1907, I began making observations on the
coagulability of her blood, her systolic blood-pressure, and pulse-
rate. She was then twenty-eight years old. Had not been taking
any drugs. Had had no fits for several days. She was in good
health ; her memory was now considerably impaired for past

Digitized by v^ooQle

780 coagulation rate of blood in epileptics, [Oct,

events, and she was childish, but of a kind disposition, and very
industrious.

Her blood coagulated quickly; for fourteen days the mini¬
mum average was 137 seconds, and, compared with most cases,
the difference between this average and the maximum was
small, e.g. 9 168 seconds. For the first seven days, duringwhich
she had no fits, the average was 143 seconds. During the next
seven days (a period of fits) the average fell to 130 seconds.

On January 24th she fell in a strong fit just before her blood
was examined. The quickest of the three samples of blood
drawn from the fingers coagulated at 135 seconds, but of two
samples drawn from the ear, immediately afterwards, the quicker
coagulated at go seconds (dotted line in the chart). Subse¬
quent examinations of ear blood, when she was free from fits,
showed that quicker coagulation was not a constant peculiarity
of this region. In the post-epileptic condition the blood was
examined on five days; there was a prolongation in the coagula¬
tion rate so that the average was now 139 seconds.

On March 13th she was put on potassium bromide} dim.,
t.d.s., and twelve days later, from 25th to 29th, her blood was
again tested and showed, as usual, a considerable retardation
in coagulating; the average for these five days was 153 seconds.

List of fits during time under observation :

January 20.

2 attacks

grand maL

21.

1 attack

»»

22.

3 attacks

23 -

1 attack

♦>

24 -

i »

25 -

2 attacks

29.

2 „

*»

3 1 *

2 M

February^

2 „

»*

3 -

i attack

9 -

2 attacks

10.

♦ ♦

11.

4 M

12.

— »>

13 -

3 >*

M-

»•

15 -

i attack

Digitized by v^.ooQle

1907.] by JOHN TURNER, M.B. 7 Si

February 16. 2 attacks grand mal.

March n. 1 attack petit mal.

„ 12. 1 „ grand mal (on potassium

bromide).

„ 13. 1 attack grand mal.

» * 4 * 1 >> »

„ 25. 1 „ petit mal.

The bromide, in her case, seemed to check the fits, but it
had a very deteriorating effect on her character. On April 21st
(after forty days’ administration) she was reported as having
“ gone quite silly,” had no energy, and acted like a person
slightly intoxicated, and her whole expression had altered and
become vacant. She was still able to do some housework.

Blood-pressure (systolic) varied between 123 mm. Hg. and 90,
average in ; the lowest readings were during the week in which
she was having a number of fits.

Pulse generally irregular; when free from fits it was fairly
constant, varying between 63 and 72. During the week of fits
it varied between 72 and 100, and whilst on bromide it was
also slightly quickened, varying between 81 and 90.

Case 5.—A. M. L—, aet. 20, has had fits since six months of
age. In fourth standard at school. When admitted in May,
1906, was in a dazed condition and was stated to have recently
been acutely maniacal. Tells me that she has not had a fit for
three or four weeks, and that now she generally goes a few weeks
without any, and that she used to have them more frequently.
She is thin but in fair health, and has a neurotic palate. After
a few months’ residence she was in robust health, very active
and industrious, of good disposition, bright and apparently of
quite average intelligence. She has an adenoid expression.
She now generally has a single attack of grand mal about once
a month and generally when getting up at 6 a.m. The fits
nearly always occur during her menstrual periods.

From January 13th to 26th, 1907, daily observations were
made on the coagulability of her blood and her blood-pressure.
She had not had any fits for several weeks previously, and was
taking no drugs. The rate of coagulation was slow, the
mimimum average was 151 seconds, the maximum 185 seconds.
She had an attack of grand mal during the night of the 14th-
15th, and on the two previous days her blood coagulated more

Digitized by C^ooQle

782 COAGULATION RATE OF BLOOD IN EPILEPTICS, [Oct,

quickly than on the two days following the fit, and the diffe¬
rence between the maximum and minimum the day before the
fit was very slight (5 seconds). On the 21st the coagulation
time was (for her) rapid (135 seconds), and during the night
following she had another attack of grand mal. On the last
day her blood coagulated more quickly than on any other
previous occasion (120 seconds); this was not followed by a fit.

She remained free from fits, and on February 2nd was
ordered drachm doses of citrate of soda t.d.s., and from

February 13th to 17th her blood was again tested, with the
result that no retardation in the coagulation was found, in fact,
the average for these five days was slightly below the average
of the first period, viz., 141 seconds for the quickest samples, and
174 seconds for the slowest. This is the third case in which I
have altogether failed to get any retardation of coagulation after
giving a citrate. The following is the list of fits [grand mal)
which she had whilst under observation:

January I3~i4th . . . 1 in the night.

„ 2i-22nd . . . 1 „ „ „

February 20th . - • 2 „ „ day.

Digitized by v^ooQle

«9°7]

BY JOHN TURNER, M.B.

783

March 20th .... 2 early in the morning.

April 17th . . . . 3 (2 during the day and

1 after going to bed).

Blood-pressure normal and consistent. The highest recorded
whilst not taking drugs was 129 mm. Hg., the lowest 102,
average 117. As in the other cases there were no variations
on the days following the two fits. Whilst taking the citrate
of soda her pressure rose daily from 104 to 140.

Pulse was frequently irregular.

This was one of the few cases where there was no general
quickening of coagulation, the average being the same as the
average of the control cases. Nevertheless there was a decided
quickening just prior to attacks of grand mol . I am inclined
to suspect that one reason for this slowness may have been im¬
perfectly oxygenated blood. The patient had some obstruction
in her nasal passage, probably adenoids, and was a mouth-
breather, and Sir A. E. Wright has established the fact that
excess of carbonic oxide in the blood hinders coagulation.
One must also take into consideration the rarity of her attacks
—seldom more than one or two in a month.

This latter probably is the more important factor, for in
another case recently examined, in which the fits were few,
only six or seven in a month, generally during menstruation,
the coagulation rate was slow, but was distinctly quicker during
periods of fits than at intervening times.

Case 6.—A. C— was first admitted in 1884, when 20 years
of age; a domestic servant; after a short maniacal attack
became a useful, active woman, but with a violent temper.
Probably of average intelligence for one of her class. Her fits
were frequent, both grand and petit mal , and she was
very bewildered after them. Discharged in July, 1889, re¬
admitted in May, 1890—maniacal. The following month had
nearly a hundred fits in forty-eight hours. Remained irritable,
passionate but industrious. Again discharged in August, 1891,
and re-admitted in June, 1906. Since 1892 has been in the
workhouse, her frequent fits preventing her from earning her
living. Was melancholic, intelligent, and industrious, except
after fits, which she generally has in batches, with frequent
attacks of petit mal . She says that she feels more stupid and
weaker after them than after the attacks of grand mal , and

Digitized by v^.ooQle

784 COAGULATION RATE OF BLOOD IN EPILEPTICS, [Oct.,

the bad effects last longer. She has sometimes an aura, a
feeling of giddiness with double vision, before her attacks.
Bodily health fair. Neurotic palate.

On December 30th I began testing the coagulability of her
blood and her blood-pressure. She was then in good health,
and taking no drugs.

Her blood coagulated quickly, the minimum average for
fourteen days being only 120 seconds, the maximum 160 seconds.

Chart 7.—A. C—.

< H- .MESiS-JlESiliiSICSSiSTiS

ll■l■■BBaBBBBBBBB^l(JBBBBBBflBBE*S“taaB

r* - 1 BBBBBBBBBB£MBBBBBBBBrt WHETail
^^^FU^^.^JBBBBBIHmBBBBBBBCEOSfrBBB

■■HHfimiHiiintiiiiiiiiik iirmi

■ BtlBBMHBB'lHBSBBBBBBLMWIffc ■■■
mrlllUirilllrtUIIIIIIIIEMRFIII
«-: '-IBDBUBBUBBMIlBBBriBBBBBBaBfcBBBMM
K - f * BUI^nUBBUBBBiaHBPBBBBBrCT<blElH
r ; « "BUB^BB^BBrlBBriVBBBaBflBBB^FT.irii-BVB

■' IlFIMBl.IIf ■■■■ililWltlLfcitJWll

—MIB^BBdBBBB^WiBBBB^Br.aBlifce&WriBil

■■BBBtlB.'IBBCBraflBBBBBHIB.^BBlf/BBB'iHia
BBUBBCB£BBB 4 BBBj iaBBBBr B « 5 f BBBB

■MMHBVBMBBBSBBBBaBBBBBBBBBaaBMI
VAVBBBBBBBBBBBBBBBBBBBBBB
i , ifii T iBBBaBBBBBBBBBBti*.'BB^Bafi
WainB’liriMPBflHR«ffi. , aBB>X«flBai

■MHHHVBrJI
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BUBnBklVBliB

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BBBBBl r .Bk T >BtV£XBBRBKXBBBBBtlBBBBBBBBBBB

iBaiaBSBassHiBS

icn^a Jiic 3 crm 3 i 3 TTQ 3 »zrr! _

There was a marked acceleration on January 6th (105 seconds)
and during this day she had four attacks of grand tnal and five
of petit tnal . Two days later her blood again coagulated at
105 seconds, but on this day she did not have any attack. For
the five days preceding a period of fits, the coagulation time
averaged 120 seconds, for the six days during fits it averaged 114
seconds, and for the three following days, during which period
she had only one fit (on the last day), it averaged 131 seconds,
showing an increased tendency to coagulate during the time of
fits. On January 12th she was put on \ drm. doses of bromide
of potassium, t.d.s., and from that date until March 8th, when

Digitized by boodle

BY JOHN TURNER, M.B.

1907.]

785

it was stopped, she had no more attacks of grand mal ,
although her attacks of petit mal were just as frequent.

The bromide did not agree with her; it made her listless,
drowsy, depressed and unable to do her work. From January
29th to February 2nd her blood was again tested, and there was
found to be a marked retardation in its coagulability, the
minimum average time for the five days being 150 seconds, the
maximum (four occasions only) 199 seconds. A month later it
still showed a considerable retardation, the minimum average
for five days being 144 seconds, maximum 178 seconds. With
the exception of two attacks of petit mal 9 March 14th to 15th,
she remained free from fits until April 16th. On that and the
two following days she had ten attacks of grand mal, and
from 26th to 29th inclusive, five attacks. She had been put
on a purin-free diet on April 6th. The minimum average
coagulation time for a period of eleven days, April 23rd to May
3rd, was 132 seconds, somewhat slower than with ordinary
diet, although the fits continued much as before. As usual a
period of quickening in coagulation corresponded to a period
when she was having fits, followed by a return to a slower
rate; this is extremely well shown in the last section of her
chart.

The drop is not so marked as in the first chart, from January
6th to 9th, when she was, however, having a greater number of
fits [grand and petit mal).

The following is a list of her attacks whilst under observa¬
tion from December 1st, 1906, to May 3rd, 1907:

Decembei

4 -

4 attacks of grand mal.

7 -

1 attack „

2 attacks „

January

4 -

4 99 99

petit mal.

5 99 99

7 -

5 99 99

12.

1 attack „

grand mal

13 -

2 attacks „

petit mal

20.

1 attack „

Bromide of

25 -

1 99 99

potassium,

26.

^ 99

i drm.

27.

3 attacks „

t.d.s.

February

1 attack „

3 attacks „

Digitized by v^.ooQle

786 COAGULATION RATE OF BLOOD IN EPILEPTICS, [Oct,

February 14.

i attack of petit mal .

Bromide of

19.

* 99 99

„ > potassium,

March

2 attacks „

„ J £ drm., t.d.s.

14.

1 attack „

! 5 -

^ 99 99

April

16.

7 attacks „

grand mal .

17-

1 attack „

18.

2 attacks „

26.

1 attack „

On a purin-

27.

2 attacks „

free diet.

28.

1 attack ,,

29.

2 attacks „

30.

2 n 99

(slight),,

No further attacks.

Blood-pressure .—For the first period (taking no drugs) varied
between 90 and 115, the average being 102 mm. Hg. Whilst
on bromide it fell slightly, varying between 96 and 107, the
average of 10 days being 100 mm. Hg. Whilst on a purin-
free diet it averaged 106. The pressure curve was much more
regular whilst taking bromide, and whilst on the special diet
than it was during the first period.

Pulse .—Frequently irregular. For the first period it varied
between 69 and 96, average 81. Whilst taking bromide it
varied between 69 and 85, average 78. When on a purin-free
diet it varied between 79 and 92, average 85.

Case 7.—H. R. S— has been subject to fits since the age of
twenty-three, and, according to her statement (which is borne
out by our experience here), they occur chiefly in the day-time,
are chiefly of the grand mal type, and she rarely has more
than two in a day. She has intervals varying from a week to
three or four months free from fits. She was in the fifth standard,
was in one situation, at £12 a year, for five years, and after
leaving that on account of her fits, assisted her sister—a dress¬
maker. She became melancholic and hypochondriacal and
was sent here, where she soon developed into a valuable
needle-woman of quite average intellect. She was querulous
and spiteful immediately after fits for a short time. Bodily
health fair, palate normal.

On March nth, 1907, I began to test the coagulation rate
and pressure of her blood. She was then 34 years old, and had

Digitized by v^.ooQle

1907 ] by JOHN TURNER, M.B. 787

been taking no drugs. The minimum average time was 135
seconds, maximum 170 seconds.

On March 15th, about ten minutes after her blood was
tested, she had an attack of petit trial. The coagulation time
was rapid, 120 seconds, rising the next day to 150 seconds, but
on the 17th, a few hours after an attack of grand mal 9 it again
quickened—135 seconds. It kept at much the same level until
the 23rd, when, whilst her blood was being tested, she had an
attack of grand mal, and there was again found to be an

acceleration in coagulation (120 seconds), which was main¬
tained on the following day.

She was put on purin-free diet on April 6th, and continued
to have fits much as usual.

The average rate of coagulation was quicker, minimum 130
seconds, maximum 166 seconds, than when on her ordinary
diet. On April 28th, just before an attack of grand mal , it
fell to its lowest limit and remained at the same level the
following day, rising on the 30th to 150 seconds. On May 3rd,
an hour before the observations were taken, she had an in¬
complete minor attack characterised by a “ nasty ” feeling and

Digitized by v^ooQle

788 COAGULATION RATE OF BLOOD IN EPILEPTICS, [Oct,

a fluttering at the heart; again there was found to be a
quickening in coagulation—120 seconds.

Blood-pressure .—For the fourteen days on ordinary diet it
varied between 109 and 144, averaging 122 mm.Hg. The curve
was very irregular. During the nine occasions it was registered
whilst on a purin-free diet it dropped considerably—its average
being no mm. Hg. and the variations between 122 and 98.

Pulse .—Sometimes irregular. There was remarkably little

Chart 9.—J. P—.

-O t- <* O- O

ISO
1 7 o

I 6 0
1*0
I 4 o
I 3 0
f 1 0
I l 0
I 00
0 O

Z 0

PUlSi

Ofl I0'7 * njUXT+IHUt—CH* jo

difference in the rate from day to day whilst on ordinary diet,
the extreme variations being 82 and 93, the average 88. The
daily rate varied more from 75 to 92 whilst on a purin-free diet,
and the average was 82 for the eleven days.

Case 8.—J. P—, set. 47. Is now demented, the result of
long continued epilepsy. Was formerly a weak-minded woman,
but capable of being usefully employed. Her fits are of the
grand mal variety, occur singly, and she has one nearly every
day, sometimes missing two or three days. She is in fair health
but thin; is taking no drugs.

The coagulation time of her blood is short, the minimum
average for fourteen days being only 127 seconds. On December

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1907]

BY JOHN TURNER, M.B.

789

18th, preceding an attack of grand mal at 8 p.m., the coagu¬
lation time fell to 105 seconds. On the 20th it was again low—
115 seconds, and on the 21st 120 seconds, and about half an hour
subsequently she had a fit. There was a considerable retardation
in the coagulation for four days in spite of a fit on the 22nd. On
the 26th she had a fit from which she had not completely
recovered when her blood was tested ; coagulation was rapid,
occuring in 110 seconds. The next day there was some retarda¬
tion although she had a fit at 5.20 p.m., and again on the 29th the
coagulation remained at the same level although her blood was

Chart 10 . —G. J. W—.

■

180

170

1 60

1 SLO

■

!■

!Ai

■

!■

nn,

□

■Ml

■

‘S'

■

■H

■

.if!

■

■M

■

■U

14 0

■

■11

13 0

■

K 1

■r]

■

■■

1 1 0

■

w:a

■

■■

1 I 0

■

■■

1 0 0

■

■;

□

■1

■

■!

■

□

8 0

■

■I

■1

—

IsgHatDcaiUinmamgjmmtagg:

tested shortly before another fit. It will be noticed in her chart
that the longest period without fits, viz ., from 9.30 a.m. on
December 22nd to December 25th, coincides with the greatest
retardation of coagulation.

Blood-pressure was low and somewhat variable. The highest
recorded was 105 mm. Hg., the lowest 85, average 96.

Pulse was very irregular. It varied between 70 and 88 except
on the 26th whilst in a fit, when it was 100.

Case 9. —G. J. W— was a domestic servant, set. 23, when
admitted, and it was stated that she had only recently
liii. 5 5

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790 COAGULATION RATE OF BLOOD IN EPILEPTICS, [Oct.,

developed epilepsy. Was in an acutely maniacal condition
with short remissions for the first ten months after admission,
having frequent attacks both of grand and petit mal (day and
night), but the fits were usually worse at the menstrual periods.
Subsequently her attacks of excitement got shorter and less
frequent, and when free from fits she was an active, indus¬
trious, fairly intelligent woman. During periods of fits she
generally had a marked trace of albumen in her urine, and
developed a transient, bright red petechial eruption on face,
chest, and sometimes on arms and legs.

Now her fits are of the grand mal type, occurring at intervals
of a few days. She is thirty-four years of age, and is in good
bodily health, an industrious woman, but irritable, and some¬
times violent.

Her blood was examined on thirteen occasions from
December 16th to 29th. The average rate of coagulation was
quick, only 127 seconds; during this period she had four
attacks of grand mal, but none, with the exception of the last,
occurred immediately before or after the times of examination.
Two of the attacks coincided with periods of quickened coagu¬
lation, two with periods of slower coagulation.

Blood-pressure somewhat low, the average being no, and
varying between 102 and 121.

Pulse irregular.

III.

These observations confirm my previous ones, and show that
as compared with persons in good health the blood of epileptics
coagulates in a shorter time, and also that this is more marked
just before or during fits than when the patient is free from
them. ( 6 )

Against the supposition that this phenomenon is merely the
result of fits is the fact that it frequently was found to occur,
immediately or several hours, before the onset of one: eg., in
Case 8 the shortest period of coagulation was on December
18th, eight hours before an attack of grand mal ; again it was
rapid on December 21st, half an hour before a fit (120 seconds).
In Case 5 the blood from December 19th to 21st showed a
progressive quickening in coagulation, which was succeeded by
a fit in the night of December 21st. In Case 7, on March i6th.

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1907]

BY JOHN TURNER, M.B.

791

the quickest coagulation time (120 seconds) occurred ten minutes
before an attack of petit tnal , and on April 28th, a quarter of
an hour before an attack of grand ntal , the same quick rate
was recorded.

It must be borne in mind that the tendency to coagulate
varies, not only from time to time, but in different parts of the
body, so that although the blood from the finger about the time
of a fit may not always coagulate with special rapidity, it by
no means follows that elsewhere in the body the rate of coagu¬
lation is not quicker. This is shown in Case 4: on January^th,
during a fit, whilst the blood from her finger took 135 seconds,
the blood from her ear took 90 seconds. Nevertheless, the
observations show that in the majority of cases, although blood
drawn from the finger at the time of a fit may not represent a
sample of that which coagulates most rapidly, there is at these
periods an increased tendency to coagulation throughout the
whole haemal system. On six occasions the patients had fits
whilst being examined. In every case the rate was relatively
quick, in four it was markedly so, in one, although quick,
slightly slower than the day before, and the sixth is the case
just referred to where blood from the ear was tested.

From my point of view it is not essential, in fact it is highly
improbable, that in every case a specially quick rate should
correspond to the time of a fit; the reverse of this condition is
the more important—that a fit should coincide with a time of
rapid coagulation. It does not follow that because the tendency
is increased that, therefore, coagulation must occur; what
immediately determines this phenomenen is outside the scope
of this paper. In my opinion it is in this connection that we
have a means of harmonising the thrombotic and the toxic
theory of epilepsy, by attributing this idiosyncrasy of the blood
to a toxin, which, when it reaches a certain intensity, excites
local coagulation. An interesting point which these observa¬
tions show is that, not only during or before attacks of grand
mat , but also attacks of petit mal, the coagulation rate is
quickened; this is shown in Case 3 and especially well in Case 7,
where, on March 16th, the rate was 120 seconds—the shortest
time recorded in her case—and almost immediately afterwards
she had an attack of petit mal . On the 22nd the rate was
quickened during an attack of grand mal , but no more than
before the attack of petit mal . After the major fit, however,

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79 2 COAGULATION RATE OF BLOOD IN EPILEPTICS, [Oct.

there was a longer period of quickening; for the next day the
rate remained the same.

Bromide of potassium has a retarding effect on coagulation.
In all five of the cases tested in this connection this effect was
noticed, and it would appear as though it was in those cases
where it had the most marked effect in preventing fits that it
retarded coagulation to the greatest extent (see Cases 2
and 3), whilst in the case where it had little effect on the
fits there was much slighter retardation (Case 1). The
two cases (Cases 2 and 6) show that its effect on the blood
continues so long as the drug is being taken, but apparently is
not manifested until the system is saturated.

Lauder Brunton (®) states that Albertoni found when bromide
was given for several weeks together to dogs, the excitability of
their motor centres was so diminished that it was almost
impossible to produce epileptic convulsions by irritation of the
cortical substance. Thus it w f ould appear as if bromide acts on
both the nervous and vascular systems, not only lowering the
excitability of the nerve-cells, and raising their threshold of
stimulation, but also retarding the tendency of the blood to
coagulate; and from my point of view that the immediate
cause of fits is local cortical stasis of thrombotic origin, we
should have in this twofold action the explanation of the very
beneficial effects of the salt, in diminishing or stopping
epileptic fits.

After the administration of citric acid Wright and Paramore
found that within a week, and for a further month, coagulation
was retarded and then returned to its former level. Although
the blood of the three cases to which I administered a citrate
was tested within the specified limits, it did not show any
retardation in coagulation in a single case, in fact in two (who
were however at the time having fits) there was acceleration.

The purin-free diet appeared to have a very slight effect; in
one (Case 6) there was some retardation, and it did not in any
of the three cases appear to diminish the number of fits. Of
course I am only speaking as to its effects on these three cases,
and during this somewhat limited period. Both the number
of cases and the time under observation were much too limited
to arrive at any general conclusion. W. Aldren Turner ( 7 ), who
instituted a series of observations at the Chalfont Colony, with
a view to testing the efficacy of this form of diet in confirmed

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1907.] BY JOHN TURNER, M.B. 793

epilepsy, found that with it there was a lessening in the severity
and frequency of the convulsive seizures, more especially when
these occurred in series, but that it had no effect on the minor
seizures.

My results, it will be seen, are diametrically opposed to
the views of Silvestri ( Gazz . degli. Osped., January, 1907), who
holds that epilepsy is due to a diminished percentage of calcium
salts in the blood, and who quotes some researches of Besta to
the effect that in thirty-seven out of forty-five epileptics the
blood serum showed a coagulation power inferior to the normal.

Blood-pressure .—There is, according to different observers,
a very considerable latitude in the range of what constitutes a
normal blood-pressure. In my opinion a systolic pressure vary¬
ing between no and 130 mm. Hg. represents very fairly the
normal limits. At any rate, although a lower one may be com¬
patible with health, I should regard as suspicious one over
130 mm. Hg., that is to say if it was at all persistent, but an
occasional rise of over 130 mm. is very common in persons with
an average low tension. According to this standard two of my
control cases and one of my epileptics had high pressures, five
controls and four epileptics a normal, and four epileptics a low
pressure. As epilepsy is so prevalent in imbeciles, and as one
of the commonest stigmata of degeneration is a small, ill-
developed heart, these results, among that class, are what
might have been anticipated. Except that I found in general
an extremely irregular curve, not more so, however, than is very
commonly the case in insanity in general, and that it was not
modified by the number of fits, my results do not coincide with
those recently obtained by C. Besta( 8 ), who found the pressure
to be raised in 63 per cent, of the epileptics he examined.

What relationship is there between the coagulation rate and
the blood-pressure ? It would naturally be expected that a low
pressure would favour rapidity of coagulation and vice versa , and
broadly speaking, this was found to be the case.

Thus in the seven controls in which the pressure was con¬
siderably higher than in the epileptics (with one exception), the
coagulation rate was considerably slower. In the one epileptic
with high pressure coagulation was slow. But there were many
exceptions to the general rule: e.g, 9 among the controls the
degree of retardation was not in proportion to the height of
blood-pressure, and the case in which coagulation was quickest

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794 COAGULATION RATE OF BLOOD IN EPILEPTICS. [Oct,

had the highest but one blood-pressure, and that in which
coagulation was slowest had a relatively low blood-pressure.
So with the epileptics, although, as I have just mentioned, the
one with the slowest average rate had the highest blood-pressure,
the one with the next to slowest average had a pressure only of
117 mm. Hg. Although the epileptic whose blood coagulated in
the shortest time (Case 2) had a low pressure, when she was
under the influence of bromide her coagulation rate was more
retarded than in any other case, without any corresponding rise
of blood-pressure. Again, in Case 6, whilst taking bromide
the pressure dropped slightly, whilst there was at the same time
a marked retardation of coagulation.

Of the five cases to which bromide was administered the
blood-pressure fell in three, in two very slightly, in the third
considerably (Case 3); in one it rose very slightly. In the fifth
the observations were not made at a sufficient time interval
from taking the drug to allow of any conclusion being formed.
In two cases the curve of pressure was much more regular
whilst taking the drug.

In the three cases which were examined whilst on a purin-
free diet, there was a slight rise of pressure in two, a fall in one.

Pulse in some cases was slightly quickened during or
immediately after a fit, in others not modified at all. It was
extremely common to get an irregularity in the rhythm, a
phenomenon observed at some time or other in all the cases.

The general result of both my series of observations on the
coagulability of the blood in epileptics has convinced me that
there is a close relationship between rapidity of coagulation
and the occurrence of epileptic attacks—a relationship, I
believe, of cause and effect—hence a search for a drug which
will permanently retard coagulation without having such power¬
ful and deleterious effects on the nervous system as bromide,
seems well worth pursuing. I believe that with such a drug at
our service we should have a valuable means towards con¬
trolling the fits and ameliorating the general condition of many
epileptics.

( l ) Journal of Mental Science, January, 1907.—(*) Lancet, October 14th, 1905.—
( s ) The Morphology of Normal and Pathological Blood, London, 1906.—( 4 ) Lancet,
October 14th, 1905.—( s ) Speaking generally, the greater the frequency of fits in a
case, the quicker is the average coagulation rate.—( 8 ) Text-book of Pharmacology ,
London, 1885.—(") Epilepsy, London, 1907.—( 8 ) Riv. Speriment di Freniat, vol.
xxxii; abstract in Journal of Mental Science, April, 1907.

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1907-] INFERENCE OF LOCAL DEGENERACY.

795

The Inference of Local Degeneracy from a Comparison
of the Vital Statistics of the People Q). By C. S.
Morrison, L.R.C.P., Medical Superintendent, County and
City Asylum, Hereford.

Public opinion of late days has been very forcibly directed
to the question of degeneracy, and in this county the increase
of the insane, with a decreasing population, has long been
awaiting some attempt at an inquiry and elucidation. I
propose, therefore, to briefly place before you a few facts,
supported by statistical figures, which represent some of the
many facets of this highly complicated question.

In industrial and social evolution, as with all evolution affect¬
ing matter and form, the trend of development is to proceed along
lines of least resistance. The stress of necessity brings into active
operation latent forces which finally overmaster the resistance
and allow other forces in their turn to become effective. The
desire for a larger holding of corn gave this country free trade,
but it was largely the means of reducing the area of its cornfields
and of shifting the balance of its population from the land into
cities.

The corn harvest from “ free trade ” and the shrinkage of
agriculture is but the industrial picture of that law which
ordains that the simpler economy cannot develop into the
more complex without casting aside the elements of simplicity
in the parent.

The inherent weakness of the simpler is also here made mani¬
fest by the power with which the more highly organised forces of
political and social economy have devised means to secure
and maintain the higher life of a people and build up their
national assets.

In time it also tends to transform the national life, and as
this life rises higher in the plane of ethical, social and material
standards the organic forces by which the changes have
been created for ever keep changing and advancing, to
support the ideals generated from the older and simpler
forms.

The outcome of complex operations, as we know, serve more
fully and profitably the wants of a complex organism, such as
our national life has become, but it may starve the weaker

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796 INFERENCE OF LOCAL DEGENERACY, [Oct.,

representatives of the same organism in effecting salutary
changes.

Agriculture is no longer made the standard of our civilisation.
It is sometimes referred to as its supplement. The hum of the
wheel, the thud of the engine, the laboratory of the chemist,
and the glow of blast furnaces have each and severally
supplanted, in their own way, the work and labour of the guile¬
less ploughman, the effort of the expectant sower, and the
hopeful anticipation of the reaper.

The accumulated prosperity of the nation, except as its
ornamental pendant, is no longer summarised in the possession
of herds, the extent of broad pastures, or the acreage of corn¬
fields, but by the number of its factories, the extent of its coal
measures and other mineral wealth, and the area of inhabited
houses.

Yet the factory and the workshop are but the differentiated
and developed outcomes of the labourer and the husbandman
in the fields. This change has also removed the balance of popula¬
tion and the balance of prosperity from the land into cities, and
has created problems of a social, moral and economic order of its
own, and resembling in many others the problems attaching to
the land and its agricultural community. The latter, in a sense,
is linked by a long chain to the former, and towed in its wake as
a sub-continent. In short, the advance of science and free trade
has led away from the land the more competent, physically
strong, and mentally balanced labourer towards the factory
and workshop, and has left behind the relatively less fit, both
physically and mentally, to populate and work the land.

The “decadent” is seen in rural areas and agricultural
communities in clearer perspective when viewed in the light of
vital statistics. Here, as elsewhere, life is ordered not logically
but psychologically, and the brain, as the central battery of its
intrinsic constitutional energy, orders and shapes the functions
of life. It is the seed from which the plant “ success ” is grown,
and the fertility of the soil and the vigour of the plant
determine the measure and quality of the success it will
achieve.

The standard by which the nation gauges its political and
industrial success is measured by the Chancellor of the
Exchequer in his financial budget. The standard of national
success in health—moral and physical—is measured in the

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1907 .]

BY C. S. MORRISON, L.R.C.P.

797

budget of the Registrar-General, and therein we find the balance
or deficit in terms of vital statistics. It is to the question of
these vital statistics that I desire to draw your attention as one
of fundamental importance to the mental and physical health
of the people of this county, which represents, perhaps better
than any other in England and Wales, a typical agricultural
community, burdened with many economic problems pressing
for solution and awaiting the discovery of a remedy to deal
with the malady of rural depletion.

Physical features of Herefordshire. —Nature in her bounty has
done all she could to enhance its fertility, to beautify its land¬
scape and bring health and prosperity to its people. The soil
has derived its characteristic richness and fertility from the
disintegration of red marls and limestone. A plenitude of
rivers and brooks trace their sinuous outlines along extended
cornfields, teeming orchards and expansive meadow lands, while
valuable timber skirts their courses and the heights above.

It is stated that the agricultural produce of Herefordshire
is of a more general character than that of almost any other
county. It has been famed for its cider and perry for centuries
past. Sheep farming has been prosperous with its breed of
Ryelands, and the outstanding speciality of the county has for
long years been its cattle. Speed, in his history of this county
published in 1610, says : “ This countys climate is most health¬
ful and temperate and soyle so fertile for corn and cattle that no
place in England yieldeth more or better conditioned.” The
longevity of the people is proverbial—the story of a Morris
dance performed by five old couples in the presence of James I
whose combined ages amounted to over 1000 years is a historic
legend of the county.

Population. —From Chart I it will be seen that the popula¬
tion of the county at each recurring census since 1801 has
shown a steady increase, reaching in 1861 an increment of
7 - 1 per cent, and falling to 1*4 per cent, in the following decen-
nium.

From 1871 forward it will be noted that the small increase
above shown actually decreased by 33 per cent, in 1881, and
again in 1891 and 1901 showed a further decrease of 4*4 and
i # 4 per cent, respectively for each of those census years. The
decrease in the enumerated population of 1901 and pro rata
decrease up to 1905 compared with that of 1871 only amounts

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798 INFERENCE OF LOCAL DEGENERACY, [Oct,

to 12,422, a number which on the surface appears inconsider¬
able and from which no issues of a serious character could be
deducted. What, however, is of greater relative importance
than the mere decrease in the enumerated population is the
number which contributed to .the decrease by migration.
When we add the difference between birth and death rates in
each intercensal period commencing about the latter half of
the last century, and the several enumerated decreases at each
subsequent census, we get the large total of 90,000 persons who
have emigrated. This decrease by migration is not equally
spread over each decennium, but probably the largest was
recorded between the years 1861 and 1881.

Chart I .—Total Estimated Population of Herefordshire at each
Successive Census, with an Increase or Decrease indicated in
Margin per 100 of Population .

Year.

Population.

Increase +
Decrease -

1801

88,436

—

1S11

93,526

• + 57

1821

102,669

• + 97

183*

110,617

• + 77

1841

113,272

. + 24

1851

>15489

* + i*9

1861

I23JI2

• + 7*i

1871

125,370

• + i '4

1881

121,249

• - 3*3

1891

” 5.949

- “ 4*4

1901

114,380

• - i *4

1906

112,948 (Estimated)

. — I‘2

The character of the migrating population will be readily
admitted to have been adults, strong, self-reliant, and with a
greater capacity to cope with the changed complex of our social
economy, introduced by the advancement of science and the
use of machinery.

Comparing the character of the emigrant with that of the
left-behind, one is compelled to recognise the possession in the
former of a larger degree of independence, courage, zeal, and a
spirit of adventure. The stay-at-home, on the contrary, by
comparison is a person of inertia and apathy and gifted with a
lesser capacity for sustained effort. We know every intelligent
effort is educative, and concerted effort is the lever that moves
mountains. A people unequal to making this effort must have
inherent adaptive deficiencies, and their weakness must begain-

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BY C. S. MORRISON, L.R.C.P.

1907 .]

799

ing in every succeeding generation fresh momentum which
will mirror itself in vital statistics.

Marriage rate. —The position of Herefordshire in this matter
I consider unique. Whereas all counties in England and
Wales except four show a decrease in the average for thirty
years, Herefordshire alone remains stationary. This is shown
in Chart II. The construction I am inclined to put on the
circumstance is this: that none of the reasons which are
recognised, or at least assigned to operate more or less among
other industrial, educated and leisured classes, severely exercised
a prohibiting influence on the marriageable population of this
county. Further, that the persons themselves were content
with a lower standard of living and had in a lesser degree the
sense of responsibility in the upbringing of their family. This
may also partly account for the well-known fact of Hereford¬
shire having the highest rate of pauperism in England and
Wales. The decrease in the marriage rate for England and
Wales is shown to be i^g per cent, as against an unaltered rate
for Herefordshire as shown in the Chart.

Birth rate (legitimate).—Before considering the actual figures
I would draw attention to the very important table shown
in the Registrar-General's Sixty-eighth Annual Report , in which
he embodies an analysis of the fertility of married women in
urban and rural areas. He states that it might be inferred
from the table showing “ Mean Annual Fertility Rate of
Married Women, per 1,000,” that in urban areas it is greater
than in rural areas, but this is disproved when the fertility of
married women is considered and compared at similar age
constitutions for urban and rural areas. The converse, there¬
fore, holds good, particularly at ages ranging from thirty-five to
forty-five years. Speaking generally, the fertility of women at
conceptive ages, viz., fifteen to forty-five years, living in the
country is from 8 to 11 per cent, greater than that of women
living in towns, and the comparatively greater fertility in rural
districts is not due to differences in the proportion of married
women. Furthur, the greater fertility in rural districts would
be much more enhanced if the age constitution of the married
women in the two areas were nearly alike. But the continuous
migration of young persons from rural to industrial areas has
considerably depleted the normal proportion of young married
women in the rural districts. In England and Wales the

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8oo

INFERENCE OF LOCAL DEGENERACY,

[Oct.,

legitimate birth rate has fallen from 292*5 per 1,000 of married
women in 1870 to 223 per 1000 in 1905. In Herefordshire for

Chart II.— Mean Annual Marriage Rates per 1000 of the Un¬
married and Widowed Population at. 15 and upwards.

the same periods the legitimate birth rate has fallen from 285*5
to 223*5, showing that the fertility rate of Herefordshire as a
rural area is considerably below what is the normal rate for all
rural areas. The assigned causes for the national decrease in

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• 9 ° 7 -]

BY C. S. MORRISON, L.R.C.P,

801

Chart III .—Mean Annual Fertility Rates of Married Women
C Legitimate Births) per 1000 Married Women at. 15-45.

Digitized by v^ooQle

802 inference of local degeneracy, [Oct,

Chart III {continued).—Mean Annual Illegitimate Birth Rates ,
1870-1905. Illegitimate Births to 1000 Unmarried and
Widowed Females, cet. 15-45.

1870-72.

1880-8 a. 1890-92.

1900-02.

1903 .

1904.

1905.

England and Wales
Herefordshire

. 17*0
. 21*4

Three year periods.

141 io*5

19*0 13*4

11 ‘2

8*4

ii*8

Years.

113

8*2

114

the birth rate, viz., greater luxury, changes in the social and
economic conditions of the people, and deliberate restriction of
child-bearing, can not be made to apply, except in a very
limited measure, to Herefordshire as a rural area.

The decrease must have, therefore, as a cause a strong endo¬
genous basis in the persons themselves. England and Wales
in thirty years shows a decrease of 19*5 per cent, in the legitimate
birth rate, whereas Herefordshire 177 per cent., thus showing a
very small difference where a much larger in favour of Hereford
was to be expected {vide Chart III).

Infantile mortality (Chart IV).—Closely connected with birth
rates is infantile mortality, and this interdependence, as you
are aware, has lately received much public attention. The
special features to be remembered with regard to Herefordshire
are the following:

(1) Enormous migration of the adult population ;

(2) An unaltered marriage rate ;

(3) A decreased fertility rate for a rural area ; and

(4) A continuously diminishing infantile mortality.

In reference to the decreasing infantile mortality of this
county I would observe that the Commissioners in Lunacy for
Scotland, by an analysis of the figures for the census year 1901,
found that the greatest number of congenitally deficient persons
received into the district asylums of Scotland came from rural
areas with the lowest infantile death rate. In Herefordshire it
has fallen from 131 per 1,000 births in 1870 to 85 in 1905,
and for England and Wales for a similar period the infantile
death rate under one year per 1,000 births has fallen from
159 to 133 as against Herefordshire, 85. To place another
graphic picture of child mortality at ages between 1-5 years
per 1,000 children born, I quote the figures of the Registrar-
General for the fifth year of age for 1895-1900. For England
and Wales 774 survived per 1,000 children born, and for Here-

Digitized by v^.ooQle

190 7 -] BY C. S. MORRISON, L.R.C.P. 803

fordshire 858, Westmoreland alone being represented with a
higher survival rate of 861.

How are we to account for the difference in the two death
rates ? I need not say that although the enormous sanitary
improvements introduced in the domain of public health have
materially reduced infantile mortality in all areas, they alone
cannot account for this great difference in the infantile mortality

Chart IV .—Infantile Mortality under cet . 1 to 1000 Births

(1870-1905).

England and Wales, black line; Herefordshire, dotted line.

between industrial and agricultural areas. The problem becomes
more entangled when we remember that at similar age con¬
stitutions the fertility of rural areas is greater than that of
urban areas, and really should show a higher mortality rate.
A higher birth rate is generally associated elsewhere with a higher
mortality rate, but it may be partly from having a younger age
constitution. Is it the only physiological explanation that can
be given ? Can the under-developed neuron of the rural child

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804 inference of local degeneracy, [Oct.,

be associated with greater phagocytic protection ? Does the
opsonic index of the rural and urban child vary ? And if it
varies, within what limits does this difference show itself, and
at what age-periods is it most marked ? The subject is suffi¬
ciently interesting to merit an inquiry.

Admissions into asylum .—You will observe in Chart V (i) the

Chart V (i). — Ratio of Insane Pauper Patients per io,ooo of
Population , 1871-1905, in Quinquennial Periods .

England and Wales, black line ; Herefordshire, dotted line.

enormous difference there has been in the ratio of persons of
unsound mind in Herefordshire as compared with England and
Wales. In Herefordshire it has risen from 35 per 10,000
population in 1871 to 55 in 1905, compared with 21 and 32 for
England and Wales for the same periods, showing in actual
numbers an accumulated increase for Herefordshire from 436*0
in 1871 to 630*2 in 1905.

I am indebted to the clerk of this asylum for figuring out

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1907]

BY C. S. MORRISON, L.R.C.P.

805

the difference in actual costs on lunatics maintained in Here¬
fordshire on the ratio of our asylum population, and what
it would have been if the ratio had been no higher than that
of England and Wales for the years 1871-1905. Assuming
the average maintenance cost in this asylum to be 9s. per week
for the whole period, Herefordshire would have saved £134,295
if the proportion of lunacy had been no higher in this county
than represented in the general population of England and
Wales. If this figure is even approximately correct it would
appear that one way of keeping down lunacy and its cost would
be for the county to start profitable industries which would
reduce migration of the adult population and indirectly help to
keep down the rates.

Chart V (ii). —Mean Annual Rate of Admissions into the
Hereford Asylum (Pauper Patients) 1871-1905, shown in
Quinquennial Periods ; also the Ratio of Admissions per 10,000
of the Population (Herefordshire) for the same period , together
with Mean Annual Numbers of Total Notified Pauper Lunatics.

Years.

Mean annual
admissions.

Rates of mean annual
admissions to io,oooof
population.

Mean annual numbers
chargeable to Herefordshire.

1871-1875

. 6025 .

4*8

436°

1876-1880

. 678

5*4

4586

1881-1885 .

. 68-8

. 5*6

4878

1886-1890

. 638 .

5*2

5370

1891-1895

. 814

S 66 a

1896-1900

• 73*8 .

<5*3

5856

‘1901-1905 .

. 82 0

630*2

Excluding boarded

out patients returned.

Thyroid insufficiency. —Lastly, I wish to draw your attention
to the increased prevalence of thyroid disease in persons
admitted into this asylum within recent years, as compared
with the number observed to be so suffering ten or twelve years
back.

From records available I find that the number has risen from
2*5 per cent, of the admissions during the decennium 1886-1895
to io'5 per cent, during the decennium 1896-1905, and last year
we admitted 37 per cent . males and 33*5 per cent, females with
goitre. Allowing for any personal equation and any fuller
observation made in the last decennium, the increase is suffi¬
ciently striking to be recorded, and has, I think, an important
bearing on the issues of degeneracy shortly commented on in
this paper. When we remember that thyroid insufficiency is
LIII. 56

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806 INFERENCE OF LOCAL DEGENERACY. [Oct,

associated with cretinism and myxoedematous insanity at one end
of its evil chain, and an enormous number of minor mental and
nervous retrogressions at the other, the evidence that thyroid
disease is more prevalent in a community than it used to be
becomes one of serious import. It comes as a stranger within
the gates we should like to eject!

Competent observers have maintained “ that the results of
imperfect development or of disease of the glands before com¬
pleted adolescence is to arrest absolutely the growth and
functions of the nervous system at the age of supervention of
the gland affection.”

Some authorities go so far as to consider that one of the
functions of the thyroid secretion is to keep the body free from
harmful organisms and their toxins. Be that as it may, if the
thyroid and para-thyroid bodies play such an important part in
the production of abnormal nervous phenomena, and is so
necessary to the bodily economy, the stigmata of goitre is but
one more link in the chain of convicting evidence.

Without troubling you further with statistics I may say there
is a decrease in the number admitted into the asylum whose
mental unsoundness was of an acquired character, and an
increase in the number of those congenitally deficient. The
features of vital statistics distinguishing this county (Hereford¬
shire) is common, I may say, to all agricultural areas, modified
by the circumstance of their having more or less the conditions
exclusively appertaining to urban or populous areas.

I think I have trespassed on your patience and forbearance
sufficiently without quoting the statistics of these counties. My
excuse for doing so is the importance the question of lunacy in
this county has acquired with a decreasing population, and
further, that your presence to-day has provided me with an
excuse to lay before you the evidence at hand invested with all
its local colouring.

If the causes of decay have been rightly surmised in this
short communication it is not difficult to suggest a remedy.
Looking back to the original cause, we find it to be dependent
on tampering with the original source of the nation’s prosperity
without leaving it with an adequate compensation.

To provide the necessary compensation to-day would be to
advocate protection for a weakened industry, such as agriculture
has become, but here we enter into debatable politics, which I

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CLINICAL NOTES AND CASES.

807

1907.]

had better let alone. I cannot conclude this short resume with¬
out expressing my acknowledgement to Drs. Herbert Jones and
H. Cecil Moore, medical officers of health, for the assistance
given me in procuring the vital statistics which form the basis
of this paper.

(*) A paper read at a meeting of the South-Western Division, held at the Here¬
ford Asylum on April 18th, 1907.

Clinical Notes and Cases.

A Case of Katatonia in a Congenital Deaf mute. By Henry
Devine, M.B., B.S., M.R.C.P.(Lond.), Assistant Medical
Officer, London County Asylum, Long-Grove.

The patient, A. W—, is aet. 18. He was admitted to the Cane Hill
Asylum on February 2nd, 1907.

The family history presents no special features of interest. The only
evidence of neuropathic tendency was in an uncle on the maternal side,
who suffered from a brief attack of melancholia subsequent to a fever.
Both parents are alive and healthy.

The following personal history was obtained. He was bom prema¬
turely and was a congenital deaf-mute. Had always been healthy, and
until now had shown no sign of mental disturbance. The temperament
is described as sensitive, but affectionate and obedient. Having received
special training he had acquired some skill in oral language, and could
interpret speech if the words were pronounced slowly and the lip
movements accentuated. He was intelligent and quick at acquiring
knowledge, and besides reading a great deal manifested artistic
tendencies, being able to draw and paint in water-colours. His chief
amusements were chess and cricket. Latterly he had been apprenticed
to a skilled trade, at which he was making considerable progress.

The present illness appears to have commenced about three weeks
before admission. Sleep was disturbed, and he suffered from gastric
disturbance and obstinate constipation. His disposition, which had
hitherto been bright and cheerful, became gloomy and perturbed. He
was apprehensive about religious matters, and told his parents that he
was very sinful. By constantly brooding over some trifling act of dis¬
obedience he magnified it into a sin for which he could never obtain
forgiveness. These morbid ideas of unworthiness were followed by
severe convulsive attacks lasting about ten minutes. There was marked
tonic spasm with opisthotonos. These were succeeded by violent and
irrational conduct, in which he would roll about the floor, and he refused
his food owing to a delusion that it had been poisoned. He became
extremely resistive, attempted to strike himself, and was extravagant and
incoherent in speech, religious phrases predominating in his deliria.

On admission .—The patient was tall and poorly nourished, but did
not present any notable anthropological stigmata of degeneration. The
temperature was 99*6° F., pulse 92, respirations 20. Knee-jerks active.

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8 o8

CLINICAL NOTES AND CASES.

[Oct,

Pupils equal, dilated, reacting to light and accommodation. He was in
a semi-stuporose state, with vacant expression, aimlessly resistive to
examination, and with cold and cyanosed extremities. The limbs were
rigid and resisted any change of position, but tended to remain in any
unnatural posture in which they might be placed. He allowed himself
to be fed.

February 3rd.—The stupor was followed by motor restlessness. At
one time he would be crawling about the floor of his single room and
attempting to extend his excursions on his hands and knees into the
dormitory, and at others trying to climb the walls of the room. Some¬
times this restless behaviour was varied by the assumption of ecstatic
and enraptured poses, the limbs becoming rigid, head turned upwards,
and hands in an attitude of prayer. He gave expression to no intelligible
speech, but only meaningless and inarticulate noises. He was neglectful
in habits.

February 4th.—Was still restless but able to be up, and it became
apparent that he had the power of speech. He was interrogated by
speech and writing, and seemed to comprehend what was said to him if
the words were pronounced slowly with distinct lip movements. His
own speech was of similar character, with no inflections of tone. He
was quite deaf. The patient could give no account of himself. He was
constantly saying, “ Round and round and round,” accompanying this
expression with circular movements of the eyes and hands in &
monotonous and stereotyped manner. His face seemed to express
intense surprise.

February 7th.—Recognised his relatives and manifested some
pleasure at their visit by a fixed and rigid smile, but showed no depth
of emotional feeling. He still repeated monotonous and incoherent
phrases of a more varied character, but conveying no real meaning. He
took his food and slept well.

February 15th.—Somewhat more rational. When asked to describe
his recent mental state he was able to express that he seemed to have
been going round and round as if his eyes had been revolved, and
thought he had seen the sun and moon, visiting the latter on an airship.
His condition varied from day to day, and consciousness gradually
became clearer. He recognised those about him, admitted that he had
been ill, attended to the calls of nature, and took his food. Amnesia
was only evident in respect to the period during which he had been the
subject of acute mental disturbance. The speech was still, however, at
times incoherent, and he would write similarly on paper. A typical
example is as follows : “ Pray to Jesus the earth is all right, be in time
to save the earth, motor-cars in the heaven, I saw him at Maskelyne
and Cook’s.”

On March 2nd a fresh and somewhat remarkable mental phase
became evident. I observed him seated on a chair with back bent,
arms by the sides, an abstracted, dreamy expression, and some nasal
mucus escaping unheeded. There was marked flexibilitas cerea. He
showed no impulses or spontaneous activity whatever, neither at this
time nor during the remainder of his stay in the asylum. With one
exception, which will be mentioned, he neither spoke nor moved of his
own accord.

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190 7 -] CLINICAL NOTES AND CASES. S09

In spite of this he was highly responsive in an automatic way to
imperative external influences. Such appeals produced the appropriate
response and nothing more, this passive obedience in combination with
the extreme flexibilitas cerea giving rise to some very striking mani¬
festations. Thus, if during the progress of any activity, elicited by
suggestion, he was suddenly told to stop, his attitude would remain fixed
indefinitely in whatever position he might happen to be at the moment
So still and immovable would he be in such a pose that he looked
more like a statue than a living man. This feature is sufficiently illus¬
trated by the photographs. The former is taken at the conclusion of
the act of writing. The pencil and paper were then slipped out of his
hand, which in the second photograph can be seen to have remained
in identically the same position as they are in the first.

Not only was such a condition apparent in the limbs but equally so
in the facial muscles. Thus at the end of his replies to questions the
mouth remained in that particular shape which it had assumed in
pronouncing the last word. This was especially obvious, because in
speaking he exaggerated the movements of the lips. To give an
instance, if “yes” was his last word and no further questions were
addressed to him, the lips would remain parted and the teeth almost
approximated. If told to smile he remained smiling indefinitely.
Asked to shake hands he held out his stiffly and kept it in that position.
When told to walk to the door he at once obeyed, but remained there
until some fresh activity was suggested to him. Even when his parents
stood in front of him interrogating the attendant as to his progress he
remained quite indifferent to, and unaroused by, their presence, until they
appealed to him personally, when he at once became aware of their
vicinity and smiled, remaining fixed in the new pose. Having thus
responded to this perception he required further objective conditions to
elicit any further response. Such were furnished by questions which
they might address to him and to which he gave suitable, but mono¬
syllabic, replies.

The following two observations which are recorded were suggested
by Dr. Mott, to whom I was able to show this case :

He was given pencil and paper and told to sketch a fellow patient.
Keeping his eyes fixed on the model he began to draw and quickly
reproduced a representation of the face. The result was of necessity
extremely crude seeing that he only looked at the model and not at the
paper, but still the main features were delineated. It reminded one of
the curious results obtained in the well-known game of drawing a pig
with the eyes shut Having completed an outline of the face he
began to draw another over the original, not once lifting the pencil.
At the end of fifteen minutes the net result of his artistic efforts is seen
in the drawing A. Naturally it is apparently only a mass of meaning¬
less lines. During the whole of this time he looked like one in a
dream, and but for the movements of the wrist remained rigid and
immobile. Towards the end the only signs of fatigue were some slight
swaying of the body and watering of the eyes. There is no reason to
suppose that he would have ceased until overcome by exhaustion, but
the experiment was concluded by diverting his attention, when he
turned his head, remaining fixed in the new pose. He was next told

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8 io

CLINICAL NOTES AND CASES.

[Oct.,

to copy the geometrical figure The result produced (B 2 ) illustrates
his method better than the preceding, as the resemblance to the original
is obvious, and he was stopped sooner in order to prevent the copy
from being too confused for recognition.

He was unable to cope with complicating circumstances in ordinary
routine activities. Thus, he was told to undress and go to bed. In
his stiff, dreamy way he removed his clothes, but was at quite a loss to
know how to proceed further as the bed-clothes had been purposely
tucked in all round, and at the head of the bed they lay under the
bolster and pillows instead of over them as is usual. It was not until
the situation was demonstrated to him that he pulled the coverings
down and got into the bed.

The only spontaneous activity he ever exhibited during this period
was in response to the quasi-external stimuli from the bladder and
rectum. To these he responded automatically and cleanly.

During this period his speech was in keeping with his limitation of
activities.

He never ventured a remark spontaneously, his conversation being a
correct, but reflex, response to questions. Such replies were always
monosyllabic, and no associated ideas were aroused in his mind leading
to any elaboration of speech or inquiries on his own account as is usual
in ordinary conversation. After his reply he would sink again into
complete immobility, apparently oblivious of his surroundings and
interrogator. The following is characteristic of such a conversation :

“ How are you ? ” 44 Quite well.”

“ Who am I ? ” “ Doc-tor.”

44 What is this ? ” “ Ther-mom-eter.”

44 When did you see your parents last ? ” “ Sun-day ”—after hesitation.

“ What are you thinking about all day ? ” 44 Nothing,” or sometimes,

44 Home, and father, and men.”

At this period he denied all hallucinations or delusional ideas.

If told to write a letter, pencil and paper being put into his hand, he
would continue writing until the sheet was filled and would then relapse
into apathy, neither turning over the sheet nor asking for another. An
example is given, and it contains phrases almost identical with those
written on other occasions. The writing is quite different from his
normal style, and it is seen to be childish and quite lacking in character.
It is also noticeable that one word is joined on to the other as he
scarcely ever lifted the pencil, and for the same reason the “ t’s ” are
uncrossed.

Physical examination showed the temperature to be invariably 98° F.,
with no evening rise. The pulse varied between 80 and 86 per minute.
The pupils were dilated. Readings taken with surface thermometers
showed the temperature of the skin to be much lowered over the
extremities, which were markedly cyanosed. There was no loss of
tactile sensation, but marked diminution of painful sensation. Taste
and smell were disordered. He could not identify the taste of quinine,
sugar, or dilute acetic acid, beyond stating that the quinine was not
bitter but seemed different from the sugar. He was unable to dis¬
tinguish the smell of cloves and peppermint, and experienced no dis¬
agreeable sensations from the smell of glacial acetic acid.

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JOURNAL OF MENTAL SCIENCE, OCTOBER, 1907.

Plate I.

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CLINICAL NOTES AND CASES.

8 l I

1907.]

In this cataleptic state he left the institution on March 31st under the
care of his parents. Three weeks after this I was able to see the
patient again in his own home. Beyond some slight nervousness he
had completely regained his normal mental condition. He recognised
me at once, and displayed with animation some photographs he had
taken and developed at the seaside, from where he had just returned.
Whilst there he had been out unaccompanied for hours together with
his camera. He had completely forgotten the earlier periods of his
illness, but was able to accurately describe many of his impressions and
experiences during the cataleptic phase. Considering his apparent
apathy it was somewhat striking to hear him speak of trifling details
which he had observed, some of his remarks being penetrating and
sarcastic. Thus he commented on my asking him to draw a patient
who was attired in ordinary working costume, because I had said:
“ Sketch that gentleman.” He seemed to consider it curious that such
a term should be applied to one so roughly clad—an erroneous attitude
not unusual in adolesence. He also expressed disapprobation of the
crude methods which some patients adopted in eating their food. The
catalepsy and lack of spontaneous activity had vanished shortly after
leaving the institution.

Communication was, of course, somewhat irksome owing to the
auditory defect which he had inherited, in fact, as I personally found it
difficult to make him understand what I might say, my usual method of
communication was by writing. With this exception he appeared to be
a normal, animated lad, full of intelligent interests.

Remarks .

The case appears worthy of record owing to its occurrence
in a congenital deaf-mute, and to the curious state of auto¬
matism and catalepsy which formed so prominent a mental
phase. To employ the record of a single case as a pretext for
reviewing the evolution of meaning which the term “ kata-
tonia ” has undergone since its introduction by Kahlbaum
would be out of place. Since, however, it has been the basis
for so much discussion and so many shades of opinion have
been expressed, it seems requisite to explain its use in the
present instance. Seeing that various authorities differ so
widely in their views it appears advisable to look on the con¬
cept katatonia as a convenient term by which to label a group
of well-marked symptoms rather than the name of a special
morbid entity. In this case the cardinal features of the kata-
tonic-symptom-complex were peculiarly well marked, hence the
use of a word which expresses them most conveniently.

As such symptoms can evidently occur in widely divergent
mental states, such as dementia praecox, senile insanity, epi-

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812 CLINICAL NOTES AND CASES. [Oct,

lepsy, and hysteria, an attempt will be made to interpret their
significance in the present instance and to discover their under¬
lying basis. The original defect in the patient was auditory, and
the mutism secondary to this had been to some extent remedied
by careful training, as is not unusual in the cleverer congenital
deaf-mutes. As will be suggested later this inherent deficiency
probably has an important aetiological bearing on the acute
mental disturbance from which he suffered. The cyclic course
of the disease is well marked: the onset with gastric disturb¬
ance and melancholia, the stage of excitement, the cataleptic
stage, and then sudden recovery. The earlier periods include
many of the classical katatonic manifestations. Its chief
features were psycho-motor agitation, convulsive attacks,
multiple hallucinations, and fleeting delusions, stupor with
rigidity or “ waxy ” muscular condition, negativism (refusal of
food and senseless resistance), mutism, stereotypy, ecstatic
poses, and personal neglect. The speech anomalies, always
important in katatonia, have an added interest in a congenital
deaf-mute. They may be included under the term “ verbigera¬
tion,” and were fully discussed in a paper by M. J. Nolan (i).
It is not only the expression of mental confusion but is actually
a disturbance of the speech centres with their associative connec¬
tions, that is, a functional aphasia. It may be manifested by
dumbness or a confused intermingling of words, often repeated
again and again and quite out of keeping with the inflections of
voice and emotional gestures which accompany them. Whereas
speech in normal human beings has become mechanical, in a
deaf-mute it is acquired with difficulty and would always require
concentration and effort, factors rendering it more liable to dis¬
turbance. Thus there was first mutism in spite of emotional
attitudes indicative of active though disordered ideation, then
meaningless and incomprehensible sounds, and still later the
constant repetition of one word with very striking motor
accompaniments. Afterwards he began to speak in jumbled
phases, not toned, however, in the manner described by Nolan,
since his voice had never acquired inflection of tone.

The cataleptic phase is especially interesting, and demands
more detailed notice. Its chief features were loss of initiative
and voluntary action, increased suggestibility, and a striking
tendency to automatism manifested by the catalepsy and the
continuous repetition of one series of movements. Such a

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1907]

CLINICAL NOTES AND CASES.

813

reduction of the personality to the status of a highly complex
automaton is closely analogous to the lighter degrees of
artificial somnambulism or hypnotism. In the more profound
stages of hypnotism there is subsequent loss of memory for
what has occurred, and also greater disorientation manifested
by the acceptance of suggested hallucinations—phenomena
which were absent in this case.

Apart from permanent dementia, which is here out of the
question, in conditions of stupor or catelepsy consciousness may
be in a state of dreamy reverie or even profound torpor, or else
dominated by the presence of some absorbing idea. The latter
(melancholia attonita) though frequently by no means easy to
exclude, was evidently not the condition present in this case;
on the contrary, an intense disturbance of the higher sensori¬
motor realms had been followed by exhaustion, which is repre¬
sented by a passive and inert consciousness rather than one active
and engrossed. If the patient had been intensely preoccupied by
some delusional idea his features would have been expressive of
some painful or ecstatic emotion, and he would have been
irresponsive or possibly actively resistant to external influences,
instead of which the face was vacant and devoid of even
momentary expressions of emotion, and he showed passive
obedience to vigorous solicitations from without. Again, the
clues obtained by speech and writing reveal no predominant
ideas, but simply ill-defined, almost subconscious yearnings for
a more familiar and congenial environment indicative of a
vague, dreamy, semi-depressed consciousness insufficient to stir
him into any form of activity.

His view also of the environment was vague and impersonal.
Apparently it appeared strange and unreal to him owing to
some residue in his consciousness of the hallucinations which
were prominent in the earlier stages. A remark made subse¬
quently to his parents in reference to the cataleptic stage lends
itself to such a view. He said that he felt as if he must close
his eyes sometimes as the light in the asylum seemed so strange
and confusing. While, therefore, he evidently perceived his
environment, and was able afterwards to comment on what had
occurred, he did not realise its relationship to himself unless
aroused into activity by some directly personal appeal. Here,
then, as in hypnosis, was a condition of narrowed consciousness
which serves to explain the suggestibility and automatism.

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814 CLINICAL NOTES AND CASES. [Oct,

“ When in states of enfeebled initiative suggestibility appears,
it does so, not as an added or accidental phenomenon, but as a
natural consequence of the former. . . . When the inde¬

pendence of initiative is reduced towards complacency, and all
assertiveness and resistance is exchanged for abeyance or
passivity, the vacating thus induced opens the channels to any
vigorous solicitations to which the mind maybe exposed. With
the normal initiative disabled or suspended the responsiveness
to suggestion follows inevitably . . .” (2). Such a statement,
though especially referring to hypnosis, applies to any condition,
whether artificial or pathological, in which there is narrowing
of consciousness.

It has been pointed out by W. R. Dawson that such a con¬
scious state is the essential factor in katatonia, and that the
various phenomena which occur are all dependent upon it (3),
because if an idea of movement is present in consciousness
with no opposing ideas and tendencies, the corresponding
movement inevitably follows. In this case, therefore, since any
idea which might be suggested from without would meet with
no associated or contrary ideas necessitating deliberation and
choice, it would remain isolated, as it were, in consciousness,
and the appropriate train of activities would of necessity ensue.
Thus arises the suggestibility. Furthermore an idea implanted
in this way tends to persist and have a continued effect. Hence
we have the various manifestations of automatism. In cata¬
lepsy the suggestion arises through the muscular sense, and the
idea of position remains indefinitely until displaced by further
suggestion. Similarly the continuous series of drawings, which
was described, may be explained. The physical basis of such
a conscious state must be functional inactivity of the higher
cerebral centres analogous to the condition of the decerebrated
frog. His activities, while not completely unconscious, were
essentially reflex, mechanical, and lacking in intelligence. Only
those elements of an activity which are normally subconsciously
performed could be elicited, those elements indicative of a
fuller consciousness giving it a purposive and intellectual
character being entirely wanting, such want of higher cerebral
control being especially obvious when the objective conditions
guiding the perceptual activities were complicated in an an-
usual way.

In such a case some modification of routine procedures is

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1907.]

CLINICAL NOTES AND CASES.

815

required in order that there may be suitable adaption to
the new conditions. Thus when the bed-clothes were changed
from their usual position merely automatic actions were
useless; there was a need for an intelligent appreciation
of the altered circumstances and an intelligent modification
of conduct in accordance with them. Such conduct he was
incapable of displaying.

The close relationship between katatonia and hysteria has
been frequently noticed, and as regards this case the relation¬
ship would appear to be particularly close, in fact, it may be
considered as a purely hysterical insanity.

S£glas and Chaslin (4), in an extensive review of the subject,
commented on the hysterical nature of the symptoms, and
Bevan Lewis (5), when referring to the cases described by
Kahlbaum, expresses a similar opinion.

The predisposing cause is to be found in the congenital
defect. While observing the patient in his own home, when he
had regained his normal personality, it was impossible not to
be struck with the relative isolation which he must experience.
Since conversation with him could only be carried on with
some effort it is inevitable that he would be only able to take a
very partial place in collective social intercourse. Hence he
sat turning over magazines or occupied with his own thoughts
for the greater part of the time. Such a life must of necessity,
even when surrounded by the closest friends, tend to be solitary
and monotonous, leading to constant morbid introspection.
The habit of day-dreaming and self-analysis, so frequent during
adolescence, would be greatly intensified in one afflicted by con¬
genital deafness. And thus the dawning instincts of sex, the
widening view of life, the vague cravings and longings, instead
of finding adequate expression, would only serve to make him
realise, as he had never done before, his severe limitations and
tinge his feelings and emotions with gloom. He would tend,
therefore, to fall into that “ hypnoid-state ” which forms the
soil for the various manifestations of hysteria (6). Under the
influence of some shock, lowered state of bodily health, or, it
may be, onanism, the nervous system—probably congenitally
unstable as he was born prematurely—would break down, and
these repressed and subconscious emotions would rise into
predominance and manifest themselves in some explosive
manner such as an hysterical convulsion.

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Viewing the case both from a psychological and clinical
aspect its hysterical nature is equally manifest. Whatever
symptoms may be especially prominent hysteria is essentially a
psychic disorder. On the one hand, beyond some capricious¬
ness and instability of character, its mental aspect may be
obscured by some somatic abnormality, and on the other hand
the mental symptoms may be so intense as to lead to grave
disorders of conduct, bringing the case under the category of
hysterical insanity. Whatever the symptoms they are all the
expression of a dissociated consciousness due to a want of
harmony between higher and lower control centres, with the
inhibitory control of the former in abeyance, an isolation, that
is, of one portion from the other. On the physical side this
may be manifested by general convulsions following some trivial
excitation of the motor centres, and on the mental side by the
exhibition of a personality a prey to an uncontrolled imagina¬
tion and influenced by emotions and images which normally
belong to the realm of the subconscious. There is more or less
extensive loss of function in some portion of the cerebral muscle
with increased potential of the rest. Such is observed in the
later stages of this case when the higher intellectual attributes
of the personality were wanting, showing loss of activity in the
higher centres; with this was increased suggestibility the
expression of increased potential in the lower.

The clinical symptoms of such dissociations are briefly
characterised by their diversity and mobility, the presence of
certain degenerative stigmata, and the rapidity by which the
control of the normal personality is regained.

All these features were noticeable in the case of A. W—.
The degenerative stigmata which are of great importance in the
diagnosis of hysteria were manifested in the marked analgesia
and the disorders of smell and taste. The sudden transition
from depression to ecstasy, the half-hearted attempts at self-
injury, the dominance of subconscious emotions, sexual,
religious, and infantile, manifested so diversely by convulsions,
stereotyped and enraptured poses, and the curious series of
childish attitudes as he crawled about the floor, are all
symptoms suggestive of hysteria. They resemble, indeed, in
nature, if not in actual sequence, those cases of hystero-epilepsy
described by Charcot.

The stage of catalepsy and automatism, with the apparent

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apathy in respect to the environment in combination with a
critical observance of trivial details, furnishes a clinical picture
equally characteristic of hysteria.

Lastly, the sudden recovery, which was so remarkable a
feature, tends to favour the view which has been advanced.

What physical conditions produced this alteration of cerebral
functions will not be here discussed. Possibly it was due to
nutritional changes the result of auto-intoxication or vaso¬
motor spasm. It is hardly, however, to be expected that any
demonstrable pathological lesion would be found in a case so
essentially functional in all its features.

While somewhat accentuating the hysterical nature of these
symptoms the ultimate prognosis of this case may still possibly
be not altogether favourable. Kraepelin appears to insist that
such symptoms are almost always followed by greater or lesser
degrees of mental enfeeblement. To what extent such will be
the case in this patient time alone will show. In a com¬
munication with the patient’s father three months after dis¬
charge he said that his boy was back at his work and seemed
quite well but for some slight want of continuous application
and a readier fatigue than he had formerly manifested. Whether
this weakness is temporary or permanent, or whether the whole
mental disturbance is but an incident in a graver disorder
leading to ultimate dementia, it is difficult to determine at
present.

In conclusion I must express my thanks to Dr. Moody, the
superintendent of the asylum, for permission to publish the
details of this case.

References.

(1) “ Is Katatonia a Special Form of Mental Disorder ? "Journalof
Mental Science, October, 1892.

(2) Joseph Jastrow, The Subconscious , fol. 501.

(3) W. R. Dawson, Journal of Mental Science t January, 1904.

(4) “ Katatonia,” Brain , vol. xii.

(5) Text-Book of Mental Diseases , fol. 272.

(6) J. J. Putman, Journal of Abnormal Psychology , April, 1906.

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OCCASIONAL NOTES.

[Oct,

Occasional Notes.

The Annual Meeting.

The Sixty-sixth Annual General Meeting of the Medico-
Psychological Association of Great Britain and Ireland, held
in London on July 25th and July 26th, 1907, yielded pride of
place to none of its predecessors in the importance of the
business matters considered, in the scientific interest of the
subjects discussed, in the number and representative character
of the members present, or in the genial and hearty nature of
the proceedings.

A society which can call together such a meeting in London
so late in the season shows a vitality and energy that may well
be a matter of congratulation to its associates.

Besides the ordinary affairs of the Association, such as the
working of the nursing system, the relations of the staff of
asylums to the new legislation in regard to employers’ liability,
and so forth, the unfortunate series of events which have come
to be known as “ the Carswell case ” were considered at length.

Dr. Robert Jones terminated his year of Presidency in which
so much useful and brilliant work had been done, and Dr. P. W.
MacDonald assumed the responsibilities of President of the
Association. Dr. MacDonald delivered an address of much
eloquence and vigour, in which he reviewed in the most
interesting way the lunacy and social statistics of his county
for the last twenty-five years. The keen observation and shrewd
thought which this distinguished and energetic superintendent
has given to his life’s work were thoroughly appreciated by his
audience, while his dignified conduct in the chair augur well
for the year of office which he has just begun.

The annual dinner was well attended, and the guest list con¬
tained many names of distinction in various walks of life. It
has rarely been our practice to refer to after-dinner speeches,
but one speech made on this occasion deserves more than a
passing reference if only for the deep impression which it pro¬
duced upon its hearers, as shown by many references in the
debate on the following day. Professor Clifford Allbutt, whose
position, character, and experience make everything that he
utters respected, spoke in weighty and well-considered words

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1907.]

on the desirability of the establishment of a ministry of public
health. His earnest reasoning was thoroughly convincing, and
we hold that it is the duty of every member of our profession to
aid by every means in bringing about an object so essential to
the advancement of the best interests of the commonwealth.
We fear it may be long before the factions, misruling our
country for the benefit of nobody except professional politicians,
can be got to see the light, but the time will come when even
party must follow the general advance of the age, and when
England will not be able to lag behind those other countries
which have found that the mere making of money is not the
sole criterion of a nation’s well-being.

Another after-dinner speaker, reminiscent, perhaps, of Robert
Burns’ line—

“ A duel's amang ye taking notes ”—

varied the flow of his polished and delightful oratory by a
humorous application of the statistical method to the question
of alcohol. The yellow press swooped gaily down upon the
convives a few days afterwards with a circular requesting
that they should advertise their sentiments and habits with
regard to the consumption of alcohol! If the yellow pressman
was under the patronage of a god as powerful as Bacchus,
probably that divinity would

“Better for his life provide
Than public means which public manners breeds.”

* * * *

The outstanding points connected with this meeting—the
points which will give it a special mark in the history of the
Association, are, besides the President’s remarkable address,
the following: Firstly, the discussion on the Carswell case, and
the vigorous action which it was determined to adopt thereon.
Secondly, the public recognition which all the speakers in the
Clouston discussion gave to the necessity of reviewing the
position of the various lunacy departments in these countries.
The feeling was general that there is urgent need of a Ministry
of Health, under whose control, and not under that of a multi¬
tude of incoordinate boards, the insane ought to be placed.
Thirdly, the demonstration by Dr. Albert Wilson, which was
as entertaining as a romance, as wonderful as the exploits of

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820 OCCASIONAL NOTES. [Oct,

Zoe, and had further beneath its fascinating attractiveness a
profound interest for us, as showing, among other things, the
vast power of personal influence in the borderland realm of
mental instability. Dr. Easterbrook’s carefully elaborated paper
on tent life indicated that the broad, physical lines of treatment
in insanity, first, perhaps, sketched by the school of Cos,
have not lost their interest or their value to the most advanced
observers of to-day. Last, though not least, we must com¬
mend to the special notice of our readers the epoch-making
observations of Drs. Ford Robertson and McRae. Such
work as this the scientific world will not willingly let die. It
can never lose its worth in the history of progress, for it can
only be superseded when it has brought forth observations
more keen, careful, and laborious than those which lend
to it eminent distinction. Such work as this is the best
answer to the shallow and ungenerous sneers of those who
strive to aggravate in modern minds the secular prejudice that
exists against our specialty by insinuating that we are unscien¬
tific and indifferent to the advance of knowledge, because most
of us are doomed under the Egyptian bondage in which we
live to make bricks without straw. Give us a public who
deems that out of the superfluity of the richest people in the
world it can afford to endow clinical and pathological research,
give us, in other words, opportunity, and the men will not be
lacking who will be ready to give their lives to the service of
science, as so many of our young men now bum to do, as so
many of our older men have done under difficulties hitherto
all but insuperable.

The Alleged Decrease of Insanity .

The alleged increase of insanity has been a perennial source
of interest in the lay and medical press for so many years, that
it is almost with regret that its demise has to be recorded, and
the introduction of a new head-line brought to notice. The
decrease of insanity is certainly a more agreeable subject,
although it cannot hope for the popular support that has been
so cheerfully accorded to its predecessor by the melancholy
pessimists, who love by pictures of decadence to make the
national flesh to creep.

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The possibility of a decrease in the occurrence of insanity
has been foreshadowed in the blue books of the three kingdoms
during the last few years, but the statistics of insanity have
been so liable to fluctuation that temporary decreases have been
regarded with distrust, as they must continue to be; neverthe¬
less, the continuance of a depression of production of insanity,
culminating in an actual diminution in the numbers of the
insane as recorded in this year’s report of the Commissioners in
Lunacy for Scotland, justifies the consideration of lunacy
statistics from the aspect of possible decrease.

The report states that since 1858 the number of lunatics
under the cognisance of the Board had steadily increased until
1904, in which year there has been a decrease in the proportion
of lunatics in every 100,000 of the population from 363 to 362.

This decrease, following on two previous years in which the
proportion has remained stationary, is significant, but by no
means conclusive.

Beyond the numbers of the insane officially recognised there
is a considerable number of persons of unsound mind not on the
register, and the temporary arrest of increase might be due to
causes limiting the previous increment from this source, or to
temporary increase in the death or recovery rate.

The decrease, however, as the Commissioners point out, can
be satisfactorily proved to be due to the diminution in numbers
who have been placed on the register during the past four years,
the maximum of 3,660 placed on the register in 1902, having
diminished to 3,449 in 1905, and 3,370 in 1906, this diminution
in a considerably increased population being really very
striking.

Still more striking, however, is the diminution in the number
of insane persons who have never been registered previously;
these had reached the proportion in 100,000 of the population
of 62^8 in 1902, falling in the last four years to 607, 6o*6, 57*6,
and to 54*3 in 1906.

This would appear to indicate a very considerable falling off
in the occurrence of insanity, but must not be relied on too
confidently. In recent years in Glasgow a considerable
number of cases of mental disorder of brief duration are treated
to recovery without admission to asylums, and it is a question
whether the number so treated may not have affected asylum
statistics.

liii. 57

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822 OCCASIONAL NOTES. [Oct,

A possible statistical fallacy is thus introduced. The two
classes of cases being treated under two independent official
bodies there is a difficulty in satisfactorily combining their
information. This is an additional argument in favour of the
establishment of a ministry of health which should have general
supervision in all health matters and furnish definite informa¬
tion in such cases.

Whether these statistics indicate an apparent or real diminu¬
tion in the production of insanity, they are at least satisfactory
as an evidence that we may expect that there should certainly
be a decrease in the rate of the erection of asylums.

Questions on the Alcohol Question: the Use of Alcohol.

The question of the use of alcohol was raised in connection
with the annual meeting, and drew the attention of one of the
most active of the daily papers to the views and habits of the
members of the Medico-Psychological Association. Publicity
has thus been given to the fact that, although as a body we
advocate temperance, and to some extent enforce total
abstinence in our asylums, as individuals the large majority
use alcohol as an habitual article of diet. It behoves us to
consider whether we are setting a bad example by habitually
using a noxious poison, or whether we are availing ourselves of
one of the means of enhancing the pleasure of life in using that
which in moderation can “ gladden the heart of man,” and thus
tends to aid his evolutionary progress.

The question, indeed, is ever the same : Is alcohol an absolute
poison, in all quantities, or has it any use whatever as a food,
stimulant, or for any other effect ?

On the one hand, the striking fact presents itself that some of
the most progressive nations have habitually used alcoholic
beverages for long periods. If alcohol is a poison why have
these not deteriorated or become exterminated ? Is there pro¬
gress in spite of, or by reason of, their alcoholic habits ? On the
other hand, the Hindoos and Mahommedans who have been
non-alcoholic for centuries, have not appeared to develop as
rapidly as the alcoholic races, and, indeed, seem—in the case of
the Mahommedans—to have undergone serious deterioration.

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823

Has the decadence of the latter been by reason of, or in spite
of, their non-alcoholic habits.

These offer the largest experience in the use of alcohol which
the history of the world presents—extending over centuries
and affecting myriads of individuals. If properly studied a
conclusive opinion can surely be formed from so vast an ex¬
periment.

The main argument from experience of the total abstinence
partisans is based on the insurance returns, and on the first
glance they are very convincing, but if they are considered
without bias they become less evidently conclusive.

The man who practises total abstinence in the midst of an
alcoholic population is either impelled thereto by a strong
determination or is compelled by his organic inability to
tolerate alcohol. In all cases, the total abstinence is a proof of
the possession of a life-long habit of self-control, which would
act also in the other relations of life, the instinct of self-pre¬
servation being highly developed. Since these individuals are
a chosen class, who devote much attention to their self-pre¬
servation, to compare them with the large majority of men who
lead a life in which the enjoyment of the present, with its con¬
sequent risks, is predominant, is not a fair comparison.

Is the longer life of the one class not due to their greater
self-care all round rather than to the total abstinence ? Would
they not live as long if they used alcohol with the strict self-
control which their character would produce ?

Again, is length of life the final test ? A total abstinent
ascetic in his cave lives to a hundred years, the Mahommedan
and Hindoo live as long, or nearly as long as the alcoholic
European, but, tested by the amount of work done, which is
the fullest life ? The non-alcoholic races may equal or surpass
the alcoholic in muscular work, but can they equal them in the
higher forms of energy, the intellectual, and in persistent
endurance of nervous stress ?

Another question is whether the non-alcoholic persons in
alcoholic populations suffer less from nervous and mental
breakdown, and whether they exhibit a greater amount of
intellectual energy ? Here, again, however, the question is by
no means simple. Very many young abstainers break down: Is it
from inherent weakness, or from loss of a racial habit ? On the
other hand, many inherit a vigorous self-control, which makes

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824

[Oct,

them a special class, but is this due to non-alcoholic habit or
heredity ?

If it is conceded that alcohol is of possible use the question
still remains whether, in consideration of the evils which are
apt to develop from its habitual employment, other forms of
food or stimulation cannot be more advantageously employed,
and whether human evolution would be hastened or delayed by
the change ? The morbid desire seems to be for Lethe, in
drink or drugs, and it has been shown that the asylum drunkard
is, almost inevitably, a degenerate person hereditarily burdened
with neurotic inefficiency.

These, and many other questions in regard to the use of
alcohol, demand a more thorough and impartial examination
than has been accorded to them, and the Medico-Psychological
Association would do well to make a serious effort to give the
public a definite answer to those which lie within the limits of
its special experience.

We fear, speaking from the depths of a profound though,
happily, only temporary ignorance, that the solution is not to
be found on the lines laid down by a recent writer in the public
press, who tells us, over letters implying that he is a physician,
that the mental defect produced by alcohol is not insanity, and
that insanity is probably produced by a trypanosome like the
“sleeping sickness.” One wonders at many things in this
lofty statement. If the Porter in Macbeth were still at hand
to be questioned, he might exclaim : “ In sooth, aye! the sleep
were a likely tale, but what of the others, my masters, the nose¬
painting, and the rest ? ”

Some poor heretics from the modern trypanosomatous faith,
living in drunken lands, and unable to shut our eyes to what is
happening under our noses, feel rather inclined to subscribe to
the old vulgar view prevalent since Noah was an exhibitionist,
and well phrased by the great thinker Berkeley when he tells
us that the experience of every village shows that drink ruins
in mind and* body every man who takes to it—“ except,” he
quaintly adds, “ a few of the devil’s decoys.”

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REVIEWS.

825

Part II.—Reviews.

A Text-Book of Psychiatry, By Leonardo Bianchi, M.D., translated
by James H. Macdonald, M.B., Ch.B.

Professor Bianchi is already so well known in this country as an
eminent and distinguished psychiatrist that the translation of this
important work from his pen will be especially welcome to all those
who are interested in the study of insanity. He has produced a book
which is worthy of the highest place in the literature of the subject, and
one which will no doubt rank as a standard work. By interpreting the
facts of insanity in the light of the most recent researches in psychology
and in the anatomy and physiology of the brain, he has placed the
whole subject on a broad and scientific basis, and presented it in a
manner which abundantly demonstrates the great progress which has
taken place in this branch of medicine in the last few years. In no
instance is the author content with a mere recital of symptoms. Each
type of mental disorder is subjected to a keen psychological analysis, in
which a consistent effort is made to trace the essential change which has
occurred in the personality and the factors which have led to its dis¬
integration. Disputed questions are treated by a historical and
impartial survey of the various views that have been advanced, followed
by a clear statement of the author’s own opinions, this impression of
individuality which pervades the whole book forming one of its most
pleasing features. Though adding to the size of the volume, it would
perhaps have somewhat enhanced its valu§ as a work of reference if a
bibliographical list had been appended to the end of each chapter.

The contents are included in about 900 pages and are divided into
three parts. Part 1 deals with the anatomy and physiology of the brain,
Part 2 with the psychological aspect of insanity, and Part 3 with the
individual forms of mental disorder. The volume is clearly printed and
contains numerous diagrams and illustrations. The subject matter is so
wide in its scope that it is only possible to mention briefly its salient
features.

In the introduction the evolution of the nervous system, with its
psychic counterpart, the mind, is shortly traced from the most primitive
to the highest forms. Purely speculative problems, such as the relation¬
ship between mind and matter, and the question of intelligence in the
lower organisms are not discussed, though a few pages are devoted to
the practical considerations involved in the association of psychic dis¬
turbances with bodily disorders.

In the chapter devoted to anatomy an excellent account is given of
the central course taken by the nerves of special sensation, and also a
description of the motor tracts and associative fibres. The much
debated “ neurone ” theory of Waldeyer and Ramon y Cajal is discussed
somewhat fully, the opposing theory of “ continuity,” associated more
recently with the names of Apaty and Bethe, receiving due prominence.
The author would seem to favour the latter view, and, indeed, in a later

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[Oct,

chapter he states that the neurone doctrine is almost dead, differing in
this respect from many of the neurologists in this country.

The whole of the section devoted to the physiology of the brain is
worthy of careful study, especially those pages which deal with the so-
called motor areas. The problem as to the true significance of this
cerebral region is beset with many difficulties. Many physiologists
regard them as a portion of the extensive sensory zones in which the
ideas and images of movements are located, these centres exciting the
true motor centres which are situated at the base of the brain. Accord¬
ing to such a view, a lesion of the Rolandic area does not cause a true
motor paralysis, but rather a functional defect of movement due to
inability to recall the necessary motor images or ideal conceptions which
must precede any voluntary activity. This position is shown to be
probably an incorrect one, and the author vigorously supports the
opinion of Ferrier and others that this region is a true motor centre in
the ordinary meaning of the term. Professor Bianchi’s views as to the
function of the frontal lobes are already well known, and they are here
stated at some length, expressing as a final inclusion that “ the frontal
lobes are, in their ultimate analysis, the organs for the direction of the
individual in the social and cosmic environment”—a sentence aptly
describing their complex significance.

Part a, devoted to psychology, both normal and morbid, occupies over
200 pages. Such an extensive survey of this aspect of insanity cannot
be considered excessive. However much light may be shed on mental
disorders by a consideration of the physical phenomena which accompany
them, the necessity for a study of the subject from its psychological
aspect cannot be over-estimated. A knowledge of psychology, divorced
from metaphysics and based upon the scientific data of physiology and
neurology, cannot fail to be of the utmost value in obtaining a true
insight into the morbid transformations of the personality which occur
in the insane, the importance of the subject justifying its full considera¬
tion in a work of this character.

The first two chapters are occupied by the consideration of sensation,
perception and attention, with their disorders, embracing naturally the
chief sensory disturbances, illusions and hallucinations.

Chapter III is devoted to the physio-pathology of memory, and
includes an account of its special and general defects. In the former
variety clinical examples are given of cases which manifest those symptoms
known by the somewhat confusing terms of amnesia retrograda and
anterograda. Several cases of duplicated personality are also described.

Chapter IV treats of ideation and its disorders with a long account of
the development of language, indicating that in its rudimentary forms it
is merely a method of emotional rather than ideational expression, and
showing how it has developed coincidently with the evolution of the
intellect. In discussing the laws of association special stress is laid on
the importance of the law of contrast in the genesis of delusional
states. It is shown that the attention devoted to an idea keeps the
contrasting idea on the threshold of consciousness, and that this
suppressed mental product is liable to obtain predominance in con¬
sciousness and manifest itself as a delusion. To mention an instance
given by the author: An individual of religious temperament may

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REVIEWS.

827

fortify herself by ideas of the Grace of God, and contrasting notions—
fears of hell, etc.—remain as a menace to her peace of mind inactively
in consciousness. If the “ regulative power of consciousness decays
the Grace of God disappears as an objective, and the ideative constella¬
tion of hell, demons and damnation with the relative emotions, is sub¬
stituted for it (delusions of contrast).” Such views have been especially
mentioned as they would appear to be very suggestive in elucidating
many cases of delusional insanity.

Chapter V deals with emotions and sentiments. James* somatic
theory is fully discussed, though the author, while recognising the
extreme difficulty of the subject, is unable to entirely accept his views.
The last two chapters of this section deal briefly with the will and
consciousness, their disorders being more fully treated in the clinical
portion of the work.

Part 3 opens with a comprehensive scheme for investigating the
“ method and field of clinical inquiry.” In this part of the work—the
study of psycho-pathology—the student cannot fail to be impressed, not
only by the broad basis of the scientific reasoning upon which Professor
Bianchi rests his analysis and conclusions, but also by the open and
generous treatment of a subject that has been so largely obscured by
the fruitless efforts of many able psychiatrists to form premature con¬
clusions and classifications which have proved to be misleading.

While admitting that our ideal should be a classification based upon
anatomo-pathological criteria, the author states that at the outset of
his work he had reluctantly resolved against presenting any classifica¬
tion of mental diseases, deeming any such classification “almost
useless, as giving only what is incomplete and therefore not very vital.”

In Chapter II he discusses the fallacies of a simple nosographic
classification, and clearly points out the confusion which arises from
that which is founded upon aetiology alone, or considered in respect to
the various epochs of life. The psychological criterion followed by
Mendel is also discarded as misleading and founded more on appear¬
ance than reality. From the classification adopted by Krafft-Ebingand
Shule, based upon aetiological and anatomo-pathological criteria,
Professor Bianchi picks out the most important features, notably those
which refer to the grade of evolution of the brain, and in a true eclectic
spirit he says : “ Having now recognised generally the impossibility of
holding to a single criterion it is clear . . . that that classification

gives promise of wider appreciation and longer duration, which assumes
the greatest number of fundamental criteria on which is based the
general knowledge concerning the genesis and nature of mental
affections.” And with this idea he puts forward—as a working basis—
a scheme “inspired by nosological, aetiological, and anatomo-patholo¬
gical criteria,” comprising three groups:

(1) Essentially evolutionary psycho-cerebral defects.

(2) Mental affections of infective, autotoxic and toxic origin
developing in individuals regularly evolved.

(3) Affections with an organic substratum, localised or diffuse, in the
central organ of mind.

That the author is fully cognisant of the difficulties that underlie even
a scheme so simple, but yet comprehensive, the next few pages clearly

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REVIEWS.

[Oct,

demonstrate; and a fitting reference is made to the clinical criterion
adopted in its widest sense by Kraepelin. It is beyond the scope of
this review to enter into the composition of the many subdivisions of
these groups, which the reader will find most instructive and interesting;
but it is not too much to say that Professor Bianchi has given us a
classification—admittedly provisional—founded on the most acute
observation, and based upon the most accurate and scientific criteria
known to the world to-day.

Of the succeeding chapters, Chapter VI, on hysterical insanity,
deserves*special mention. In it the subject of hysteria, so frequently
elusive and enigmatical to the student, is treated with masterly clear¬
ness and unfailing interest The views of Sollier and of Janet are briefly
reviewed by the author, and a useful footnote for reference and
explanation is inserted—a feature which might have been extended
with advantage to the reader of this work. Many instructive observa¬
tions on cases, and several good illustrations illuminate the context

It is difficult to select points of interest to comment upon from a
book that from cover to cover is so productive alike of interest and
knowledge; a reference must, however, be made to the chapter on
sensory insanity—Chapter XVI. It is scarcely too much to say
that here the student will find himself conducted to heights from which
he may look down upon those other and lesser eminences which he may
have climbed or essayed to climb without ever obtaining so clear and
uninterrupted a view of the geography of the realm he studied to know.
From this point of vantage he may obtain a clearer understanding of
such vexed terms as “ amentia/’ “ acute dementia " and “ mental con¬
fusion,” and attempt to unravel the tangled controversy over the
“dementia praecox,” so ably described by Kraepelin—a syndrome
which was never intended to be more than a mile-stone on the road to
the understanding of an important group of psychoses, and as such has
been of infinite service to those who have profited by the direction it
conveyed without wasting time in criticising its terminology. In most
instances these mental states are regarded by the author as only
syndromes, “ particular attitudes of the disease, not the disease in its
entirety,” or “ a chronological feature of a complex psychosis.” Professor
Bianchi, from his wide experience, has closely studied the disease from
its beginning, and he says, “ the almost constant fact is the hallucinatory
explosion.” He regards hallucinations as the radical and substantial
phenomena which provoke the abnormal intellectual and affective
states, which are now familiarly known in asylums under various names,
but which, he maintains, are not to be assigned the dignity of psycho¬
pathic entities, but must be “ framed in the picture which includes
them all,” viz., the essential sensory disorder. This disease is traced
through many grades, and instructively illustrated by well-described
cases.

It is not possible to over-estimate this step forward in the interpreta¬
tion of these various syndromes; and the light shed by the author’s
clear insight into their inception, and acute observation of their pro¬
gress here as well as in his exposition of many other psychoses, notably
paranoia and the neurasthenic states, will go far to elucidate those diffi¬
cult problems which are the essence of psychopathology, and upon the

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solution of which must rest the first attempt at a truly scientific classifi¬
cation of mental disorders. This review would be incomplete without
a reference to the great service rendered by Dr. James MacDonald in
presenting so admirable a translation to the many students of Professor
Bianchi who are unable to read his work in the original tongue.

Physiological Economy in Nutrition , with special reference to the
Minimal Proteid Requirement of the Healthy Man: an Experi¬
mental Study . By Russell H. Chittenden, Ph.D. London :
Heineman, 1905. Pp. 473. Price 14 s. nett.

This important work on nutrition, how best to maintain the human
body in health and strength with the least expenditure of energy, has
been produced to show by scientific investigation what the physiologi¬
cal necessities are. The experiments were conducted with professional
men, with volunteers from the United States Army, and with University
athletes. Photographs of the subjects are given, and exact details of
the conditions observed. The subject is not new, and the usual
dietetic error of overfeeding has been attacked by many before and
since Cornaro. It is not from the merely personal standpoint that
Professor Chittenden states the case; it is rather as the result of accu¬
rate experimental research. It is apparent that the products of proteid
metabolism constitute a menace to health, and the aim of those who
desire the highest efficiency must therefore be to attain that efficiency
on the smallest amount of food. Professor Chittenden, by careful
analysis of the dietary, and of the excreta, justifies the general conclu¬
sion that a professional man can live on a much smaller amount of pro¬
teid food than is usually considered essential without loss of vigour;
that soldiers require less than 50 grammes of proteid daily instead of
105 grammes. This economy led to an improvement of the neuro¬
muscular apparatus with less sense of fatigue, under observation of five
months 1 duration.

In short the work is an appeal for temperance, for “ moderation in
diet, especially in the taking of proteid foods, which means a great
saving in the wear and tear of the bodily machinery.”

Some years ago, in 1893, a committee of the Medico-Psychological
Association reported upon Asylum Dietaries. In view of the work
accomplished by Professor Chittenden since that time, and the increased
importance of metabolism recognised as a factor in the causation of
insanity, it is apparent that the time has arrived to reconsider our posi¬
tion. Dr. L. C. Bruce urges that milk and plentiful hot drinks are
demanded in the treatment of certain forms of mental disorder. Pro¬
fessor Meyer, of Gottingen, found that artificial feeding was rarely
required, and Dr. Jules Morel, of Mons, has also been sparing of the
stomach tube in his practice. The vulgar notion that every sick person
should have a plethora of nourishing food is no longer tenable ; and it is
therefore of the utmost importance that we should make further inquiry
into asylum methods in the light of strict experimental research. The
value of Professor Chittenden’s work has been widely acknowledged,
and it should not be allowed to remain a dead letter for us.

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830 REVIEWS. [Oct,

Metabolism and Practical Medicine . By Carl von Noorden. English
issue under the editorship of I. Walker Hall. London:
Heineman, 1907. Price, complete in 3 vols., £2 12s. 6 d. nett

This translation is now before us in the first two volumes. The third
volume is not yet to hand. The first volume deals with the Physiology
of Metabolism in relation to Food stuffs, Digestion, and Absorption,
Fate of the Food-stuffs in the Tissues, and Metabolism in Man. The
new view that the splitting up of the protein in the intestines is that the
albumen of the food can be changed into the albumen of the tissues.
The chemistry of the process is shown to be more complicated than
was formerly believed, for the organism can interchange the proteins of
tissues. Thus the intestinal process is not complete in itself, still the
defect of intestinal physiological processes may seriously affect the
general economy, and in cases of insanity form the nidus of disease.
The specific ferments, which act on proteins, are now recognised, and
the physiological chemistry of such bodies as uric acid and purin bases
is discussed at length. In dealing with the average efficient intake of
proteids it is stated that “ one may scarcely call in question Professor
Chittenden’s results, but his conclusions are rather too general and are
scarcely warranted,” and, further, “those suffering from illness—the
liver, kidneys, and, perhaps, above all, the nervous system—may be
injuriously affected by such a diet.” It is not likely that Professor
Chittenden would press his conclusions to such extremities; the dietary
which he prescribed for experimental purposes affecting healthy males
must of course be adapted to the circumstances of disorder and
degeneration.

Much was expected from over-feeding and massage when it was
introduced by Dr. Weir-Mitchell, little good has resulted in asylum
practice. We find it stated in this work that “ the direct effect of mas¬
sage has been extraordinarily over-estimated.”

The second volume is of great practical interest. It deals with
Hunger and Chronic Starvation, Over-feeding, Fever and Infection,
and the various diseases of the bodily organs and systems. The
result is a treatise on the metabolism of diseased conditions, an
explanation of morbid phenomena of the highest importance. Professor
von Noorden has associated with himself authors whose studies are
authoritative in the domain of physiology and pathology, and the rela¬
tions of metabolism in health and disease. For those who are
endeavouring to illuminate the dark places of psychiatry the work is
indispensable.

Zur Psycho-pathologie des Alltagsleben [The Psycho-pathology of Every¬
day Life\ By Prof. S. Freud. 2nd Edition. Berlin: Karger,
1907. Pp. 132, 8vo. Price mk. 3.50.

In this volume (which is enlarged from a pamphlet published several
years ago) Prof. Freud discusses such problems as the causes of forget¬
fulness (more especially in the case of fairly familiar facts), lapses of
speech and of action, and, more generally, the significance of trifling,
involuntary, even unconscious actions and words as the expression of

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831

underlying and suppressed thoughts. The great actress, Eleanora
Duse (the author mentions), when representing the part of a wife who
is about to be unfaithful to her husband, mechanically plays with her
wedding-ring, removing it, replacing it, removing it; the ring automa¬
tically becomes the symbol of the wife’s fidelity.

All their lives, Freud believes, people are similarly revealing their
secrets in an automatic manner, and the skilful physician of the mind
is he who has trained himself to read that automatic language.

The general principle underlying all such phenomena is that imper¬
fectly repressed psychic material, even though pressed out of conscious¬
ness, is still not deprived of every means of outward expression. A
process goes on somewhat similar to that which, in a previous volume,
Freud has sought to trace in dreams, real feelings and ideas being
mechanically translated into new and perhaps trifling forms. In this
way, Freud believes, all sorts of secret and even unacknowledged pre¬
occupations and wishes, sometimes of a sexual character, become trans¬
formed into an entirely different shape, which may, however, be traced
back to their real source by careful psycho-analysis, because there are
always links of connection. These involuntary words and actions of
ordinary life are thus formed in exactly the same way as Freud believes
that the symptoms of hysteria and obsessional neuroses are built up;
“the boundaries between the normal and the abnormal nervous state
are fluctuating, and we are all a little * nervous.’”

Freud makes little reference to the work of other psychologists who
have sought to elucidate the phenomena, as, for instance, to the
American psychologists who have investigated lapses. He works out
his own ideas, relies on his own observations, and adds to the interest
of his book by the frankness with which he treats himself as a case for
demonstration. Some of his demonstrations, as of a wrong word which
persistently presents itself to the mind in place of the right word
which cannot be recalled, though highly ingenious and elaborate, at
times carry conviction. The author’s faith in his method leads him to
apply it to phenomena which usually receive a quite different kind of
explanation. For instance, he believes that the illusion of false recog¬
nition, by which we seem to recognise a place we have never before
seen, is not really an illusion at all; it is “ the reminiscence of an un¬
conscious day-dream,” more especially when associated with some
emotionally disturbing event.

There can be no doubt about the truth of the general principle on
which Freud lays stress, that even the most trifling actions have a
meaning, and are not without cause. Sometimes, also, the explana¬
tions reported by Freud in special cases are so adequate and apparently
so demonstrable by independent evidence, that we cannot refuse to
admit them. But in many cases, and especially when no independent
evidence is available, doubt is inevitable, because other explanations
suggest themselves. Thus, Freud is staying at an hotel where a young
man, awaiting the arrival of his wife, seeks his society; a day or two
later the wife arrives; Freud’s society presumably becomes unnecessary,
but the husband introduces the wife, and casually invites Freud to join
the couple at their breakfast table; when, however, Freud arrives the
third chair is occupied by the husband’s overcoat. Freud argues that

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REVIEWS.

[Oct,

the coat has been placed there automatically, as the expression of a
concealed feeling that the professor’s society is no longer welcome.
That is possible, but it is also true that, in the absence of any kind of
feeling, conscious or unconscious, the husband, with thoughts centred
on his newly-arrived wife, might still fling his coat on the one available
chair. I go to a locked drawer and automatically select from the bunch
the wrong key. There is a reason for that wrong selection. But the
reason is not, as Freud might be inclined to suppose, any secret
emotion or desire, sexual or other; the wrong key I have automatically
selected simply happens to be the key that I have lately most frequently
required,—that is to say, my action has been determined by the general
tendency of nervous action to flow in the direction of least resistance,
in the channel formed by habit.

Thus automatic actions are not always due to latent specific causes,
but often to latent general causes. And in every particular case we
have the problem of deciding between the possible specific cause
and the perhaps more probable general cause.

Such criticism, however, by no means destroys the interest and
value of Freud’s work, which cannot fail to be attractive to those whose
business it is to search beneath the surface of human speech and
human conduct for underlying causes.

Havelock Ellis.

Premiers Memoires de Siguiti sur P Idiotic (1838—1843). Publics par
Bourneville, Paris, 1897. 8vo. pp. 182.

Traitement moral Hygihie el Education des Idiots et des autres Enfants
arriirls. Par Edouard SfouiN. Preface par Bourneville.
Paris, 1906. 8vo. pp. 530.

In the first of these books we have the earliest writings of Dr. Edward
Seguin explaining the methods of teaching which he employed for
the training of idiots in the Bicetre. A suggestive paper is entitled
“ Advice to A.M.O. on the Education of his Son,” and also a larger
one on “ The Education of Backward Children and Idiots.”

In the second and larger volume we have a reprint of Dr. Seguin’s
French work on The Hygiene and Education of Idiots , first published in
1846.

Dr. Bourneville announces that he will bring out a volume containing
reports and memoirs by Seguin from 1846 to his death in 1880, and a
translation into French of his book On Idiocy and its Treatment by the
Physiological Method , New York, 1866. It is by this book that Seguin
is known to readers in the English language, and it includes the best
ideas of the preceding ones.

Leaving France in 1850 for the United States, with his great talent
and marvellous enthusiasm, Dr. Seguin gave a powerful impetus to the
establishment of training institutions for idiots in the New World. This
was the main object of his life. He practised for some time as a physi¬
cian, and wrote a good book on Medical Thermometry , but his last years
were spent in establishing, along with his second wife, in New York
City, a training school for feeble-minded children.

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PHYSIOLOGICAL PSYCHOLOGY.

833

Since the publication of his last work there have been advances in
the pathology of idiocy, but his writings still deserve study for his able
clinical observations and his acute analysis of mental symptoms.

The principles of education laid down by him in different treatises
are still the basis of all teaching of the feeble-minded, and, indeed, are
useful in ordinary pedagogy. The ingenuity of his methods, his skill in
teaching, and his indomitable perseverance are beyond all praise. Like
most enthusiasts, Seguin advanced beyond the strain of ordinary
endeavour; he was willing to bestow his efforts to arouse the most
torpid mental faculties. Utterly unselfish, he would not have sought a
fitter memorial than this republication of his labours which will still
carry on his life-work. These writings will be read with much profit by
all who are engaged in the teaching of the feeble-minded.

Much praise is due to Dr. Bourneville for including these works in
his Bibliothbque <Teducation speciale . This distinguished physician has
done a great work for the benefit of idiots and imbeciles by his vigorous
revival of the training at the Bicetre, and by his numerous and valuable
contributions to the pathology of idiocy.

William W. Ireland.

Epitome of Current Literature.

i. Physiological Psychology.

The Theory of Hysteria [.Hystirie et Somme if]. (Arch, de Neurol.; May
and June , 1907.) Sollier , P.

Sollier here presents a new statement of his theory of hysteria as a
form of sleep (first brought forward in 1897, and now based on a study
of 200 cases), at the same time answering various objections. As
before, he maintains the need of a physiological explanation of hysteria
as against Janet's psychological theory. But he admits that (as Binet
and Ingegnieros have pointed out) his and Janet's theories complete
each other rather than stand in opposition, Sollier maintaining that
the evolution of a symptom, in however masterly a manner it may be
unravelled, by no means constitutes a pathogenic explanation of the
disease presenting that symptom. Sollier's definition of hysteria now
is “ a functional physical trouble of brain, consisting in a localised or
generalised torpor or sleep, temporary or permanent, of the cerebral
centres, and translated according to the centre affected by manifesta¬
tions of a vaso-motor, trophic, visceral, sensorial or motor-psychic
nature, and also, according to its variations, its degree and its duration,
by transitory crises, permanent stigmata or paroxystic accidents.” Con¬
firmed hysterical subjects are thus simply persons in a state of vigil-
ambulism, whose sleep is more or less deep, more or less extended;
but Sollier now adds that whatever part of the cortex is affected,
sensibility, objective and subjective, is immediately and necessarily

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EPITOME.

[Oct.,

affected. “ Anaesthesia is the real sigillum hysteria .” Hysteria being
thus a sleep, treatment consists in a process of awakening by means of
super-nutrition, functional re-education, mecano-therapeutics, etc.
Sollier admits that hysteria is not a normal sleep, so that his definition
thus becomes more like an analogy; as he himself says, the sleep of
hysteria is more like that of a compressed nerve which, in popular
phrase, “goes to sleep.” Havelock Ellis.

The Value of Freud's Psycho-analytic Method \Die Bedeutung der
psychoatielytischen Methode nach Freud], ( Clbtt. f Nervenheilk. u.
Psychiat.,January , 1907.) Sadger .

For the past nine years Sadger has employed Freud’s methods of
treating hysteria and obsessions. He attaches more importance to the
practical side of Freud’s doctrine than to his theory, which has con¬
stantly developed, and cannot yet be considered to be in a satisfactorily
final state. But Freud’s central idea, that early sexual experiences have
a determining and decisive influence on the later history in congenitally
predisposed subjects, seems to Sadger, like Lister’s ideas in surgery, to
inaugurate a new epoch. Before Freud, hysterical symptoms could
neither be understood nor permanently removed; in both respects the
psycho-analytic method has effected a change. It will be seen that
Sadger is an uncompromising champion of Freud’s main idea : “ Behind
every symptom of hysteria and obsessional neurosis lie.concealed a mass
of sexual wishes,” to some extent stretching back to early childhood,
sometimes even to the first year of life. Sadger claims that when
hysteria is thus understood, no one who properly grasps the technique
of the psycho-analytic method can fail to cure it in every case. In the
hysterical we are always concerned, he believes, with what are, funda¬
mentally, childish feelings and desires; the hysterical combine the
intelligence of the adult with the logic of a child. The germs of all
kinds of perversities are to be found at the roots of the hysterical state,
not only (and very frequently) homosexuality, but also traces of sadism,
masochism, exhibitionism, fetichism, etc. It has been objected that
unconscious suggestion plays a large part in this method. Sadger
denies that this is the case, and asserts, on the contrary, that the
hysterical are peculiarly rebellious to any kind of suggestion outside
that of their own ideas. A more serious objection, he admits, is the
difficulty of the technique of the method and the length of time required
to leam it; he considers that it cannot be completely mastered in less
than three years. Under these circumstances it is to be feared that the
psycho-analytic method, whatever its merits, will be long in gaining
recognition. Havelock Ellis.

The Theory of the Duplex Brain [^wr la Symetrie Bilatlrale du Corps et
sur rindependance Fonctionelle des Hemispheres Clrcbraux ]. ( Arch,

de Neurol ., March — June^ 1907.) Bonne , Ch.

In a recent book, Sabatier—setting forth afresh in a very thorough¬
going and comprehensive manner an ancient theory—has argued that
throughout the greater part of the zoological series the entire organism
and the consciousness are alike dual, and that simple consciousness is

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NEUROLOGY.

835

I 907.]

based on a fundamental double consciousness. This theory, which
is both biological and psychological in character, Sabatier terms
“ duplicism.” In a series of four long and detailed articles, Dr. Bonne,
of Braqueville Asylum, traverses the entire field and shows that dupli¬
cism is contrary to all the data of biology, and also fails to afford any
satisfactory theory of the psychological facts it undertakes to explain.
He points out that even the concessions made twenty years ago by
Ribot as to the possible independence of the cerebral hemispheres under
some circumstances are to-day no longer admissible. Dr. Bonne’s
articles are too closely argued to be easily summarised, but they may be
commended to those who may still be inclined to think that the theory
of a duplex brain furnishes an easy explanation of complex psychic
phenomena. Havelock Ellis.

The Affective Characters of Perception [Les Caracteres Affectifs de la

Perception\. {Journ. de PsycholNorm . et Path. y July y 1907.)

Waynbaum.

The mental product of perception is a state of knowledge. Besides
the intellectual factor, however, perception also possesses an affective
factor. This emotional element arises in one of two ways : (1) because
the perception is not in harmony with the preceding mental state, and
thus enters the mind with a certain shock, or (2) because the perception
intrinsically contains an emotional element, the latter being, as it were,
carried in from the outside world. As regards the first variety the
emotional element disappears with repetition, and varies inversely with
the preceding state of preparedness of the consciousness. In this case
the emotion is due to a direct action upon the lower centres without the
intervention of the higher—it is perceptivo-emotional. In the second
variety, however, the higher centres are essentially involved, and the
process is ideo-emotional. The perception originates an idea, and the
idea originates an emotion. The arousal of sympathy is an excellent
example of this second type. Bernard Hart.

2 . Neurology.

Remarks on the Investigation of the Ganglion Cells in the Fresh State
\Einige Bemerkungen zur Untersuchung der Ganglien-zellun in
frischem Zustand ] (Centralbl. fur Nervenheilkunde y No. 238.)
De Montet\ Ch .

After describing some of his methods pf staining nerve-tissue, Dr.
Montet observes that when an examination of considerable area is to
be speedily made it is best to examine the tissues in the fresh state
without fixing them in any way. He makes a thin section with a
double knife and then stretches the preparation. The object glass
should be large and slightly warmed, and the staining solutions care¬
fully dropped upon it. After a minute the covering glass is put on.
Under this treatment the form of the nerve-cell is preserved and the
Nissl corpuscles come well out. Dr. Montet has found that with this

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836 EPITOME. [Oct.,

process of stretching the preparations suffer less change than when
subjected to great variations of temperature and osmotic pressure, and
that they present the most natural forms. In sections made on frozen
tissues, without formalin hardening, the nerve-cells are too much
injured. After formalin hardening the colouring by neutral red does
not turn out well.

Dr. Montet observes that this method of stretching sections is not
adapted to all inquiries nor can it take the place of sections with the
microtome. It is most useful when the examiner is pressed for time.

William W. Ireland.

3. ^Etiology of Insanity

On the Direct Descent of Hereditary Insanity [Ueber die Klinischen
Formen der Psychosen bet direkter Erblichkeit ]. (Centralbl. fur
Nervenheilkunde , No. 230.) Foerster .

Dr. Foerster has made a diligent inquiry into the history of families
in which there was a neurotic heredity. He carefully excluded all
cases in which the diagnosis was doubtful and arranged his material
into two groups. The first group, consisting of ascendants and descen¬
dants, comprised twenty-five families; the second group, consisting of
sisters and brothers, comprised thirty-one families. Each of these
groups were sub-divided into a and b , which stands for similar or dis¬
similar heredity. Group 1 a consists of eleven families in whom the
children were born eight times before and three times after the nervous
disease of the parents. In Group 1 b out of fourteen families the
descendants were born twelve times before and twice after the appear¬
ance of the disease in their parents. Group 2 a comprises twenty-three,
and Group 2 b only eight families. It is difficult to go into further
details without a prolonged abstract One result comes out that
dementia praecox and manic-depressive insanity often occur in direct
descent Only in four families was the hereditary disease more severe
with the children than with the parents. In the discussion, which
followed the paper, Dr. Thomson stated that in his observations, he
found the disease more severe with the children.

William W. Ireland.

4. Clinical Psychiatry.

Writers Cramp treated by the Method of Ligature \Crampe des
Acrivains guirie par la Ligature elastiquc], (Arch, de Neurol ., fuly f
1906.) Hartenburg , P.

The author has systematically employed the method of ligature,
originally advocated by Bier for arthritic cases, in various neuro¬
muscular disorders, contractures, spasms, cramps, etc. The results
have, on the whole, been satisfactory.

In the case of writer’s cramp described in the present paper, the

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CLINICAL PSYCHIATRY.

837

patient’s fingers became immediately rigid whenever he attempted to
write. When the case came under the author’s care, the condition had
already persisted for fifteen years, and numerous methods of treatment
had been employed without avail. The patient was directed to tie
a piece of indiarubber tubing around the upper arm, the ligature being
applied for twenty minutes morning and evening. The object aimed
at was the induction of venous stasis. An almost complete cure
resulted in two months. The author is of opinion that the effect
cannot be ascribed to suggestion, as he only saw the patient once during
the whole period of treatment. Bernard Hart.

Delusion of Altered Personality [Sur un cas de Dllire Mitabolique de la
Personnalite lii a des troubles de la Ccenesthesie\ Arch . de Neurol .,
October , 1905.) Deny , G., et Camus , P.

A female patient, aet. 37, was admitted to the Salp£tri£re with the
following history. As a result, apparently, of prolonged emotional
stress, a state of anxiety appeared, with obsessive self-absorption, agita¬
tion, weeping, etc. Hypochondriacal ideas of negation then arose, and
finally ideas of corporeal transformation. The patient believed herself
changed into a dog, a bull, a man—she no longer recognised herself,
and bewailed the metamorphosis of her old personality. Limited at
first to her physical self, the change gradually involved the psychical
self. Similarly the patient’s family and surroundings appeared to be
changed: her mother became the Virgin Mary, her husband Jesus
Christ. In spite of the grandiose character of these delusions, the
depression and anxiety persisted. Orientation in time and space was
very defective.

The author ascribes the ideas of corporeal transformation to a dis¬
turbance of the cortical centres in which are registered the organic
sensations underlying our notion of bodily existence. The ideas of
transformation are due to a false interpretation of the abnormal sensa¬
tions experienced by the patient. The disturbance of the cerebral
cocnaesthesia affects the organic element of the sensorial perceptions,
leaving their specific element intact. Hence the patient recognises and
identifies persons and things up to a certain point, but maintains that
they have undergone some kind of change. The present sensations,
moreover, being deprived of the affective element inseparable from their
coenaesthetic component, cannot be superposed on those fixed by the
memory. Hence the doubts, hesitations, and profound disorientation
with regard to time and space.

The above interpretation is simply a development of that already
applied to similar cases by Ribot, Cotard, and S^glas.

Bernard Hart.

Eroticism in an Eunuch [Eunuchisme et Erotisme]. (Le Prog. Med .,
Jan. 26M, 1907.) Marie .

This very brief note refers to a case seen by Dr. Marie in Dr.
Warnock’s asylum at Abbamih. The patient, a slave from Kordofan,
aet. about 40, had been completely castrated in infancy. He was con¬
genitally dlbile, and for some years before his admission to the asylum

LIII. 58

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EPITOME.

[Oct.

he had been addicted to the use of haschisch. Under the influence of
this intoxication, he developed an imperfectly organised delirium of
exaltation, the most remarkable feature of which was its sexual content
He had hallucinations of connection with an invisible princess, from
which he professed to experience extreme voluptuous sensation with
emission, and he had delusions of vast amorous and procreative
powers. Rectal examination showed that the prostate was normally
developed and that the vesiculae seminales were not atrophied. The
author inclines to the view that the persistence of these organs may
account for the emissions alleged by the patient, the peripheral stimulus
being properly supplied by irritation of the urethral mucous membrane.
He further emphasises the bearing of the case as evidence of the
possibility of psychical erotism independently of the functional aptitude
of the sexual organs. W. C. Sullivan.

Right-handedness and Left-handedness in connection with Functional
Asymmetry of the Brain \Destrismo e Mancinismo in relazione colic
Asimmetrie Funzionali del Cervello\ (Arch, di Psychiat ., vol. xxviii,
fasc. Hi, 1907.) Lattes.

In this paper, the author considers the question of dextral pre-eminence
in connection with the researches which he has recently made regarding
cerebral asymmetry in normal and criminal subjects (vide ‘Epitome,’
July, 1907). The conclusions which he drew from these researches
were that the usual mode of such asymmetry consists in a predominance
in the left hemisphere of the Rolandic and occipital areas, and in
the right hemisphere of the parietal lobules and the anterior frontal
region, a condition which he interprets as meaning that in the course of
evolution there has been a greater development in the left brain of the
centres of projection and in the right brain of the centres of association.
Right-handedness, therefore, he would regard as simply a functional
manifestation of this general tendency to the more extensive develop¬
ment of the psychically inferior centres in the left brain, other instances
of which are to be seen in the usual localisation on the same side of the
secondary speech centres. An inversion of this arrangement would
account for left-handedness so far as concerns its occurrence in otherwise
normal persons. In the case, however, of the criminal and the epileptic,
in whom, according to the Italian school, left-handedness is extremely
common (occurring in from 23 to 30 per cent, of such persons), the
author has to seek a different explanation, for in his investigations he
has failed to find in the criminal brain any such inversion of the con¬
volutional pattern as this view would require. To meet this difficulty
he has recourse to a somewhat fanciful theory: arguing from the
observation that the convulsive discharge in a large proportion of
epileptics is either earlier or more marked on the right side ot the body,
he takes this to mean that in the epileptic, and therefore, ex hypothesi
Lombrosiana , in the criminal, there exists a pathological condition of the
left hemisphere, in consequence of which its functional activity is
lowered, so that right-handedness fails to develop. He distinguishes,
accordingly, two types of left-handedness—one, which he terms atavistic
and constitutional, being connected with an inversion of the usual

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SOCIOLOGY.

1907 .]

839

cerebral asymmetry, while the other is the manifestation of a lesion in
the left hemisphere. The ascription of any alleged peculiarity of the
criminal to a pathological rather than to an “ atavistic ” source is un¬
usual in the pages of this journal. W. C. Sullivan.

5. Sociology.

Mentally Abnormal Children in Schools, (/oum. de Mid. de Bordeaux ,
June 2nd andqth, 1907.) Regis, E.

Dr. E. Regis, a well-known writer and lecturer on insanity, has
collected much information about the progress of the movement for the
education of mentally deficient children throughout Europe. After
detailing what has been already done in Switzerland, Holland, Belgium,
and Italy for the establishment of special schools, he observes that the
organisation of the education of mentally abnormal children in England
is well advanced. He presents a table of thirty-one English towns
which have special schools, numbering 152 in all, with 7,383 pupils.
London alone counts eighty-nine special schools, with 4,423 pupils.
He adds that in England these special schools are completed by different
institutions designed to give manual education to the children, improve
their physical defects, and to protect them when their formal education
is over. Dr. Regis does not mention the Royal Commission for
inquiry into the existing methods of dealing with idiots and epileptics,
and with imbecile, feeble-minded or defective persons under the
lunacy laws in Great Britain and Ireland, which has been collecting
evidence for two years, and may be expected soon to issue a report.
In the German Empire, there are now 150 towns which have 230
Hilfsschulen with 660 classes and 15,000 children. He thus sums up:
We see that most of the countries of Europe have instituted special
classes for the education of abnormal children; some of these classes
are attached to the ordinary schools, but most of them are in separate
schools, either as out-door pupils, or keeping them for the day, or
caring for them entirely. The number of pupils is generally about
twenty for each class. In some towns children of both sexes are
educated together.

Dr. Regis confesses that France has remained behind in this general
movement, but she appears to be awakening. A commission instituted
in 1904, and composed of some distinguished men under the
presidency of M. Leon Bourgeois, has issued a report which is
being embodied in a law to be proposed by the Minister of Instruction.
This will lead to the creation of special schools, some attached to the
ordinary schools, others for boarders and half-boarders.

In the meantime, the municipalities of Paris, Lyons, and Bordeaux
have been taking the lead in trying to associate philanthropists, doctors,
and teachers to interest themselves on behalf of these unfortunate
children. In Bordeaux, a census has been taken of the children
who are unfit to be educated at ordinary schools, and amongst 8,735
male pupils at the public schools 45 2 were found to be abnormal—that

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NOTES AND NEWS.

[Oct,

is, 5*17 per cent. Of these abnormal children, 134 were put down as
backward ( arrierh) and 318 as feeble-minded. Dr. Regis proposes to
have four special schools in Bordeaux for the 800 or 900 pupils who
require such an education. Each of these schools should have a
gradation of eight classes. He considers that in France the sexes
should be separate. Dr. Regis informs us that in 1904 the Minister
for Public Instruction created a Chair for “ Abnormal Pedology ” in
the Normal School for Teachers of the Seine, to which Dr. Gauraud
was appointed. Dr. Regis’s proposals comprehend the training of
teachers for these special schools, and gratuitous consultations for the
parents of such children given by physicians specially qualified.

William W. Ireland.

Part IV.—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The sixty-sixth annual meeting of the Association began at 11 a.m. on
Thursday, July 25th, 1907, at n, Chandos Street, Cavendish Square, London, W.;
Dr. Robert Jones, the retiring President, occupied the chair.

Present: F. Beach, G. F. Blandford, C. H. Bond, D. Bower, A. H. Boyle, J. F.
Bristoe, L. C. Bruce, J. Carswell, J. Chambers, W. S. Clapham, T. S. Clouston,
R H. Cole, H. Corner, S. Coupland, M. Craig, J. F. Dixon, T. O. C. Donelan,
A. C. Dore, A. R. Douglas, T. Drapes, G. J. Eady, C.C. Easterbrook, F. A. Elkins,
J. A. Ewan, R. W. Gilmour, E. Goodall, H. E. Haynes, G. S. Hine, C. K. Hitch¬
cock, G. Johnston, Robert Jones, N. Lavers, H. W. Lewis, A. C. MacBryan, P. W.
MacDonald, T. W. McDowall, W. J. Mackeowen, D. McRae, H. J. Manning,
M. E. Martin, W. F. Menzies, C. Mercier, J. Merson, W. I. Mickle, A. Miller,
C. S. Morrison, D. Nicholson, W. F. Nelis, H. Hayes Newington, ConoUy
Norman, J. A. Oakshott, D. Orr, L. R. Oswald, M. E. Paul, E. Powell, H. Rayner,
W. F. Robertson, J. Round, R. G. Rows, G. H. Savage, J. Scott, G. E. Shuttle-
worth, R. Percy Smith, J. B. Spence, R. H. Steen, W. H. B. Stoddart, D. G.
Thomson, T. S. Tuke, A. R. Turnbull, A. R. Urquhart, E. B. Whitcombe, E. W.
White, A. Wilson, D. Yellowlees.

Among the visitors were: T. F. Althaus, W. N. Bullard, W. S. Chisholm,
A. J. R. Foulnton, A. H. Hogarth, E. Howard, H. M. Hurd, N. Keith, Mrs. Pegler,
L. H. Pegler, C. Rolleston, Mrs. H. Soley, E. E. Southard, M. White.

Thirty-six members intimated their inability to be present.

The minutes of the preceding annual meeting were taken as read, confirmed, and
signed.

Election of Officers and Council.

For the election of officers and council the President nominated Dr. Paul, Dr.
Goodall, Dr. Maurice Craig, and Dr.Turnbull, to act as scrutineers. The following
were declared to be unanimously elected:

President .P. W. Macdonald.

President-elect . Chas. H. Mercier.

Ex-President ....... Robert Jones.

Treasurer ........ H. Hayes Newington.

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NOTES AND NEWS.

84I

Editors of Journal .

General Secretary

Registrar .....

Examiners for Nursing Certificate
Auditors .

( Henry Rayner.
Alex. R. Urquhart.
Conolly Norman.
James Chambers.

C. Hubert Bond.
Alfred Miller.

'A. R. Turnbull.

< Conolly Norman.

. Bedford Pierce.
Theo. B. Hyslop.

\ D. G. Thompson.

Members of Council .

Joseph S. Bolton, Thos. S. Clouston, Theo. B. Hyslop, Geo. H. Savage,
John Turner, T. Outterson Wood.

Officers and Council elected by the Divisions.

South-Eastern Division .—A. N. Boycott, C. H. Fennell, Chas. A. Mercier,
R. H. Steen ( Secretary ), Ernest W. White.

South-Western Division. — H. T. S. Aveline ( Secretary ), F. St. J. Bullbn,
Edwin Goodall.

Northern and Midland Division. —J. A. Ewan, T. W. McDowall, Bedford
Pierce ( Secretary ), David Orr.

Scotch Division .—Lewis C. Bruce, Hamilton C. Marr ( Secretary ), A. R.
Turnbull.

Irish Division. — W. R. Dawson ( Secretary ), Thos. Drapes, M. J. Nolan.

Examiners for England. —Maurice Craig, Robert Jones.

Examiners for Scotland. —L. R. Oswald, W. Ford Robertson.

Examiners for Ireland. —W. R. Dawson, Wm. Graham.

Dr. Hyslop and Dr. Thomson were elected auditors.

The President, before proceeding with the next business, said it was a pleasure
to welcome to the meeting, on behalf of the Association, Dr. Hurd, from the Johns
Hopkins University, Baltimore.

Election of Standing Committees.

The President then put the list of gentlemen to form the Parliamentary Com¬
mittee, and it was carried.

Dr. Yellowlees desired that the name of Dr. Oswald should be added to the
Educational Committee, since he was now Lecturer on Insanity at Glasgow
University.

Dr. Clouston seconded, and the amended list was unanimously agreed to.

The President said the names on the Library Committee at present were:
Dr. Fletcher Beach, Dr. Rayner, Dr. Outterson Wood, and Dr. R. H. Cole. All
those gentlemen were now proposed for re-election. The names were unanimously
agreed to.

Report of the Council.

The General Secretary (Dr. Hubert Bond) read this report and moved its
adoption.

The Council reports that the number of members—ordinary, honorary, and
corresponding—on December 31st, 1906, was 685. This is a decrease by three, as
compared with the corresponding figure for the previous year, and is explained by
the heavy number of deaths and removals—namely, 37. Thirty-six new members
were registered during the year, and five resigned. The following Table shows the
membership during the past decade:

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NOTES AND NEWS.

[Oct., 1907.

| Members.

I897

1898

1899

1900

1901

190s

1903

1904

! »»«5

1906

Ordinary

524

540

550

568

580

586

597

620

1 .

641

: 638

Honorary

I 35

Corresponding

| Total

574

590

598

6l6

628

635

645

670

688

685

The Council regrets to have to chronicle the deaths during the year 1906 of the
following thirteen members : Drs. W. L. Andriezen, C. Angus, F. Hurst Craddock,
A. J. Grant, W. H. McCutchan, J. G. McDowell, J. Malony, A. H. Nash, G. H.
Pearce, R. S. Stewart, and G. P. Torney. This unusually heavy list has been
augmented during the current year by the loss by death of two distinguished
honorary members.

The usual quarterly meetings took place in February, May, and November.
That in February was, by the courtesy of Dr. A. M. Jackson, held at the Notts
Countv Asylum, Radcliffe-on-Trent, an asylum opened within the last six years,
and which afforded the members a very pleasant visit. At the November meeting
an illuminated address was presented to the President in recognition of his long
and valued services as General Secretary, which extended over nine years. Eleven
divisional meetings were held.

The important question of the attitude of the Association towards the proposed
union of medical societies has been under further consideration during the year.
For weighty reasons the Association has been unable to see its way to join in the
newly formed Royal Society of Medicine.

The Educational Committee, under the chairmanship of Dr. Mercier, and the
Parliamentary Committee, under the chairmanship of Dr. Ernest White, present
their reports, which reflect arduous and valuable work, accomplished and in progress.

In addition to the business of the standing committees, much important work
delegated to special committees has been overtaken.

The Statistical Committee continued to act as such until the presentation of
their report at the last annual meeting, when the new set of tables were finally
adopted. The new year saw the first fruits of their labours in the coming into force
of the Lunacy Commissioners’ new registers, in which the material to be tabulated
will be found conveniently arranged. In readiness for early next year, when the first
set of the new tables will fall due, compilation-forms and expansion-tables have
been devised and are now obtainable from the printer.

The Classification Committee also brought up their labours to a close at the last
annual meeting, and, following the adoption of their report, the new list of insanities
is now in general use.

A Workmen’s Compensation Act Committee was appointed to deal with some
important matters in connection with the new Act, to which the attention of the
Association had been drawn by the treasurer.

The Housing Committee, in view of the probably imminent building operations
on the part of the Medical Society, is again active.

The Journal continues under the same acceptable editorship, and a satisfactory
circulation of it is maintained.

The Library Committee continue their work.

The number of entries for the nursing certificate were not so numerous in 1906
as in the previous year, nevertheless the work of the registrar has been heavy. To
him, the divisional and other secretaries, the best thanks of the Association are due.

The President asked whether anyone wished to offer any remarks upon it.

Dr. MacDonald seconded the adoption of the report, and it was carried.

The Treasurer’s Report.

The Treasurer (Dr. Hayes Newington) read his report and moved its
adoption.

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WOODINGTON, F.C.A. H. HAYES NEWINGTON, Trea*crsr.

844

NOTES AND NEWS.

[Oct.,

Dr. Yellowlees seconded, and with special thanks to the Treasurer for the
admirable resumd in which he had presented the financial history of the Associa¬
tion during a number of years.

The report was agreed to.

Auditors’ Report.

Dr. Spence submitted the auditors’ report, and took the opportunity of con¬
gratulating the Treasurer on the way in which the accounts were kept. He thought
the Association had a most admirable Treasurer. He proposed its adoption.

Dr. Thomson seconded the adoption, and it was carried without discussion.

We have examined the accounts of the Treasurer for the year ending December
31st, 1906, and have seen the vouchers, and have found the same correct

E. B. Whitcombs, \

July 24 th % 1907. J. B. Spence, J Aud,tors *

The Treasurer briefly acknowledged the kind words of Drs. Yelbwlees and
Spence, and said that the prosperity of the Association must, of course, depend on
the energy of the general secretary, the other secretaries, and the members
generally.

Report of the Editors.

Dr. Urquhart expressed his regret that Dr. Rayner was not present, but the
Editors’ report was of the simplest possible character. It merely stated that the
operations of the Journal had been conducted upon the same principles as hereto¬
fore, and that the sales and advertisements had been adequately maintained. He
proposed that the report be received.

Dr. Clouston said he had much pleasure in seconding the adoption of the
report. As a past editor he thoroughly agreed that the Journal was uncommonly
well edited; and it was of great interest, not only to members of the Association,
but to the whole medical profession.

Agreed.

Standing Committees.

Report of the Principal Work of the Educational Committee since
the Annual Meeting, 1906.

A resolution was passed at the Annual Meeting, 1905, to the effect that a
preliminary report of the year's work done by the Educational Committee be
issued some time prior to the reading of the full report, as is customary at the
annual meeting.

The following is a brief account of the work done by this Committee up to, and
including, the last May meeting:

The Educational Committee have held many meetings during the year, and have
had several important subjects before them for consideration. Amongt other
matters the following have been dealt with :

At the request of the Educational Committee the examiners for the nursing
certificate conferred together to inquire whether it was possible to improve the
method of marking in the written portion of the nursing examination. After duly
considering the matter the present examiners have decided that each examiner
will hand over to the other examiners his “ markings ” in case of failures, and
that all the candidates’ papers will be preserved until after the following examination.

The Sub-Committee re Nursing Certificate was re-appointed, and has made a
further report to the Educational Committee. This report is still before the
Committee, and will be thoroughly considered at the July meeting.

According to the instructions given to the Educational Committee at the last
annual meeting, the revision of the Nursing Handbook has been begun, and the
Committee appointed has had several meetings.

The publishers of the Nursing Handbook have been instructed to issue a small
reprint of the present edition of the handbook pending the publication of the new
edition.

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NOTES AND NEWS.

845

I907.]

The Sub-Committee re Disciplinary Cases have had several meetings, and were
present at a conference with the Association solicitor and the counsel selected by
him. As a result of the Sub-Committee’s recommendation a letter has been
drawn up, and will be sent to the medical superintendents, heads of nursing
homes, etc. The object of this letter is to advise an employer to apply to the
Registrar of the Association to learn whether the name of any nurse applying for
employment who states that he or she is a holder of the Association nursing
certificate is still on the register.

The Registrar reported that 143 candidates entered, and 102 passed, the nursing
examination held in November, 1906.

(Signed) CHARLES MERCIER, Chairman.

MAURICE CRAIG, Hon. Sec.

Continuation of Report of Educational Committee to Annual Meeting , 1907.

As a general instruction to the Registrar, it has been decided that nurses com¬
pleting a training of three years in a general hospital containing 100 or more beds,
and in which probationers are received and training given, be admitted to the
nursing examination under the two-year rule.

As a general instruction, it has been decided that in the case of a nurse losing
his or her certificate, application may be made to the Registrar, accompanied by a
recommendation from any member of the Association, identifying the applicant as
a nurse who has taken the certificate. On receipt of such letter the Registrar be
empowered to issue a letter stating that the applicant is on the register.

The Registrar reported that 449 candidates sat for the nursing examination in
May, and that 341 were successful (75 per cent.).

Four candidates entered for the professional examination in July, and all passed.

There was no candidate for the Gaskell prize.

One essay was received for the bronze medal, but the examiners did not consider
it of sufficient merit to award the prize.

Dr. Craig read this report, and moved that it be received and adopted.

Dr. Mercier seconded.

Dr. Oswald said that at an annual meeting of the Association he asked whether
it would be possible to have mentioned in the report as to the nursing examination
how many failed in the written portion and how many in the oral. In reply he
received a conditional promise that it would be given. No information, however,
was given as to whether there was a larger percentage of failures in the written or
in the practical portion; but considering the greater importance of the practical
as compared with the theoretical, he thought it should be stated. He had a strong
belief that a much larger number failed in the written than in the practical, and he
did not think that should be. The practical examination wa^ infinitely more
important than the written, and he did not think the practical part would be satis¬
factory until the Council took the matter into its own hands and conducted it, as
they conducted the written part. He asked whether it would now be possible to
learn the numbers who failed in the practical part of the examination.

Dr. Millar (Registrar) said he could say at once that the number of failures in
the oral examination was but a small fraction of those who failed in the other.
During his five years of office it had invariably been the case that the failures at
the paper examination represented practically the entire failures, the others being
quite insignificant.

The report was agreed to.

Report of Parliamentary Committee.

During the past year the Committee has met six times, and its Lunacy Legislation
Sub-Committee twice.

The Carswell Case.

The Committee recommended '* that the Association should take such steps as
it can towards obtaining in any further Lunacy Act relating to England such
alteration in the present provision (Section 330, Lunacy Act, 1890) for the pro-

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846

NOTES AND NEWS.

[Oct,

tection of medical men giving certificates as will cast the duty of proving neglect
or bad faith on the person bringing an action under that Section.” It further
recommended “ that steps should be taken to secure proper protection to medical
men giving certificates in Scotland and Ireland.”

Royal Commission on the Care and Control of the Feeble-minded for England and

Wales.

After meeting representatives of the British Medical Association and finding
them in general agreement with our views your Committee resolved that evidence
be given to the following effect:

(1) That two additional Medical Commissioners should be appointed.

(2) That Assistant or Deputy Commissioners should be appointed in such
number as may be required in view of any increased duties that may be imposed
on the Commission, the Assistant Commissioners only to visit in the place of
Commissioners as and when directed by the Board, and to be attached to the
London office and not to any local district.

(3) That where visits are now required to be paid by two or more Commissioners,
a visit bv one or more should be sufficient.

(4) That the Commissioners themselves should alone carry out the ordinary
visitation of asylums, hospitals, and licensed houses.

(5) That the disqualification for appointment as Lord Chancellor’s Visitor and
Lunacy Commissioner imposed by Sections 158 and 165 of the Lunacy Act, 1890,
on certain medical practitioners connected with licensed houses should be
abolished.

The State Registration of Mental Nurses.

The Committee and Sub-Committee gave much time to the consideration of
this matter, which was raised by Dr. Outterson Wood, to whom the Committee is
greatly indebted for drafting the letter and petition, and for his history of the
movement printed in the April number of the Journal, and which relieves this
Committee of the necessity of reporting at length.

The petition forms were returned (signed) promptly in many cases, very slowly
in some, and not at all in a considerable number, although it was kept open till
June 13th.

The petition, with 8,150 signatures attached, was sent to the Prime Minister on
June 13th, 1907, by the Honorary Secretary of the Committee, who called his
attention to the fact that the petition hnd been widely signed, not only by large
numbers of the ordinary staff of the various asylums, but in most cases by the
medical staff, and in many cases by the members of the asylum committees
appointed by the county councils.

Possible Irish Legislation.

At the instance of Dr. Dawson, Honorary Secretary of the Irish Division, who
came specially to London on two occasions and presented a memorandum on the
possible effect such legislation might have on lunacy administration in Ireland,
the Committee addressed a communication to the Secretary of State for Ireland
on April 7th, which was duly acknowledged.

The text of the communication appears in the April number of the Journal.

Superannuation cf Irish Asylum Officials.

A memorandum on this subject was received from Dr. Conolly Norman at the
meeting on May 16th. It was pointed out that this matter was included (para¬
graph 7) in the communication recently made to the Chief Secretary.

(Signed) Ernest W. White, Chairman ,

June 19th, 1907. David Bower, Honorary Secretary .

Dr. Bower submitted this report for acceptance. It had been in the hands of
members, but required slight verbal correction to indicate that the remarks con¬
cerning the Royal Commission on the Care and Control of the Feeble-minded
were confined to England and Wales. With that trifling correction he moved its
adoption.

Dr. Ernest White seconded, and it was agreed to.

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NOTES AND NEWS.

847

Report of Library Committee.

Dr. Fletcher Beach said the Library Committee had not met very lately, and
therefore they had not presented a report that day. The books in the library were
in good order, and books would at any time be thankfully received from members.
He hoped the Association would accept that verbal report. The library did not
cost the Association anything, because the interest on the Hack-Tuke Memorial
Fund practically paid for the carrying on of the work there. Something had to be
paid to the man in charge for looking after the books, and books could now, under
certain rules, be sent out to members; i. e., if a member wished for a book, he had
to send up the name and to pay the carriage on the book back to the library. He
proposed the adoption of that verbal report.

Dr. Oswald seconded, and asked whether it would not be better if the journals
sent in exchange could be available to members. He had recently had occasion to
ask for foreign journals, and by the kindness of the editors they were sent. He
thought members would gladly avail themselves of the opportunity to see other
journals, and therefore made that suggestion in seconding the adoption of the
report.

The President said Dr. Oswald’s suggestion was a very reasonable one, and he
was sure the Library Committee would gladly consider it.

Dr. Fletcher Beach said that everything the Library Committee could do
would be done to meet Dr. Oswald’s wishes.

The report was agreed to.

Reports of Special Committees.

To receive from the Council a communication as to a committee appointed by
itself in May, 1907, for the purpose of considering the future accommodation of the
Association and its library, and with power to confer with other bodies if neces¬
sary. The President said that he was asked to state that the matter had been
before the Council that morning. There was a Housing Committee, which was
making inquiries into the accommodation proposed to be added to the premises.
That committee had had several sittings.

Dr. Hayes Newington, in the enforced absence of Dr. Percy Smith, the
Chairman of the Committee, said it might be within the recollection of those who
attended the May meeting that the question to which the President had alluded
was then brought forward; and a few words were necessary by way of explana¬
tion and history. Some years ago the proprietors of the building wherein
they were then thought of extending the accommodation ; and as the Association
were old tenants they naturally offered, under certain conditions, some increased
room which was so much desired for the library and other purposes. That ques¬
tion was hung up for a time by the proposal to form a Royal Academy of Medicine.
The Association had not found itself able to join, nor had the Medical Society of
London, who were the owners of the premises. Therefore the question between
these two latter bodies had come up again, and as time was rather pressing the
Council appointed the committee of four or five members to negociate, and several
meetings had been held. The matter was still the subject of negotiation, and it
would be undesirable to enter into particulars at that stage. But he could report,
on behalf of the Chairman, that the Council had seen fit that morning to re-appoint
the same Committee, with power to negotiate, but with no power to accept any
proposal without full consent. The notice would not have been on the agenda that
day had there not been a chance of the Association being called upon to come to a
definite conclusion on the matter. The chance was a small one, but it might have
arisen. But as matters now stood the Committee had not been able to recom¬
mend to the Council the closing of the matter yet. Therefore action by the
annual meeting would have to be postponed. If the Council went far enough to
come to any provisional agreement with the Medical Society the question would
come up again to receive the sanction of the next annual meeting. No doubt the
Council would see fit to give some notice of any proposal to all members. At all
events it would be on the agenda paper, so that every member would have ample
opportunity to turn the matter over in his mind and come to a conclusion. He

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NOTES AND NEWS.

848

[Oct,

concluded by moving that the action of the Council in re-appointing the Corn-
mittee be endorsed.

Dr. Urquhart seconded.

Dr. Clouston pointed out that part of the resolution was “to take such action
on the Council’s communication as may be deemed to be expedient,*' and asked if
that meant that the Committee virtually had power to commit the Association to
the expenditure of any amount per year for extra accommodation.

Dr. Newington said it was a notice to the Association itself to take such action.

Dr. Clouston said, in that event, the words “ by the Association ” should be
added after “ expedient."

The President said he thought that was guarded against in the Standii^
Orders. The Association had power to spend only jfio without coming to the
meeting.

Dr. Bower said he did not think those two lines were included in the main
resolution.

Dr. Newington said the annual meeting was asked to receive from the Council
a recommendation. The second portion was to ask the annual meeting to take
such action on it as might be deemed expedient, should it be found desirable to
propose action. But there was not yet anything of that nature before it.

Dr. Clouston said he was satisfied. It was merely that he had had a doubt in
his mind.

Report from the Workmen's Compensation Act Committee.

Dr. Newington said he had, as chairman of the Workmen’s Compensation Act
Committee, to present their report. It would be remembered that at the last
general meeting in May a statement was made by himself on the possible effects of
the Workmen's Compensation Act, and it seemed to him and the members of the
Association generally that some steps should be taken to see that the public did
not suffer at the hands of the insurance offices from ignorance of the actual facts.
The Committee of the Association had taken a considerable amount of trouble in
getting returns, and it desired to thank cordially all those superintendents who had
been kind enough to help them, as the great majority had done. A confidential
statement had been circulated, and he thought the effect of the Committee’s work
had been satisfactory. At all events, as was now well known, the bottom was
knocked out of the excessive demand which was made in the first instance by
insurance offices. The insurance could now be effected at rather reasonable rates,
and the Committee claimed to have done something in bringing that about It
also undertook to bring the question before associations and corporations of
nurses, because serious mischief might easily arise from an accident arising in a
private house to a nurse who had not been insured by anybody. The Committee
were informed that the onus would then fall on the head of the house. There
might be some doubt about that. But anyhow, supposing the head of the house
had the necessity to pay, say, ,£500 for a permanent injury to a nurse, there would
be a great outcry, and it would be asked how it came about that, without any
warning, such a source of danger was brought into a private house. It would
follow as a necessity that medical men, especially those who consulted on insanity,
would advise that a nurse should be never taken into a house unless some steps
were taken to have her or him insured. The Committee found that several of
these bodies had taken the view that the nurse should look after herself, but, as the
result of the Committee’s representations, the principal Corporation had written a
rather nice letter, saying that in consequence of the Committee’s advice it had
insured all its nurses. One or two other bodies had also, he thought, adopted the
Committee’s advice. Returning to asylum risks, the Committee wished most
emphatically to repudiate the idea that in contesting the extravagant notions of the
insurance offices it was depreciating the actual risk that was run in asylums. The
figures given showed that the risk existed substantially, and was in some cases
exceedingly serious.

Dr. MacDonald seconded the report of the committee. The thanks of the
meeting and of the whole Association were due to it for its great energy and hard
work, and for the private information circulated.

Dr. Bower confirmed these remarks. The Asylum Committee, on which he sat,

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1907 .]

849

postponed the whole question until the committee of the Association had done its
work.

The President said that the Council had considered the report before the
annual meeting and all agreed that there was a tremendous amount of work repre¬
sented in it, and they specially thanked Dr. Newington for the trouble and interest
which he had taken in the subject. It must be of very great importance to the
administrators of asylums to know exactly how the risks stood.

The President then said that a very special subject was dealt with by the Council
that morning. All the members had had circulated to them the Report of the
Parliamentary Committee, in which occurred a particular paragraph, commencing,
M The Committee recommended that the Association should take steps,” etc.
This referred to a member of our Association, and all other members felt great
sympathy with Dr. Carswell, and he thought it would be well to ask that gentle¬
man to state what he wished to bring before the annual meeting of the Association.
The Council felt so strongly on the matter that they had asked Dr. Clouston,
who had taken special interest in the subject, to bring a special recommendation
to the Association at that meeting.

Dr. Carswell said the questions which had arisen in connection with the case
that he had had an unfortunate association with were, mainly, two. The first of
those, relating to civil actions, was dealt with in the report, which was in the hands
of members; and he supposed he might take it—at least he read the report of the
Parliamentary Committee to mean—that if adopted by the Association members
were free to consider what steps might be taken to give practical effect to the
recommendations of the Association for the protection of the medical man against
civil actions. And he supposed that the subject might come up again through
reports from the Scotch and Irish sections. Personally, he had been forced to give
the question of civil procedure against medical men for the granting of certificates
very close and serious attention, and he had come to the distinct conclusion that
anything short of making a demand for full protection would weaken their position.
He was aware that to ask that the profession should be placed in exactly the san\p
position as a trade union—which had been put outside the common law by
legislation which followed upon the Taff Vale decision—was quite impossible,
because they had not got the votes to return Members of Parliament who
would secure what his hearers regarded as an act of justice. It seemed to him
a very extraordinary position that the public, in the lunacy legislation for
their own protection, had laid upon the profession the duty of certifying people
before they could be put in asylums, and the public had taken no risks
at all, but had passed on the entire risks to the profession. It was to
save the public from being shot, being murdered, or being maimed, that the
lunacy legislation was framed. And the public, under that legislation, took no
responsibility whatever. That he regarded as not at all a fair bargain. When
the public sought to restrain criminals, and even petty offenders in the way of
drunkards, etc., they placed the duty of laying them by the heels on the magistrate
and others, but those magistrates were not rendered liable to civil action. And he
thought the profession had good cause for making out a very strong position in
asking for some protection which would not be merely imaginary, but would be a
real and substantial protection. What steps were necessary to secure that would
require further and careful study. But, from the public point of view, a more
serious series of questions had arisen by the ultimate proceedings in connection
with the man William Purvis. It would probably be within the recollection of
most of those present that that man was tried before the High Court at Glasgow,
and that the Crown, following the precedent of a case which had been tried in
Edinburgh before the Lord Justice General of Scotland, set up the plea of insanity,
the result of which was that the defence was in the peculiar position of trying to
prove an indictment against the accused, and the Crown was in the equally
peculiar position of trying to prove the innocence of an accused person. That
course was followed in consequence of a precedent set up in what had come to be
known as the Cumnock poisoning case, where five judges of the High Court of
Justiciary ruled that the question of insanity in a trial might not be tried by a
judge, but might be passed on to the jury along with the merits of the case. The
result had been a considerable bewilderment in the public mind as to the precise
position of lunacy in criminal procedure. And while he thought that the course

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[Oct.,

followed by the courts and by the criminal authorities in Scotland in those two
cases had given rise to a good deal of bewilderment, they were open to explanation,
if not even to justification. But in any case the state of matters had forced to the
front, in Scotland at any rate, the whole question of whether the question of
insanity—the insanity of a lunatic charged with crime—should be left to a jury at
all, or whether it should be simply in the hands of the judge. He had been told,
since coming to the meeting, that to suggest an alteration of that sort was some¬
thing like suggesting a revolution to the mind of the English jurist; but he would
remind his friends in England that they in Scotland were perfectly familiar with
the procedure of dealing with the question of insanity by the judge alone, without
a jury. The plea of insanity in bal*of trial was always tried by a judge without a
jury, until the precedent set by the Cumnock case, when the five judges sitting
there passed on the question to the jury; but the new procedure had not given
satisfaction to the public mind, nor to many even in their own specialty. The
question of dangerous lunatics charged with crime was especially provided for
in the Lunacy Statutes of Scotland; they went before the sheriff, without a jury.
They in Scotland even went further than that, because the sheriff had power to
pass on a person charged with crime and said to be a dangerous lunatic to the
Inspector of Poor, even without a cognition before him at all. Civil actions in
Scotland under the Lunacy Act were taken before a judge without a jury; indeed,
the only cases where they had a jury trial and the question of insanity was raised
were two, so far as he could remember. One was a cognition before the High
Court, which, he thought, had not taken place in Scotland to the knowledge of
anyone. It was a most cumbersome procedure. The other case was the ordinary
one of a man being charged with a crime when insanity was set up as a special
defence. In a recent article in the Glasgow Herald , which he knew expressed the
views—though not written by that gentleman—of one of the keenest legal minds
in the country, the opinion was held that the Purvis case raised the whole ques¬
tion, and that the principle underlying the precedent of trying the case by a
judge without a jury, which had been created by Lord Kingsburgh in a
previous case—might be expressed succinctly by saying that insanity was not
a question of fact, but of opinion. It was therefore a question suitable for
decision by a judge, with the assistance of medical experts. It was, said the
Herald t as difficult and complicated a question, in many cases, as any legal
problem; and no one would suggest that legal problems should be left to the
arbitrament of a jury. He, Dr. Carswell, therefore said that a case was made
out for considering carefully the present practice in relation to criminal pro¬
cedure where the accused person was alleged to be a lunatic. He was obliged
to the Council for allowing him and others to bring the matter forward, because
the public mind was keenly interested in the question, and he thought the Associa¬
tion might very well, at the present juncture, review the whole position. He was
very glad that Dr. Clouston had undertaken to move a resolution which would, if
passed, allow the question of criminal procedure to go to the consideration of
Committees. He hoped the Association would see its way to adopt Dr. Clouston’s
proposal. His own personal view in the case of Purvis was that it was an extra¬
ordinary thing that a jury which had been practically charged by the judge to find
that the man was insane, found, instead, that he was not insane; at least, that was
the decision implied in the verdict, although they did not say, in explicit terms,
that he was not insane. At the same time the jury found that he shot without
intention to do any grievous bodily harm. The judge promptly said he would
take that from no man, and emphatically backed his opinion by sentencing the
accused to seven years’ penal servitude.

Dr. Clouston remarked that, as the President had so sympathetically said, it
was desirable to first express the unbounded satisfaction felt by the members that
they had again among them their friend Dr. Carswell, living and well. (Applause.)
With regard to the motion which was in his name, he was in the unusual position
of having been asked by the Council to move it; therefore it did not come from
him " off his own bat,” as it were, but in the name of the Council. He could not
speak of the Irish law, but all present were aware that in regard to England and
Scotland there were two different systems of jurisprudence applicable to insanity,
in the case of both civil and criminal actions. It was well known that, partly by
the exertions of the British Medical Association and the profession in general, and

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8 5 I

1907.]

partly by their own Association, there was inserted in the last Lunacy Act of
England the clause to which the President had alluded. Lawyers said that the
clause was all very well, but it might cost as much anxiety and trouble and
expense to prove that there was no malice as to prove the main proposition. But,
be that as it might, there was no doubt that the English Lunacy Act did afford
protection to the members of the profession which it had not previously enjoyed.
The only protection which the profession had in Scotland in such cases was, that
an action could not be brought against the medical man after twelve months from
the discharge of the patient. And the profession was astounded and amazed at
the result in what he might speak of as the Carswell trial. At once a number of
medical men occupying fairly representative positions asked the Lord Advocate to
see them, and he did so one morning. He (Dr. Clouston) was deputed to act as
spokesman, and he put before the Lord Advocate the harshness with which the
profession in Scotland was treated. The Association would excuse him for having
also said it was a shame that they in Scotland should be exposed to those risks
when their English brethren had almost no risks whatever. The Lord Advocate
shook his head, and said Englishmen had also risks. But he practically undertook
that if there was any chance of bringing in a bill to put Scotch medical men on, at
all events, an equality with Englishmen, he would certainly see that it was done.
That was what the Association desired, in the first place, with regard to civil
actions. That was neither the time nor the place to further expound the criminal
law in regard to insanity, in either Scotland or England ; but so far as Scotland was
concerned, as Dr. Carswell had so well said, they were absolutely in a state of
chaos. After the Cumnock trial he wrote a letter to the Scotsman, putting the matter
from the medico-psychological point of view, and entirely endorsing the position
taken up by the Lord President of the Court of Session. The result was that, with
the exception of a few medical friends, the letter was universally condemned in
Scotland. People said he had written nonsense, and dangerous nonsense at that.
The lawyers and the public said that it seemed an unjust thing to try a man for a
crime and then, before he was proved guilty, to find him insane and send him to a
criminal lunatic asylum for life. The precedent of the Cumnock trial was promptly
reversed in the trial of Purves for shooting Dr. Carswell, but there was greater con¬
fusion still. In regard to the whole question he said to the President and to every
man present that they ought to go to their friends and say to them: '* For Heaven’s
sake join a defence association promptly, before to-morrow.” The resolution he
had to propose was: " That it be remitted to three committees, representative of
the three parts of the United Kingdom, to consider the present practice in criminal
procedure in relation to the question of the alleged insanity of accused persons, and
to consider whether any alteration is advisable, and to report, with any suggestions
that they may consider expedient, to the next annual meeting of the Association.”
If that resolution were passed there was ncf doubt that those committees would
have to consult lawyers as well as doctors. If such committees were appointed
they in Scotland would endeavour to get access to some of the judges, to some of
the senior counsel, and also, as far as possible, to ascertain public opinion on the
matter. He proposed that resolution, and would like at the same time to nominate
the Scotch committee—his English brethren would excuse his doing that first.
The English members must nominate their own committee, and the Irish members
theirs. He proposed the names of Dr. Carlyle Johnstone, Dr. Carswell, Dr.
Urquhart, Dr. Oswald, and himself to represent Scotland. He had no doubt that
a gentleman from South of the Border would nominate the English committee.
But perhaps it would be more convenient to move the resolution first, leaving the
nominations until afterwards.

The President said it would be much better to deal with the resolution first.

Dr. Rayner seconded the resolution.

Dr. Mercier said there could be no two opinions on the subject under discus¬
sion among members of the Association, nor scarcely in the minds of any reason¬
able men, that in the two actions which together composed what had be*n called
the Carswell case a gross injustice had been done. Dr. Carswell had suffered
undeservedly for merely doing his duty. He had suffered very severely, and his
persecutor, though it was true he was now being punished, was punished, appa¬
rently, as a sane man, and there was no sort of protection to Dr. Carswell or
guarantee that when that man was liberated he would not repeat the act which he

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852

NOTES AND NEWS.

[Oct.,

had already done. The present state of affairs in that regard was intolerable, and
something must be done, and done promptly, by the Association in order that such
proceedings might not be repeated. When he looked at the terms of the resolution,
however, he found that they did not completely cover the case that the Association
had to deal with. The terms of the resolution were that “ it be remitted to three
committees, representative of the three parts of the United Kingdom, to consider
the present practice in criminal procedure in relation to the Question of the alleged
insanity of accused persons, and to consider whether any alteration is advisable,
and to report, with any suggestions that they might consider expedient, to the next
annual meeting of the Association.” That, however, covered only part of the
ground. The main stress laid by both Dr. Carswell and Dr. Clouston was upon
the fact that medical men in Scotland had not the protection in signing certiflcates
and in carrying out the proceedings under the Lunacy Acts which existed in
England. That matter was not covered by the resolution at all. »

Dr. Carswell said it was understood that that was covered by the report of the
Parliamentary Committee, which was in print, but which might be more con¬
veniently embodied in that resolution.

Dr. Mbrcier said it seemed to him that while the committees were considering
one question it would be very expedient indeed that they should include the other,
and that what recommendations they had to make should cover the whole ground,
and should regard not only the mode of dealing with accused persons, but also the
question of the protection of medical men. The question was a legal one, and, as
Dr. Clouston had already said, it would require the assistance of legal authorities.
It was clear that no committee which could be formed out of that Association
would be able to lay down precisely what was the present practice in criminal
procedure in reference to the question of the alleged insanity of accused persons ;
and Dr. Clouston proposed that eminent legal authorities should be approached,
and, as he gathered, influenced in their favour. But he would go further than that.
He thought that before they could know the facts with accuracy it would be
necessary to empower those three committees to obtain legal assistance in order
to ascertain the facts; that they should have access to the legal authorities, not for
the sake of influencing them favourably, but for the purpose of ascertaining the
actual facts, and in precise terms. To do that he thought it would be necessary,
almost, to have a lawyer sitting on the committee, or at any rate, that the com¬
mittees should be able to consult with him, or with some reliable authority, so that
the facts of the case might be precisely before the committees before they made
their report. It had happened in trials m this country that that protective clause
in the Lunacy Act which was supposed to give protection to, or to confer immunity
on, medical men from persecution, had been pleaded, and in such a case more than
once it had happened that the judge had completely overridden and disregarded
that clause. The Act of Parliament laid it down that an action could not be
brought after the lapse of a certain time, and it had been shown in a case in which
the action was brought after the lapse of that time that the clause could be
pleaded, and was pleaded, and yet the judge allowed the action to proceed.
There was another condition also ; he forgot at the moment its precise terms, but
it was equally stringent, which it was necessary the plaintiff in such an action
should fulfil. In an action which was tried it was not fulfilled, and yet the action
was allowed to go on. And then, of course, as had been noticed in the report of
the Parliamentary Committee, the onus of proving that the defendant acted in
good faith and with reasonable care, was thrown upon the defendants. Of course
the contention of the Association was that the onus of proof that he did not act
with reasonable care and good faith ought to be thrown on the plaintiff. And
that made all the difference. It was a fine legal point, which any lawyer would
understand, and which, from want of knowledge of a legal character on the part
of the persons who urged the insertion of the protective clause in the Act, was
inserted in the form in which it now stood. If legal advice had been taken on
that occasion the protection of the medical man might have been complete
instead of ineffective. There was a section in the Act which allowed, in this
country, an action to be stayed by application to a judge in chambers. And
if such application was made on the ground that there was no reasonable
cause for alleging want of good faith or want of reasonable care, in that case,
again, the onus of proof lay upon the defendant, not upon the plaintiff. It seemed

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1907.]

to him that in all those cases the onus should lie on the plaintiff. That would
place the defendant in a very much more favourable position in any future
legislation and any recommendations which those committees might make, and
he heartily concurred in the proposal for their appointment. He hoped the points
which he had mentioned would be well considered.

Dr. Clouston asked the leave of the President and of the meeting to meet the
very proper suggestion of Dr. Mercier by adding after the words “ accused per¬
sons,” “ to consider also the practice in civil procedure following upon the carrying
out of the Lunacy Acts by medical men.” The resolution would then proceed,
“and to consider whether any alteration is advisable, and to report, with any
suggestions they may consider expedient, to the next annual meeting of the
Association.” He was quite willing, and he was sure Dr. Carswell would also be
willing, to carry out the suggestion so properly made by Dr. Mercier.

Dr. Urquhart said he thought what was intended was that the paragraph in the
Parliamentary Committee’s report should be incorporated with what Dr. Clouston
previously moved—that the committee recommended that there should be protec¬
tion for medical men giving certificates, such as would cast the duty of proving
neglect or bad faith on the person bringing the action under that section, and
further recommended that steps should be taken to secure protection to medical
men giving certificates in Scotland. Some such wording as that was required.

Dr. Mercier replied that that was not enough. The giving of certificates was
not the only act which medical men had to perform under the Act of Parliament.
Actions were frequently brought against persons who had had care of lunatics, but
who had not given certificates. He preferred that the words suggested by Dr.
Clouston, or in some similar purport, should remain. Or he would agree to more
general terms.

Dr. Conolly Norman wished to support the resolution as moved by Dr. Clouston,
with the amendment which he had made. Before entering into any details he
might perhaps be allowed to join with all the previous speakers in congratulating
Dr. Carswell on being able to be present among his fellow members, and to express
his admiration for the modest and telling statement with which he had introduced
the subject. The Irish law was founded upon the English in those matters, and
Irishmen were liable to the same dangers which formerly assailed the English
medical man in relation to lunacy cases. The recent Act, by which the Englishman
was afforded a certain amount of protection, did not extend to Ireland, so that
Irishmen were in the condition of the primitive English. As in Scotland, according
to what they had heard that day, and as he believed occasionally occurred even in
highly advanced and civilised England, the law in Ireland was occasionally made
for the purpose by the judges as they went along. So that on one occasion where
an action was taken against him and against the medical man who had signed the
certificate of a patient who was admitted to his asylum the judge summarily
dismissed the action against Dr. Norman for having received the patient, and
against the medical man who had signed the certificate, by stating that their action
was privileged. The judge was a highly eminent judge, whose opinion every one
respected. Dr. Norman was satisfied that there was nothing to prevent some of
his brethren reversing that remarkable decision to-morrow or the next day.
Therefore for personal as well as general reasons he was very glad to support the
resolution.

The President said that, as Dr. Clouston remarked, it was a most important
resolution. The Council thought it was so important that Rule 95 was brought in
to deal with it; the President read the rule to the meeting. The resolution which
had been read by Dr. Clouston had the full approval of the Council. Dr. Clouston
had rightly referred to the cost, and it was only fair that the Association, assembled
at the annual meeting, should have some say with regard to the limitation of cost.
Therefore he would ask the Treasurer to add his quota of criticism to the
resolution.

Dr. Hayes Newington said he had intended to ask a question about the cost,
and also concerning the matter being dealt with by three committees. Why should
there not be one committee with three lobes to it P Otherwise it was possible that
two committees might want one form of procedure while the third one might want
another, and it would be a little trying to the annual meeting to have to decide
between them. If three sections representing the whole committee could meet
LIII. 59

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[Oct,

before the next annual meeting it might very likely result in the presentation of
a co-ordinated report, and he suggested that it should take that form. And he was
intending to ask how far it was proposed the matter should be taken. It was not
known whether it would be necessary to take legal opinion, but if so, it might be
necessary to go to the House of Lords in order to settle between themselves what
the law was. Primd facie they felt sure that the shoe was pinching somewhere,
and it was for the Association to say that it was pinching and where the pain was
felt, rather than to ascertain how it was that the shoe came to pinch at all, and how
the disability was to be removed. The matter was a very complicated one, and it
seemed to him they ought to say what they wanted, and having agreed, as an
association, what they wanted, then to put the question before the lawyers, for
them to carry out as best they could. Was there any necessity to take high legal
opinion before bringing the subject up at the next annual meeting? If so,
he thought it was necessary to have a special motion involving the expenditure of
money. A motion involving the expenditure of £25 might not be made or enter¬
tained except at an annual meeting, and two gentlemen had already spoken of
the necessity for taking legal opinion. He bowed to their opinion, but they should
state to what extent they proposed to go, and what the probable cost would be, so
that the Association might know how far it was involved.

Dr. Rayner said the work which the Association was proposing to undertake
was practically voluntary, and perhaps legal opinion could be obtained by inviting
representatives of legal societies to join in the work and meet the Committee of
the Medico-Psychological Association.

Dr. Morrison said that, except for Dr. Merrier, who had very properly pointed
out the fact, the speakers did not fully appreciate that the resolution was to deal
with criminals, and to place the criminal in some different position from that which
he occupied in the past. To allege insanity in the case of a person charged placed
the onus of proof on the defendant. No doubt, as Dr. Merrier pointed out, it was
a very unfair position to place the defendant in, for instance, under the following
circumstances : A man committed a crime, and the Home Office was appealed to
on the plea of insanity in regard to the responsibility of that man. A report favour¬
able to the person may have been given to the Home Office; but at the trial the
prosecution never produced the evidence which was in favour of the prisoner, but
allowed the defendant to bring such evidence as he might be able to get at the last
moment, without knowing fully the facts already known to the Crown. Then, in
thecaseof the poor criminal, the judge called upon a junior counsel—insufficiently
instructed—to defend the prisoner-

The President reminded Dr. Morrison that the question was the appointment
of the Committee, and he asked him to confine his remarks to that subject.

Dr. Morrison said he was speaking to the resolution in favour of a Com¬
mittee.

The President said it was necessary that Dr. Morrison should confine his
remarks to the appointment of a committee for the three portions of the Kingdom.
The President then put it to Dr. Clouston whether he would admit a variation
of his wording to the effect that there should be one committee, with repre¬
sentatives of the three countries, rather than three separate committees.

Dr. Clouston said that he and his seconder were in the hands of the meeting
as to what plan would be most efficient for bringing about what was desired. There
must at least be three subdivisions of the committee.

Dr. Craig asked whether the question of the expenditure of money for the pur¬
pose had been settled. It was the fault of the medical profession itself that it had
not more protection than was at present the case, nor as much as it used to have.
Up to the passing of the Medical Act of 1858 he believed that every medical man
was protected against everything he did, medical or surgical, and it was only when
he asked for leave to be able to sue persons for his fees that that protection was
taken away from him. As the Treasurer said, a large principle was involved, and
it might be a very expensive business before it was finished with. It was a question
whether the principle should not be settled before appointing the committee or
settling what it must do.

The President said he thought it was agreed that there should be a committee.
The expenditure could be discussed later. He would like to hear any views
as to the appointment of the proposed tripartite committee. He asked whether

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855

Dr. Clouston accepted the suggestion that it should be one committee with
three sections.

Dr. Morrison rose, on a point of order, to point out that the resolution had not
yet been put to the meeting. That was the point in reference to which he had been
called to order.

The President replied that it had been put, but had not yet been carried. The
amendment had not yet been accepted, but if it was he would put it as a substantive
resolution. But before that he invited further criticism.

Dr. Carswell asked, as a point of order, whether, if the Association appointed
one committee with three subdivisions, that implied that the reports of the three
subcommittees would require to come before a general meeting of the whole com¬
mittee and be passed on oy them to the annual meeting of the Association. That
would be the only natural course; but it would involve a journey, probably to
London by the Irish committee and the Scotch committee. And for what
purpose ? Practically for no purpose, because the law was so different in the three
countries. After the questions had been thrashed out in the minds of the members
of the committee there was nothing to be gained by bringing those members to
London to discuss the matter all together.

The President said he did not think it followed that they should be in London
or anywhere else. A meeting would be held in the provinces shortly, but he
thought it was desirable that the three divisions of the subcommittee should meet as
a general committee.

Dr. Thomson said the diseases might be all different, but the remedy wanted
was the same.

Dr. Clouston said he was willing to alter the resolution—and he believed that in
that Dr. Rayner concurred—to a remission to a committee to consist of representa¬
tives of the three parts of the United Kingdom, which meant the three countries.
He asked how much money the committee would be entitled to spend without
coming to the Association for the ordinary printing and such routine expenditure ?

Dr. Hayes Newington said he did not think there was any limit to the
expenditure of a committee in that direction. It had been held that the natural
expenses of a committee, such as for the agenda and reports, did not come within
the rule as to expending ^10; the limit was for outside work, such as consulting a
lawyer.

Dr. Clouston said they did not contemplate having to pay lawyers’ fees at all.
He thought he could speak definitely for members of the Bar in Scotland. Very
representative men would take sufficient interest, from a jurisprudence point of
view, to act as all present were acting, without making any charge.

Dr. Spence said he strongly supported the idea that a general committee should
be appointed, equally representing the three countries, and with power to discuss
the matter from the point of view of the country which they represented. He
thought it was hardly necessary they should meet again, but their views might be
brought together and homologated, and then presented to the Association at
another meeting.

Dr. Hayes Newington said he had a further suggestion to make. If it was the
wish of the Association to appoint one committee with three sub-divisions, it should,
in passing the resolution, include the chairman aad secretary of the committee.

Dr. Clouston thought it would be better for the committee itself to choose those
officers.

Dr. Hayes Newington said it would involve a meeting in London to set the
machinery at work. But if a meeting had to be held in London, unless it were
held on the following day, it might be months before the committee would get
together.

The President said that Rule 82 stated, “ Every committee, at its first meeting,
shall forthwith appoint a chairman and a secretary.” He thought there had been
sufficient discussion on the matter, and he would therefore put it to the meeting.
It seemed to be agreed that there should be one committee with three divisions.

The President read the resolution, as follows : “ That it be remitted to a com¬
mittee representing the three parts of the United Kingdom to consider the present
practice in criminal procedure in relation to the question of the alleged insanity of
accused persons. To consider also the practice of civil procedure following on the
carrying out of the Lunacy Acts by medical men; ana to consider whether any

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NOTES AND NEWS.

856

[Oct.,

alteration is advisable, and to report, with any suggestions that they may consider
expedient, to the next annual meeting of the Association.”

Agreed.

He said the next question was the nomination of members of the committee.

Dr. Clouston said that, in order to expedite business, he had nominated the
Scotch representatives, as follows: Drs. Carswell, Carlyle, Johnston, Urquhart,
Oswald, and himself. He proposed that the committee should number fifteen—
five representing each country.

Dr. Ernest White seconded.

Agreed.

The following gentlemen were nominated to act as the English section: Dr.
Craig, Dr. Ernest White, Dr. Newington, Dr. Merrier, and Dr. Savage.

Dr. Conolly Norman suggested, as the Irish representatives, Drs. Dawson,
Nolan, Drapes, James John Fitzgerald, and himself.

These names were then put to the meeting and agreed to.

The President then asked the Treasurer to speak on the question of expenditure.

Dr. Hayes Newington said it was rather for the gentlemen to say what they
wanted. The Association had £1 100 accumulated in stock and cash.

Dr. Clouston suggested that the question of expenditure should be left alone.
The mere fact of the committee being appointed by the Association enabled them
to incur the ordinary expenditure for printing and postages, and for any extra¬
ordinary expenditure the Treasurer was empowered to go up to £ 25.

This was agreed to.

Dr. Mercier said it should be made clear whether that £2$ was included in the
ordinary expenses of the committee or was outside it.

Dr. Newington replied that it was beyond the ordinary expenditure of com¬
mittees.

Election of Members.

The President said that the Council had proposed for election as an honorary
member Professor Leonardo Bianchi, of Naples. He had been proposed by six
members of the Association, and needed no introduction. Dr. Ferrari, of Bologna,
was also up for election as a corresponding member.

After the ballot the President announced that all the members proposed had
been duly elected.

The following candidates were unanimously elected:

As an honorary member, Professor Leonardo Bianchi, Naples, who, since 1896,
had been a corresponding member (recommended by Robert Jones, A. R. Urqu¬
hart, William W. Ireland, James H. Macdonald, R. Percy Smith, and C. Hubert
Bond).

As a corresponding member, Dr. Giulio Cesare Ferrari, Director of the Instituto
medico - pedagogic© Emiliano, at Bertalia, Bologna, Italy (recommended by
William W. Ireland, James H. Macdonald, R. Percy Smith, and Robert Jones).

As ordinary members, Geoffrey Clarke, M.D.Lond., Second Assistant Medical
Officer, London County Asylum, Long Grove, Epsom (proposed by C. Hubert
Bond, John R. Lord, and H. Hayes Newington) ; William Norwood East,
M.D.Lond., M.R.C.S., L.R.C.P., Deputy Medical Officer, H.M. Prison, Brixton
(proposed by James Scott, James Chambers, and John Baker}; Thomas Guy
Macaulay Hine, M.A., B.C.Cantab. (proposed by P. W. Macdonald, Hubert Bond,
and J. W. Miller).

Dr. Clouston’s Motion Regarding Dates of Meeting.

Dr. Clouston proposed the motion standing in his name in the agenda, as
follows : “ (1) That the meetings of the Association and those of the Council shall
in future be held on Tuesdays; or, if that be not carried : (2) that the May meet¬
ings of the Association be held on Tuesdays.” He said he did not think the motion
needed any recommendation. He could see no possible objection to meeting
on a certain day in the week, which enabled members to put down their engage-

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1907]

NOTES AND NEWS.

»S 7

ments beforehand. The reason for the resolution would be clear. Edinburgh
was 400 miles from London, and Perth and many other places were further; and
that journey had to be accomplished and paid for by the Scotch members. There
was a most convenient arrangement in regard to week-end tickets, which members
naturally wished to take advantage of, and no one in the room would wish to say
them nay. The Secretary had issued a supplementary circular on the points, and
he would be glad if the meeting could be given some statistics.

Dr. Bond said that ninety-five replies had been received out of a total member¬
ship of about 700. Thirty-nine of them were from the South-Eastern Division,
fourteen from the South-Western, twenty-five from the Northern and Midland,
fifteen from Scotland, and two from Ireland. The card gave four methods of
reply; (a) I prefer the present usual days; (£) Willing that the meetings of the
Association and those of the Council should in future be held on Tuesdays;
(c) Willing that the May meetings of the Association should in future be held on
Tuesdays; ( d ) other suggestions. Seven replied under (a). Sixty-three were
willing that the meetings of the Association and Council should be on Tues¬
days. Twenty-two were willing that the May meetings of the Association
should be held on Tuesdays. Only three made any other suggestion.

The President pointed out that only 13 per cent . had sent in replies, and
whatever day the Association might fix would not be convenient to all.

Dr. Newington said he had much pleasure in seconding Dr. Clouston’s motion.
He reminded members that some years ago a similar postal vote was taken, which
resulted in Thursday being chosen by a considerable majority. That was in the
old days, when there was not half the important business which was now done.
Instructed by the Council he had tried to get the various railway companies to
accept the principle of granting week-end tickets from the outside towards London,
but without success. All the big railway companies issued week-end tickets
cheaply from London to places on the coast, but they could not be induced to
reverse the process. But the lines running from Scotland did give that privilege,
and the members might well enable their brethren to accept it, to the saving of
their pockets.

Dr. Mercier said that whenever the question of the settlement of days of
meetings came before the Association he had raised his humble protest against
any one day of the week being fixed permanently for all the meetings, because it
was manifest, if it were so, that someone must be always excluded. There must
be certain persons who could never attend the Association meetings at all if they
were always held on a certain day of the week, as it was notorious that Asylum
Committee meetings were fixed for different days in the week, different places
having different days. Whatever day might be fixed could not cover every
member of the Association. By all means he would agree to the majority of the
meetings being held on Tuesdays, or any other day which might be thought
desirable, but he thought there should be some relaxation of the rule, so that every
member should have an opportunity of attending the Association meetings without
very great personal inconvenience.

Dr. Clouston said he could quite see Dr. Mercier’s argument, and he would
quite agree to the majority of the meetings being held on Tuesday if it met with
the approval of the Association generally. After all, it was a matter of personal
convenience for those who came from a long distance, and he was sure they would
be willing to do anything reasonable.

Dr. Yellowlees said he was supposed to be interested in the matter, but he had
not been able to seethe advantage which Dr. Clouston had discovered in the scheme.
It meant keeping men longer from their asylums, and if the meetings were held
on Tuesday they must travel home by night trains. It would demand that some
of the meetings must be held on Monday. So it was manifest that expense would
not be saved if it meant a day longer in town. He had not been able to see any
advantage to Scotsmen in the suggested alteration, though he did not wish to
make any move against it, since others seemed to desire it.

Dr. Conolly Norman wished to support the idea which had been mentioned
by Dr. Mercier, in consequence of which he understood the resolution had been
modified. The fixing of a day for the quarterly meetings prevented some members
attending them at all. For example, on the third Thursday in the month his own
committee sat, and it was sitting that day, and needless to say he had come away

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858

NOTES AND NEWS.

[Oct.,

at great inconvenience. That occurred every quarter, and the consequence was
that he might be debarred from attending at any time, except at the annual meeting.
Therefore he thought the days ought not to be fixed by resolution.

Dr. Bower said he thought Dr. Mercier’s view might be met by simplifying Dr.
Clouston’s motion, and he therefore moved, as an amendment, that the May and
November meetings of the Association should be held on Tuesday. There were
four meetings of the Association in the year. One was the annual meeting, whicn
might be anywhere, the February meeting was held in the provinces, and the May
and November meetings were held in London. If these two latter meetings were
held on Tuesdays that would cover both Dr. Clouston’s and Dr. Mercier’s views.

Dr. Thomson seconded Dr. Bower’s motion.

Dr. Newington said he thought some of the lines would grant a reduced ticket
to Scotland on Sunday night, so that an energetic member of Council could start
on Sunday night and attend the important committees.

The President then put the amendment that the May and November meetings
be held on Tuesdays, for that year only. It was lost, only three voting for it. The
amended motion, that the majority of the meetings, including the May meeting,
should be held on Tuesday, was then put and carried.

The President said the time had arrived for him to vacate the chair in favour
of his successor; but before doing so he wished to announce that, consequent
upon the resolution passed in the morning, there would be a meeting on the
following morning of the committee which had been appointed for the three
portions of the kingdom to discuss and consider the question raised at the morning
session.

Vote of Thanks to Retiring President and Officers.

Dr. Mercier said it was his pleasing lot to have to propose a vote of thanks to
the retiring President and to the Officers of the Association. That was a matter
which would not require any insistence on his part. Dr. Robert Jones was a very
old friend of theirs; he had been the Secretary of the Association for many years.
He had, with remarkable distinction, presided over their deliberations for one year,
and Dr. Mercier was sure he would carry the sense of the meeting with him when
he said that the Association had never been so prosperous as it had since Dr. Robert
Jones took over the secretariat; that the meetings had increased in number and in
interest, and the papers read before it had been of high quality and importance.
Indeed, the whole Association had been revivified, and had new life infused into it
when Dr. Robert Jones took over the secretariat; and it had in no wise fallen back
since that gentleman had been the Association’s President. The Treasurer needed
from him no commendation; he had been re-elected to his office this year unani¬
mously and by acclamation. And the auditors had not exactly gone out of their
way to refer to the Treasurer, but they had made a particular point of the admir¬
able manner in which the accounts were kept. But the keeping of the accounts
was but a small part of the Treasurer’s duties. The Treasurer was really the
umbilicus of the Association ; he was the nucleus which kept it together ; he was
the nucleus in a biological sense, since without him he thought the whole body
would perish—or at all events, without his office, and no one could fill the office
better than did Dr. Newington. The Association had had a short experience of
Dr. Bond as the new Secretary, but he made an admirable secretary to a very
important committee previously, and his services in that connection commended
him very much to their suffrages when he was elected General Secretary of the
Association. He could say that not only had Dr. Bond not disappointed them, but
he had exceeded their expectations, and he had formed a worthy successor to his
excellent predecessor, their retiring President. One of the most important officers
of the Association was the Registrar, whose task was more arduous than that of
any other officer; and it sometimes became a wonder how any man could take
upon himself duties so multifarious, and requiring so much judgment and tact,
without any remuneration. The Treasurer intimated at the morning sitting that
the Association had a very handsome balance at the bank and actually invested,
and as the time seemed to be approaching when the Association would “ flourish
like a green bay tree,” he thought the officers should receive a handsome

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1907 -]

NOTES AND NEWS.

859

honorarium. He said that entirely without prejudice—(laughter)—because it
might be thought by some that he had a personal feeling in the matter, though he
assured members that no such idea had entered his head. He thought the Asso¬
ciation could congratulate itself on having the very best set of officers possessed by
any organisation, and he was sure his hearers would unite in according them a very
hearty vote of thanks.

Dr. Blandford said he had very great pleasure in seconding the motion. He
could echo everything which Dr. Mercier had said concerning the abilities of the
Association’s officers, especially that in reference to Dr. Jones, who was going out
of office, while the others remained in theirs. He need not describe the admirable
manner in which Dr. Jones had conducted the business of the Association during
the past year. Members had seen him at those meetings for a great number of
years, and he hoped they would continue to do so for a great many more.
(Applause.)

The vote was carried by acclamation.

Dr. Robert Jones, in acknowleding the vote, said it was a day of mingled
feelings for him, as he severed his official connection with the Association that
afternoon. Dr. Mercier, with his usual skill and tact, had already carved out for
himself a nice honorarium. He was fore-shadowed into office, and he (Dr. Jones)
hoped he would be able to do something to get the honorarium for him. (Laughter.)
He need not say that the post of president was a more or less formal office; he was
only the figure-head, for the time being, of the Association. He had been secre¬
tary, and he knew the secretary was the tail which made the dog wag. He had
been for one year their president, and he gratefully acknowledged that the
position of president was one which was held by the suffrages of the members
only. He was exceedingly grateful to the officers who had upheld the president
by their work. Were it not for the gentlemen whom Dr. Mercier had mentioned—
Dr. Bond, to whom he was under many obligations, and the Registrar, whose
responsibilities were exacting and onerous—the office of president would be a very
difficult one to fill. He thanked Dr. Mercier for the very kindly and affectionate
way in which he had referred to the president’s duties. The year just closed had
been a successful one. Their membership had never been higher, aud they had
had a paper which had filled every chair in the room—Dr. Ford Robertson’s—
which was an epoch-making contribution to their annals. There was an old Welsh
proverb which said that the man with the golden tongue had many friends. He
wished he had the golden tongue in order to speak adequately of his successor,
Dr. MacDonald, but he was not in need of any commendation from him, he was so
well known and had been unanimously accepted. He was known to be a self-reliant
man, he had the affairs of the Association intimately in his mind, and he also had
them at heart. They knew his value on committees, and he had great pleasure in
inducing him to the chair. The work done in the committees of the Association
was the muscles which moved the skeleton, and the work so done was very

onerous, as the Treasurer, who had passed through the chair, well knew, and

to him also he was under constant obligation for advice and help. In relinquishing
the office of president he had much • pleasure in thanking Drs. Mercier and
Blandford and the whole of the Association.

The Chair was then occupied by Dr. P. W. MacDonald, who delivered his
presidential address.

Dr. G. H. Savage said the present was nearly the fortieth address which he had
heard at meetings of the Association, and he could certainly say he had never heard
a more eloquent or a more impassioned address. One believed that the new
President felt what he said, and felt deeply. It was not permitted to him (Dr.

Savage), or to others, to criticise that address. It was for him “ not to bury him,

but to praise him ” if he could—and he could. Dr. MacDonald first touched gently
on the losses to the Society; the obituary references had been in the very best of
taste. In the next place, he (Dr. Savage) could not help thinking of the book
recent published by Sir Frederick Treves, Highways and Byways of Dorset. One
felt that they had been studied by Treves in one way, and by the President in
another; and that if houses were to be built well and firmly, the bricks and stones
must be good and sound; that if there were to be good principles evolved from
their observations they must have true observation—narrowed perhaps, specialised
into small areas. It was of the utmost importance that men like the President

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86o

NOTES AND NEWS.

[Oct.,

should give their experience. And when one heard him speak as strongly as he
had done, one fancied that, if his views got disseminated far and wide, he might
suffer as some of the doctors did who wrote in the Lancet about teetotalism. Their
lives were rendered, for a time, rather unhappy by virtue of the number of pamphlets
they received on the question, setting forth the vices of alcohol. He felt very
strongly, with the President, that alcohol was not the great cause, in the present
day at all events, of any increase of insanity. (Hear, hear.) He was glad the
President referred so markedly to what was said by the Irish Commissioners. It
was mentioned in the report of the Irish Commissioners last year that the most
potent cause of the increase of insanity was the use of tea. So when one heard
of alcoholism and of people being intemperate, as was pointed out some time ago,
one might as well accuse a person of being a caffein maniac, or a tea maniac, as an
alcohol drinker. He agreed with what the President said about heredity; he had
had most ample opportunities of making careful observations, and it was not sur¬
prising that it should form such a potent factor in the development of insanity in a
rural district; because there was not only the elimination of the fittest by migra¬
tion and by emigration, but there was intermarriage, and the intermarriage of the
degenerate. He could not agree with all the President had said about sentiment.
It was all very well, but we were not yet governed by reason. It had heen said we
could not reason, we could only feel, as a rule, and the feeling might be right, or it
might be wrong. Certainly we were more governed by sentiment than by reason.
Sentiment was strong against certification, and it might die out, but it would not die
out in a generation, and that fact must be accepted. It had been a great pleasure
to him—and doubtless to all—to hear what the President had said, and one felt
that while it might be true that the wise men came from the East, the psychologists
came from the North. (Applause.)

Dr. Clouston said he rose with very peculiar pleasure to second the vote of
thanks which had just been proposed. It was quite certain that one always enjoyed
an address when the man who made it was an enthusiast and when he was in a
fighting attitude. There could be no doubt that the President had said things
which there was not a man in the room would not dearly like to contradict. That
was one of the advantages of an address of that kind. If Dr. Mott were present he
would be boiling over with a desire to contradict the anti-syphilitic theory of general
paralysis. And he saw Sir John Tuke fidgeting in his chair at the remarks in the
address concerning the certification of insanity. He (Dr. Clouston) could scarcely
keep his place when the President talked about the non-effects of alcohol and the
bad effects of tea. All those things added enormously to the interest of the
address, and when to those was added the personality of the speaker, there were
perfect conditions for a perfect hour spent. He had much pleasure in seconding
the vote of thanks, and he was sure all would agree that Dr. MacDonald deserved
it. (Applause.)

Dr. Savage put the vote to the meeting, and it was carried by acclamation.

The President said he was very much obliged for the kind vote of thanks.
Perhaps the heartiness of his thanks was enhanced by the fact that the vote had
been proposed and seconded by those gentlemen who had known so many presi¬
dents, and who were, therefore, so well able to express an opinion on the point.

Dr. Easterbrook then read a paper entitled “The Sanatorium Treatment of
Active Insanity by Rest in Bed in the Open Air" (see p. 723).

SECOND DAY.

Sir William Gairdner’s Decease.

The President said that before commencing the business set out on the agenda
he would call upon Dr. Yellowlees.

Dr. Y ellowlees said that at the wish and with the approval of the President
he moved that the Association should follow the course which had been customary,
and express their regret at the sudden death of Sir William Gairdner and their
sympathy with his relatives. He was sure this would be agreeable to the Associa¬
tion, as Sir William was a former President. It seemed fitting that he should
move that resolution, because it chanced that he was the last friend with whom

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1907 .]

NOTES AND NEWS.

861

Sir William spoke. He visited him on the afternoon of his death, and found
him on his couch reading. He was feeling quite well, and looked so; the
pulse was calm and strong, though only 22 per minute. On parting, after a very
pleasing talk, he said good-bye cordially at the hall door, sent a kindly message to
a medical gathering to be held that evening, and returned to his reading. Half
an hour afterwards, or thereby, the servant found him dead on his couch. There
was no sign, no warning, nor any indication of the impending end; but the heart
condition was very remarkable. It had been as slow on some occasions as 10 beats
per minute, then it rose to 15, and then to 20 or 22, which was its usual rate.

Dr. Clouston said he had a sad satisfaction in seconding the resolution. Sir
William Gairdner was not so intimate a friend of his as he was of Dr. Yellowlees,but
he and Dr. Clouston were two of the few students who attended the students’ course
before Sir William was in the Glasgow Chair. They lived in fellowship, and to
live in fellowship with Sir William Gairdner was to love him.

The vote was then carried in silence.

Congress of Neurology in Amsterdam.

Dr. Robert Jones said he desired to make a statement, which he ought to have
made before vacating the chair on the previous day. The Medico-Psychological
Association had been requested to name two delegates to represent it at the
Congress at Amsterdam. He proposed that the matter should be left entirely in
the hands of the President to name delegates. A certain number of members of
the Association would be attending the Congress.

Dr. Yellowlees seconded. He said he supposed no one would go for the
purpose of being a delegate, but when the President learned who was going he
could name two of them.

Dr. Urquhart said that if the gentlemen who had made up their minds to go
to Amsterdam would communicate with the Secretary they would obtain from the
President a letter of authority to represent the Association. That had been done
at several of the Societies in Scotland already.

Dr. Clouston introduced a discussion on “ Psychiatry as a Part of Public
Medicine” (see p. 704).

Following Dr. Clouston’s reply, and after the adjournment for luncheon, a
resolution proposed by Dr. Yellowlees, and seconded by Dr. Hayes Newington,
was adopted as follows: “ That it be remitted by the annual meeting of the
Medico-Psychological Association to the Parliamentary Committee of the Associa¬
tion to co-operate with the British Medical Association or with any committee of
other medical associations, with a view to securing the appointment of a minister
of health, with a seat in the House of Commons, or to initiate such proceedings.”

Dr. Albert Wilson then read a paper on "The Psychology of Crime,” and
supplemented it with a clinical demonstration.

It was agreed, in view of the special circumstances under which Dr. McRae had
attended the meeting, and Drs. Lewis Bruce and Devine consenting to their papers
being held over for another meeting, to adjourn the full discussion on this paper
until the November meeting, in order that Dr. Robertson’s and Dr. McRae’s joint
paper might be included in the work overtaken.

The President thanked the Salvation Army for the kind way in which they had
helped Dr. Wilson and contributed to the Association’s edification.

Ur. Douglas McRae then read a paper, jointly by himself and Dr. Ford
Robertson, entitled “ Observations on the Treatment of General Paralysis and
Tabes Dorsalis by Vaccines and Anti-sera” (see p. 750).

The President, in announcing that the end of the programme had been reached,
expressed his gratitude to all who had come to support him at that meeting, which
would remain in many ways a memorable meeting of the Association, largely
because of the numerous attendance and the very valuable contributions which had
been made by their own members. The Association was not afraid of criticisms,
nor of just comparisons. They had reason to be proud of their past, and for look¬
ing forward with confidence to the future.

Dr. Hayes Newington proposed a vote of congratulation to the President on
his having presided over such a successful meetings

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862 NOTES AND NEWS. [Oct.,

The President begged the meeting to accept his grateful thanks, and the
meeting terminated.

The following members attended the Council meeting on July 25th, 1907, at
9.30 a.m.: Lewis C. Bruce, C. Hubert Bond, David Bower, James Chambers,
T. S. Clouston, Maurice Craig, Th. Drapes, Alfred Ewan, E. Goodall, Robert
Jones, T. W. McDowall, P. W. Macdonald, Alfred Miller, F. Hayes Newington,
Conolly Norman, H. Rayner, R. Percy Smith, H. Savage, R. H. Steen, A. R.
Turnbull, D. G. Thomson, A. R. Urquhart, David Yellowlees, Ernest White.

GIRGENTI INEBRIATE REFORMATORY.

When the Reformatory was opened some seven years ago, Dr. Carswell was
convener of the Committee of the Glasgow Corporation engaged on the work of
this important institution. They purchased the property of Girgenti, which is
situated in Ayrshire, some twenty-one miles from the city, for ^7000, and spent
an additional £2000 in making the house suitable for the purpose intended. The
inmates were to be selected from persons belonging to Glasgow who have been
sent for trial to the Sheriff of Lanarkshire, habitual drunkards who are not
criminals, who are not prostitutes, nor suffering from serious diseases. These
limitations have not been entirely observed.

We are now favoured with the Sixth Annual Report for the year ended 31st
December, 1906, and find that it presents features of special interest. In the
Report for 1904, the Committee made suggestions for amending the Inebriates
Acts—giving the magistrate as well as the sheriff power to commit drunkards;
giving the magistrate powers of detention in prison or poor-house while the
inebriate is awaiting trial; giving power to commit these persons to the care of
the Parish Council; giving power to commit drunkards who have been charge¬
able as paupers four times during the preceding twelve months; giving power to
the sheriff to commit drunkards who have not been police cases; and giving
powers to facilitate transfers.

In spite of the reasonableness of these proposals and their favourable reception
by the Secretary for Scotland, nothing has been done to pass them into law. The
consequence is that the Corporation of Glasgow, last March, resolved to discon¬
tinue the Girgenti Reformatory; and they feel further justified by the reduction of
the Treasury grant from xos. 6 d. to 7 s. a week per inmate, although the whole
cost is about 245.

The Reformatory is lioensed for 58 female inmates, and the average number
resident was 42. The numbers received for the last six years were 39, 40, 39, 27,
41, and 44—showing a slight annual increase. Altogether 130 have been admitted,
and of these 18 have been regarded as hysterical and explosive, 17 weak-minded,
22 periodical drunkards, and 73 ordinary chronic inebriates. Several of those
licensed out have done well, and notes of 8 of these cases are presented; but the
general results are as hopeless as might be expected in dealing with such a
population. Dr. Cunningham reports unfavourably of atropine treatment, and
directs attention to the relationship between epilepsy and inebriety.

It will be most unfortunate if this experiment is to end in failure. The Govern¬
ment has not encouraged the Corporation of Glasgow in their attempt to deal
with the worst class of drunkards, and it is high time that a revision of methods
and a national system was adopted. The kingdom of Belgium has shown what
can be done in clearing the country of these waifs of society—insisting on useful
work and cleanly living. Scotland should not lag behind.

A PRESENTATION TO AN EX-PRESIDENT.

Dr. T. Outterson Wood, who has been for many years Senior Physician to the
West End Hospital for Nervous Diseases, Welbeck Street, Cavendish Square, W.,
has been presented with a handsome silver bowl by members of the Committee of
Management and Medical Staff upon his retiring from the active staff and being
appointed Consulting Physician to the institution.

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1907.]

NOTES AND NEWS.

863

CORRESPONDENCE.

To the Editors of The Journal of Mental Science.

Dear Sirs, —May I venture to suggest that as now there are so many of our
asylum trained and certificated nurses engaged in private nursing, it would be well
for our Association to found an occupation bureau for them somewhat upon the same
lines as the Chartered Nurses’ Society was founded in connection with the nurses
of the Royal British Nurses’ Association which we inaugurated some time ago, and
which has been such a conspicuous success.

A start has already been made in this direction by Miss Hastie, 115, Edgware
Road, W., and the appointment of a small committee of management composed of
members of our Association would ensure its success and its development upon
right lines, while it could not fail to be a great boon to our nurses and to the
public. The Mental Nurses’ Co-operation would be a suitable title.

Yours faithfully,

October yrd, 1907. T. Outterson Wood.

OBITUARY.

Sir William Tennant Gairdner.

Sir William Tennant Gairdner, K.C.B., M.D., LL.D., etc., etc., Physician in
Ordinary to the King in Scotland, and one of the greatest Physicians and Medical
Teachers of his time, died peacefully on June 23rd, 1907, in his 83rd year.

He was for thirty-seven years Professor of Medicine in the University of
Glasgow, and a clinical teacher in its Western Infirmary. His professional life
was one of entire devotion and strenuous activity. He was greatest as a teacher,
and was never happier than when investigating and explaining the intricacies of
disease, their causes, relations, and results. His expositions, whether written or
oral, were distinguished by singular lucidity of expression, by a philosophic
breadth of view, and by the fine scientific spirit which—unwarped by previous con¬
ceptions and intolerant of unproved conclusions—seeks for truth, and truth alone.

He was a prolific writer, chiefly, perhaps, on cardiac and circulatory diseases,
but there are few departments of medicine which have not been illumined by his
pen. He was so engrossed by daily work that, with the exception of his Clinical
Medicine , his writings were chiefly in the form of Contributions and Addresses.
His lectures on Insanity, when Morrisonian Lecturer in 1879, were never fully
published. His address, when President of the British Medical Association in
1888, on “ The Physician as Naturalist,” will not soon be forgotten.

In personal character Gairdner was a genial and cultured gentleman, with an
eager open mind, a beautifully transparent and truthful nature, a warm and
sympathetic heart, and a deeply religious spirit. Such a character enhanced all
his attainments, gave him a wonderful influence over his students, and attracted
many friends.

He was fully worthy of all the love and honour which he so abundantly
eceived.

Of the many tributes paid him during his long life, perhaps none was more
appreciated than the Presidentship of the Medico-Psychological Association
in 1882. The Association has very rarely chosen a President from outside its
specialty, and Gairdner deemed his appointment a great honour and a recognition
of the wide view of Medicine which he had always maintained.

His death, though sudden, was not unexpected. For several years his pulse-rate
had been under 28, and often much lower. He took the keenest professional
interest in his own case, and often dictated reports as to his condition and feelings,
which might elucidate it. His mind was clear throughout the long illness. He
took all his old interest in things professional and in current events, welcomed the
visits of old friends, read a great deal, and was happy in the family affection which

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864

NOTES AND NEWS.

[Oct,

surrounded him and had always been his chief earthly happiness. Thus with
characteristic calm acceptance he awaited his Father’s will. His death was worthy
of such a life. He has left a great name and a high example.

George Harold Urmson.

Many members of the Medico-Psychological Association will have learnt with
deep regret, and with almost a sense of personal loss, of the death, on September
22nd, of Mr. G. H. Urmson, Commissioner in Lunacy, at the comparatively early
age of fifty-six. He had been incapacitated from duty since Last December, when
he underwent a severe abdominal operation; but for several months, during which
he bore his trial with characteristic fortitude and cheerfulness, there was reason to
hope that he might eventually be restored to health and usefulness. In the summer
he was able to spend a month in Switzerland, whence he returned unhappily not
improved. Shortly after his return graver symptoms appeared, and he rapidly
lost strength, so as to be unable to be removed to his home at Limpsfield from
St. Leonard’s, where he died.

Harold Urmson was the son of the late Mr. George Urmson, and was born
at Canton. He was educated at Eton and Christ Church, Oxford, where he
achieved distinction as an athlete, becoming President of the University Athletic
Club. He graduated with First Class Honours in the Jurisprudence School,
entered the Inner Temple, and was called to the Bar in 1877. In 1889 he was
appointed Secretary to the Lunacy Commission in succession to Mr. Spencer
Perceval, who had filled that office for seventeen years. The changes in adminis¬
tration due to the passage of the Lunacy Acts of 1890 and 1891 must have entailed
on the new Secretary much laborious work, besides enabling him to become fully
conversant with the somewhat intricate working of the Acts. The death of Mr.
C. P. Phillips in 1895 created a vacancy on the Board, which was filled by Mr.
Urmson’s well-earned promotion, and for the past few years he has been the senior
legal Commissioner.

His charming personality and generous disposition rendered him peculiarly
fitted for his office, the duties of which he performed so well and so unselfishly,
taking a keen interest in the welfare and treatment of the patients, many of whom
will sadly miss his helpful and encouraging counsel. The Commission can ill
afford to lose him at a juncture when, as is probable, new and wider spheres of
duty may be imposed on it, for which his experience and judgment would have
been invaluable. But above all his colleagues will feel deeply the loss of one who
invariably showed such keen and practical interest in the work of their department,
and who was, moreover, a man of high principle and a true and loyal friend.

Paul MdBius.

In the Psychiatrisch-Neurologische Wochenschrift, Nr. 43, 1907, there is a heart¬
felt notice of Dr. Paul Julius Mdbius, who died in the beginning of this year of
affection of the heart and kidneys. Born in Leipzig in 1853, after studying
theology for some sessions he turned to natural history and medicine. He became
Doctor of Philosophy at Marburg, and took the degree of Doctor of Medicine at
Leipzig. After spending several years as a military surgeon, he settled in his
native city in 1883, devoting himself mainly to nervous diseases. He married the
daughter of a Leipzig professor, but the union ended in a separation. His wife
died in 1902. Though not connected with any lunatic asylum, Dr. Mdbius became
the most popular writer on subjects relating to nervous affections in Germany.
This was owing to the breadth of his culture, the force of his style, the origin¬
ality of his views and his choice of subjects. In his religious, devout, and ideal
vein of thought Mdbius bore a resemblance to his teacher, Fechner. This was
shown in his essays on religion, metaphysics, and psychology. Mdbius detested
materialism; his biographer tells us that in his last illness he felt assured that he
was going to the realm of souls, and that what constituted our essence would
again be found in the heart of the world. The hope of a blessed life with God
gave him a full consolation in his departure, yet he forbade the ministration of any

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NOTES AND NEWS.

1907.]

865

clergymen at his funeral. Breaking away from the isolation in which psychiatry
had got, he brought his knowledge of neurology and philosophy to bear on one
subject. His division of nervous diseases into exogenous and endogenous was
given for the first time in his Abriss der Lehre von den Nervenkrankheiten, 1893,
and excited some controversy. His literary activity was incessant. Among his
contributions may be mentioned works on the Diagnosis of Nervous Diseases,
Megrim, Basedow’s Disease, Tabes, and Headache. His studies upon the patho¬
logical aspect of men of genius, as Rousseau, Goethe, and Schopenhauer, and his
essays on art and artists and on the aptitude for mathematics made his name
known to general readers. His work on the physiological weakness of women,
which was reviewed in this Journal, has come to the eighth edition.

This pamphlet, which excited lively recriminations, was followed by some
measurements of female heads, showing that they were smaller than male heads. •
Keeping up his polemic, Mdbius wrote another treatise on the differences between
the sexes in twelve numbers ( B extrage but Lehre von den Gesclechtsuntershieden).
He also published, anonymously, a Kalender for good and naughty ladies, which
was, we suppose, of a humorous character.

The following passage will give an idea of the wideness of his views: " If the
alienist will rightly fulfil his mission, no domain of mental life must be strange to
him. He must know the bounds of mental health, as those who profess to give
attention to hygiene must know the condition of bodily health. Psychiatry, so
comprehended, will become the ruler instead of the servant, the psychiater will
become the judge in all human affairs, the teacher of the jurist and the theologian,
and a guide to the historian.

William W. Ireland.

APPOINTMENTS.

Dr. Norman Lavers, M.D.Brux., M.R.C.S., L.R.C.P.Lond., Medical Super¬
intendent of the Canterbury City Asylum, has been appointed Physician Super¬
intendent of Bailbrook House, Bath.

Dr. Ernest F. Sail, M.R.C.S.Eng., L.R.C.P.Lond., has been appointed Medical
Superintendent of the Canterbury Borough Asylum.

Sammon, W. D., L.R.C.P. and S.I., Clinical Assistant to the Richmond District
Asylum, Dublin.

Riggall, Robert Marmaduke, L.R.C.P., etc., third Assistant Medical Officer to
the Devon County Asylum, Exminster.

Smith, Charles Mollison, M.B., Ch.B.Aberd., Junior Assistant Medical Officer at
the County Asylum, Prestwich, Manchester.

Allen, L. L., M.R.C.L., L.R.C.P., Junior Medical Officer in the Lunacy Depart¬
ment, New South Wales.

NOTICES OF MEETINGS.

Quarterly Meeting .—The next Quarterly Meeting will be held in London on
Tuesday, November 19th, and the following Meeting on Tuesday, February 18th
(Provisional).

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INDEX TO VOL. LIII.

Part I.—GENERAL INDEX.

Address, presentation of, to Dr. Jones, 216
„ presidential, 677
„ to nursing staff at York Retreat, 121
Adult dementia, 107

„ „ aetiology of, 108, 110

Agrammatism, 405

Alcohol, injection of, into nerve-trunks, 650
„ and insanity in Dorset, 691

„ question, the, 822

Altered personality, 837
Amentia and dementia, 84, 423
Amnesia, negativistic, case of, 647
Amyotrophic lateral sclerosis, mental symptoms in, 182
Anaemia, cerebral, a cause of convulsions in epilepsy, 70
Angeiomata in epilepsy, 25
Annual meeting, the, 818
Anthropology, criminal, 578
Anthropometry, criminal, 580
Anti-sera in general paralysis, preparation of, 754
Aphasia without lesion of Broca’s convolution, 392
„ sub-cortical sensory, 407
Appointments, 232, 421, 676, 865
Asylums, pathology in, 636

„ treatment in, 635

„ of U.S.A., visit to, 660

„ reports, 200

Asymmetry of brain, 838, 650
Attention, 177, 180
Ayr asylum, new hospital at, 548

Bacillus paralyticans , 593, 751
Basedow’s disease, treatment of case of, 660
Baths in treatment, 189
Bethel Hospital, Norwich, 227
Betz cells in epilepsy, 64
Bisexuality, human, 178
Blood, coagulation of, in epileptics, 73, 7 66
„ pressure in epileptics, 793
Bones, changes in, in general paralysis, 194
Brain, the senile, 391

„ in epilepsy, sclerosis of, 60
Bromocarpine, 364

Carswell case, the, 840

Cerebral function, localisation of, 138

Cerebellum, sclerosis of, 626

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868

INDEX.

Character, formation of, 121
Children, care of, in asylums, 541
“ Children’s crusade,” 322
“ Climacteric ” dementia, 84
Clinical psychiatry, 403, 645, 836
Communicated insanity, 274
Congenital deformity in families, 648
,, mental deficiency, 644
Congress, Milan, 225
Credivity and credulity, 191
Cretins, brain in, 649
Crime and heredity, 584
Crimes, interchange of, 360, 568
Criminal anthropology, 578
Criminals, cerebral morphology in, 193
„ classification of, 196
„ physiognomy of, 584
Crusades, psychology of, 322

Decrease of insanity, 820
Defective children, 406

„ „ teaching of, 380

Degeneracy, mental, 409

„ in Hereford, 797

Demoniac possession, 413
Deputy Commissioners, 145
Derangement of action in the insane, 380
Dementia, 84

„ of maturity, 107
„ paralytica in Brazil, 507
„ praecox, 423

„ „ stereotypy in, 183

„ premature, 423

,, „ catatonic, 451

„ „ hebephrenic, 440

„ „ paranoid, 463

„ pre-senile, mania with, 90

„ „ melancholia with, 93

,, „ simple, 104

Diphtheroid bacillus in general paralysis, 590
Dipsomania and heredity, 254
Drunkenness and homicide, 348
Duplex brain, theory of, 834

Epilepsy, anaemia, cerebral, cause of convulsions in, 70
„ angeiomata in, 25

„ a study of, 639

„ Betz-cells in, 64

„ blood pressure in, 404, 793

„ „ vessels, changes in, 66

„ brain changes in, 60

„ coagulation of blood in, 73, 766
„ cord changes in, 68

„ heterotopia of cord in, 41

„ pathology of, 1

„ pulse in, 404

„ thrombosis in, 2, 640

Epileptic insane, management of, 361
Eschars in general paralysis, 410
Etiology, 181. 399, 644, 836
Eunuch, eroticism in, 837
Eye in the insane, the, 647

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INDEX.

869

Facial aspect in insanity, 280
Family care in Saxony, 415
„ insanities, 400
Fatigue, clinical measurement of, 475
Foreign bodies, removal of, from vagina, 628
Folie k deux, 274
Formation of character, 121
Frontal lobe, functions of, 398
Fugues, 646

Gait in insanity, 283

Ganglion cells, investigation of, 835

General paralysis, aetiology of, 181

„ „ changes in bones in, 194

,, „ deaths from, 154, 159, 182

„ ,, diphtheroid bacillus in, 590

„ „ eschars in, 410

„ „ experimental production of, in rats, 595

,, „ infective foci in, 602

„ ,, influence of race on, 510

,, „ juvenile, 513

„ „ remissions in, 222

General paralysis and tabes dorsalis, bacteriology of, 590
„ „ treatment by anti-sera, 750

„ „ some statistics of, 508

Generative disorders in insanity, 286
Girgenti inebriate reformatory, 862
Gliosis in epilepsy, 59
Grantham railway disaster, 147

Hsematoma auris, 192
Hallucinations, negative aspect of, 180
Hearing in dogs, testing of, 640
Heredity and crime, 584

„ and dipsomania, 254

„ in insanity, 695

„ of insanity in general paralysis, 255

„ race and, 399

Hermaphroditism, 170
Heroinomaniacs, 652
Homicide and drunkenness, 348

„ psychic hyperesthesia and, 649
** Homolateral ” pyramidal tract, 398
Homo-sexuality, 178
Hydrotherapy in mental disease, 656
Hygiene of the mind, 376
Hypnotics in treatment, 187
“ Hypo-chlorisation ” in epilepsy, 36*1
Hypochondria, 645
Hysteria, 833, 834
Hysterical laughter, 411
Hysterics, responsibility of, 199

Impulsions, pathogenesis of, 179
Increase of insanity, 151, 155
Indoor rest treatment, 727
Insane, family care of, in Saxony, 415
Insanity, aetiology of, 181, 399

„ age periods in relation to, 264

„ and alcohol in Dorset, 691

„ and marriage, 277, 710

„ and mysticism, 171

UII. 60

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INDEX.

870

Insanity, communicated, 274
„ decrease of, 820

„ expectation of life in, 272

„ from occupation, 185

„ growth of nails in, 185

„ hereditary, 401

„ idiopathic, 238

„ increase in, 219, 245

„ „ of, 151, 155

„ in Dorset, 679

,, pathology of, 192, 649

,, prognosis in, 233

„ surgery in, 654

„ sympathetic, 234, 238

„ time of mental processes in, 184

I ntra-vascular thrombi in epilepsy, 3

International committee on causation of insanity, nominations to, 672

Laughter, hysterical, 411
Left hemisphere and motor actions, 176
Leucocytosis in acute mania, 170
Localisation of cerebral function, 138
Lombroso and spiritualism, 396, 633
Lunacy Commission, 144

„ legislation (Ireland), 418, 661

McDonald, Dr., 385
Mania, acute, leucocytosis in, 170
„ „ with depression, 651

Marriage and insanity, 710
Mechanism of attention, 177
Melancholic folie raiscnnante , 615
Mental processes in insanity, time of, 184

Medico-legal cases—Rex v. Tunnicliffe, 141 ; Criminal Law Amendment Act,
under, 143

Medico-legal procedure in America, 386
Medico-psychological Association, balance sheet, 843

„ „ notices of meetings, 232,421, 675,865

1 * „ >. by registrar, 420,672

„ „ presidential address, 677

„ „ report of meetings of, 214,417, 661,840

Metabolism, and practical medicine, 830

„ influences of mental processes on, 408
Milan International Congress, 225
Morison lectures, 233
Morphiamaniac, trial of, for murder, 198
Motor actions and left hemisphere, 176
Multiple personality, 173
Mysticism and insanity, 171

Nerves, lesions produced by toxins, 367
Nerve-cells, changes in, in epilepsy, 62
Neurasthenia, lectures on, 641
Neurology, 175, 397, 642, 835

„ and psychiatry, clinical, 182
Nomadism, 646
Nurses, address to, 121
„ male v. female, 563

„ registration of, 370, 632

Nutrition, physiological economy in, 298
„ regarding prognosis, 282

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INDEX.

8/1

Obituary, 229, 419, 670, 863
Obsession, remarks on, 218
Occupations and insanity in Dorset, 688
Open-air rest treatment of insanity, 723, 733
Opsonic index, technique, 525
Oral sepsis, 283, 366

Paranoia, developmental, 465
„ dissolutive, 465
Pathology in asylums, 636
„ of epilepsy, 1
„ of insanity, 192, 649
Patient's letters, 204
Perception, affective characters of, 835
Personality, multiple, 173
Petition to Sir H. Campbell-Bannerman, 373
Pharyngeal reflex, clinical study of, 403
Phobias, 184

Physiological psychology, 177, 833
Poisoner, report on mental state of, 416
Pre-frontal area, 138
Premature dementia, 423
Pre-senile dementia, 84

„ insanity with dementia, 101

„ mania with dementia, 90

„ melancholia with dementia, 93

Primitive man, 385

Private asylums, letter to the editor, 228
Progress of psychiatry in America, 385
„ ,1 in France, 390

„ „ in Germany, 393

„ „ in Italy, 394

Psychiatry, clinical, 403, 645, 836
„ new journal of legal, 379
Psychology, 643

„ of the crusades, 322

„ physiological, 177

Psycho-therapeutics, 190
Pyramidal tracts of man, 397

Race and heredity, 399

Recidivism, 341, 568

Recidivist, insanity in the, 570

Recovery, influence of age on, 264

Registration of nurses, 370, 632

Remission in general paralysis, 222

Reply by Dr. Campbell to Dr. J. S. Bolton, 138

Reports, asylum, 200

Responsibility, 195

Resume of Morison lectures, 274

Season incidence of insanity, 267
Sedatives in treatment, 186
Sexual life of our time, 637
Skin in insanity, the, 281
Sociology, 195, 4x3, 839
“ Spiritism,” 396

Statistics of crime in Scotland and England for 1903, 344

Status epilepticus, treatment of, 365

Stereotypy in dementia praecox, 183

Stress as a cause of insanity, 260

Suggestion and persuasion, 190

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872

INDEX.

Tea drinking as a cause of insanity, 694
Telephonists, nervous injuries in, 402
Temperance, increase of, 146
Templars, the, 327
Thalamus in epilepsy, atrophy of, 62
Thaw trial, the, 630
Therapeutics of mental disorder, 188
Thyroid disease, increase of, 805
Training of mentally deficient, 380
Treatment of insanity, 186, 650
Tubercle in the insane, deaths from, 154
„ liability of insane to, 522
Tuberculo-opsonic index, 522

Vision, field of, in the insane, 647

Work curves, 478

Workmen's Compensation Act, 663, 848
Work values, comparison of, 488
Writer's cramp, treatment of, by ligature, 836

Part II.—ORIGINAL ARTICLES.

Baird, Dr. H., a case of sclerosis of the cerebellum, 626

Barham, Dr. G. F., notes on the management and treatment of the epileptic
insane, with a special reference to the NaCl-free diet, 361

Bolton, Dr. J. S., amentia and dementia ; a clinico-pathological study, 84, 423

Campbell, Dr. A. W., on the localisation of cerebral function: a reply to
Dr. Bolton, 138

Clouston, Dr., and others, psychiatry as a part of public medicine, 704

Easter brook, Dr. C. C., the new hospital at Ayr Asylum, 548

„ „ the sanatorium treatment of active insanity by rest in bed

in the open air, 723

Fennell, Dr. C. H., the care of children in county and borough asylums, 541

Ireland, Dr. W. W., on the psychology of the crusades, 322

Macdonald, Dr. P. W., presidential address, 677

Moreira and Penafiel, Drs., a contribution to the study of dementia paralytica in
Brazil, 507

Morrison, Dr. C. S., the inference of local degeneracy from a comparison of the
vital statistics of the people, 795

Nolan, Dr. M. J., study of a case of melancholic folie raisonnante , 615

Orr and Rows, Drs., a demonstration of the lesions, experimentally produced, in
the spinal cord and cranial nerves by the action of toxins, 367

Pringle, Dr. A. D., notes on a case where a large number of foreign bodies were
removed from the vagina, 628

Robertson and McRae, Drs., further bacteriological and experimental investigations
into the pathology of general paralysis and tabes, 590
„ „ observations on the treatment of general paralysis and

tabes dorsalis by vaccines and anti-sera, 750

Shaw, Dr. C. J., liability of the insane to tubercular infection, as demonstrated by
an examination of the tuberculo-opsonic index, 522

Specht, Dr. W., the clinical measurement of fatigue; translation revised by Dr.
T. Johnstone, 475

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INDEX.

873

Sutherland, Dr. J. F., recidivism, 341

Turner, Dr. J., anatomy and pathology of epilepsy, 1

Urquhart, Dr. A. R., insanity, heredity and prognosis—the Morison lectures, 234

Part III.-REVIEWS.

Bloch, Dr. I., Das sexualleben unserer zeit, 637
Bianchi, Dr. L., A text-book of psychiatry, 825
Bruce, Dr. L. C., Studies in clinical psychiatry, 169

Clouston, Dr. T. S., The hygiene of mind, 376

Chittenden, Dr. R. H., Physiological economy in nutrition : an experimental study,
829

Freud, Prof., Psycho-pathologie des Altagsleben, 830

„ „ Sammlung kleiner schriften zur neurosenlehre, 172

Guiseppe, Dr. M., Avviamente all’educazione e intruzione dei deficienti, 380

Kronthal, Dr. P., Metaphysik. in der psychiatrie, 381

Legrain, Dr., ISMments de medicine mentale appliques h. l’£tude du droit, 377
Liepmann, Prof., Ueber storungen des handelns bei gehimkranken, 380

Marie, Dr. A., La d£mence, 382

„ „ Mysticisme et folie, 171

New journal of legal psychiatry, 379

Noorden, C. von, Metabolism and practical medicine, 830

Paton, Dr. S., Psychiatry, 165

Prince, Dr. M., The dissociation of a personality, 173

Report (Sixtieth) of the English Commissioners in Lunacy, 149

„ (Forty-eighth) of the General Board of Commissioners (Scotland), 151
„ (Fifty-fifth) of the Inspectors of Lunatics (Ireland), 162
„ Supplement to Fifty-fourth, of the Inspectors of Lunatics (Ireland), 155

Savill, Dr. T. D., Lectures on neurasthenia, 641

S6guin, Dr. E., Premiers m^moires de S^guin sur l’idiotie, 832

„ „ Traitement moral, hygiene et education des idiots, 832

Turner, Dr. W. A., Epilepsy, 639

Zuccarelli, A., Gli uomini primitive, 385

Part IV.—AUTHORS REFERRED TO IN EPITOME.

Alt, 415

Bacelli, 192
Behr, 413
Bernheim, 190
Besta, C., 404
Bischoff, 400
Bodil Hjorth, 182
Bonvicini, 407
Brissaud, Sicard, and
Tanon, 650

Cullerre, A., 182
Cullum, S. J., 186
Crothers, 198

D’Abundo, 194
De Boeck and de Rode,
416

Denny, G., et Camus, P.,

837

Dromard, G., 183
Ducost6, M., 646

Duhem, P., 652

Fabrizi v. Forli, 648
Falciola, 185
Foerster, 835

Forli, V., et Guidi, G., 403
Franz, S. T., 184

Hallpach, 185
Hartenburg, P., 836
Heilbronner, K., 405

Digitized by v^ooQle

874

I KB EX.

Hocfcmf, G6o
Hoffc, A-,643

J-> *96, 4 J

P„ 179

Ktfackf, 0_ 642
K2mpefj. t, 658

K«PP J *U654

Kntil^ 408

Latses, 630. S3*

Leroy Bntt, 654

L™*“t 399

Xvdaad, 409
M jrgau . t&2

M*xo> 649

Mfrir, ct Bailfiart, P-,
^47

Moogoi, L, 181
M <tem o aad S ei r aliro
Estaae , 197

Moron, J., aad Prfxolo,

A-,418

Niche, P-, 178
Naync, 177

*75

Pa^bs, B_, 656

*88, 199,
Racfcanfa, 194
Roococcei, 398
Rosesfcki, 406
Roy, P., 645

Saifio, P., S33

Schota and Tlagerh, 649

Schloss, 644

S^fco ,647
Steves, H. C, 180

Tories, 184
Tboma, L, 406
Tbap-Meyer, 660
T%fo* 4 *>i

Touock and Criw, 195
Tom, Cbo, 180
Toro, 193

UjoJotti, F, J97

Vyr o ti , A-. 410

Wagaer, 658
Witte, Max EL 654
Wolf, 651

ILLUSTRATIONS.

Quarts Ci^tratlag Dr. Urq*kart*s article on M Tbe Morisoa LatTO,” 396, 397,

yrf. 306.307 309 y»o

Qjra - atncif Dr. Wilhelm Spccht's paper on * The Qmical Meaw oeeat of

Fac^e. ’ 477. 479. 48a 481, 48 3. 4S6, 501
Qarts „-atra^f Dr. Trraer s article oa "Coa^alatioa Rate of Blood ta
E?l>c^cs.- 77*. 774. 777. 779. 782, 764, 787-8-9
Charts zz —tstrate Dr. Mottjcq s article 00 " Inference of Local Degeneracy/*

Sco 5 c:. 5 ct Sea.

Fsires Dr. SstSeriaarf s article 00 " Reodrrism,’' 347, 354

F-^ire rstratnrg Dr. Easterbrochs paper oo * Sanatorreai Treatment of Actrre

I tsar: ry 729

_-iscra ri g Dr. S itberlaic s article 00 ** Recidirisen,” 574; chart, 582
Mjcro-pcccc^ntis Laserar.tg Dr. T er s er s paper oa ‘'The Anatomy aad
Pat 5 *-: egy of Ep-'epsy. 16. 34. 66 : diagram, 28 ; durt, 76
Macrc-tcctc^nrfis ul-^scrabsg Dr. Baxnf s paper oa “ A Case of Sclerosis of tike
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Paces : Dr. Derise's artick oa * A Case of Kata*onia in a Coogenital

EVaf-Vite. $06

Wocccrt _^stnn=g Eh- Easterbrook s artick oo " The New Hospital at Ayr
Air ;^=t, 533 ; pUe, 552-

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Full text of "The Journal Of Mental Science. 53.1907 Harvard"

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