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PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY

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PRINCETON UNIVERSITY

THE JOURNAL

MENTAL SCIENCE.

EDITORS:

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

J. Chambers, M.D.

ASSISTANT EDITOR:

J. R. Lord, M.B.

VOL. LVI.

J. & A. CHURCHILL,

7, GREAT MARLBOROUGH STREET.

MDCCCCX.

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PRINCETON UNIVERSITY

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“ In adopting our title of the Journal of Mental Science, published by authority
of the Medico-Psychological Association, we profess that we cultivate in our pages
mental science of a particular kind, namely, such mental science as appertains
to medical men who are engaged in the treatment of the insane. But it has
been objected that the term mental science is inapplicable, and that the term
mental physiology or mental pathology, or psychology, or psychiatry (a term
much affected by our German brethren), would have been more correct and ap¬
propriate ; and that, moreover, we do not deal in mental science, which is pro¬
perly the sphere of the aspiring metaphysical intellect. If mental science is
strictly synonymous with metaphysics, these objections are certainly valid ; for
although we do not eschew metaphysical discussion, the aim of this Journal is
certainly bent upon more attainable objects than the pursuit of those recondite
inquiries which have occupied the most ambitious intellects from the time of
Plato to the present, with so much labour and so little result. But while we
admit that metaphysics may be called one department of mental science, we moun¬
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 airn' at such iiiet.r-
physical knowledge as may be available to our purposes, as the mechanician uses
the formularies of mathematics. This is our view of the kind of mental science
which physicians engaged in the grave responsibility of caring for the mental
health of their fellow-men may, in all modesty, pretend to cultivate; and while
we cannot doubt that all additions to our certain knowledge in the speculative
department of the science will be great gain, the necessities of duty and of danger
must ever compel us to pursue that knowledge which is to be obtained in the
practical departments of science with the earnestness of real workmen. The cap¬
tain of a ship would be none the worse for being well acquainted with the higher
branches of astronomical science, but it is the practical part of that science as it
is applicable to navigation which he is compelled to study.”— Sir J. C. Bucknill,
M.D., F.R.S.

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PRINCETON UNIVERSITY

THE

MEDICO-PSYCHOLOGICAL ASSOCIATION
OF GREAT BRITAIN AND IRELAND.

THE COUNCIL AND OFFICERS, 1909-10.

president. —W. BEVAN-LEWIS, M.Sc.
president elect.— A. R. TURNBULL, M.B.
ex-president.— CHAS. A. MERCIER, M.D., F.R.C.P., F.R.C.S.
treasurer.— H. HAYES NEWINGTON, F.R.C.P.

(HENRY RAYNER, M.D.
editors op journal. -{A. R. URQUHART, M.D.

I.JAMES CHAMBERS, M.D.

assistant editor (not Member of Council).—JOHN R. LORD, M.B.
divisional secretary for south-eastern division.— R. H. STEEN, M.D.

DIVISIONAL SECRETARY FOR SOUTH-WESTERN DIVISION.— H. T. 8. AVEI.INK, M.D.
DIVISIONAL SECRETARY FOR NORTHERN AND MIDLAND DIVISION.

T. S. ADAIR, M.D.

divisional SECRETARY FOR SCOTLAND.— HAMILTON C. MARR, M.D. F.F.P.8.
DIVISIONAL SECRETARY FOR IRELAND.— WILLIAM R. DAWSON, M.D., F.R.C.P.

GENERAL SECRETARY. —C. HUBERT BOND, M.D., D.Sc.

SECRETARY OP EDUCATIONAL COMMITTEE. — W. H. B. 8TODDART, M.D., F.R.C.P.
(appointed bvEducational Committee, but with sent on Council).
registrar. —ALFRED MILLER, M.B.

MEMBERS OF COUNCIL.

REPRESENTATIVE.

A. N. BOYCOTT
C. H. FENNELL
H. WOLSELEY-LEWIS
F. W. -MOTT

F. StJ. BULLEN

P. W. MACDONALD

G. E. MOULD
DAVID ORR

R. D. CAMPBELL
R. D. HOTCHKIS

S.E.

Div.

W.GRAHAM.

JAMES J. FITZGERALD

|Ireland.

^ S.W. Div.

| N. & M. Div.
j Scotland.

NOMINATED.

ROBERT JONES
JOHN MILLS

L. R. OSWALD
R. PERCY SMITH
W. J. VINCENT
T. OUTTERSON WOOD

[The above form the Council.]

AUDITORS.

MAURICE CRAIG, M.D.
JOHN R. LORD, M.B.

EXAMINERS.

ENGLAND

SCOTLAND

IRELAND

j ROBERT JONES, M.D.

]T. B. HYSLOP, M.D.

( HAMILTON C. MARR, M.D.
]N. T. KERR, M.B.

(M. J. NOLAN, L.R.C.P.

]R. R. LEEPER, F.R.C.S.

Examiners for the Nursing Certificate of the Association :
CHAS. A. MERCIER, M.D.; ADAM R. TURNBULL, M.B.;
BEDFORD PIERCE, M.D.

PARLIAMENTARY COMMITTEE.

FLETCHER BEACH.

W. BEVAN-LEWIS (ex officio).
GEO. F. BLANDFORD.

C. HUBERT BOND (ex officio).
DAVID BOWER (Chairman).
LEWIS C. BRUCE.

JOHN. CARSWELL.

JAMES CHAMBERS.

THOS. S. CLOUSTON.

WM. R. DAWSON.

J. O’C. DONELAN.

THOS. DRACES.

CHAS. K. HITCHCOCK.

P. T. HUGHES.

W. F. MENZIES.

CHAS. A. MERCIER.

H. HAYES NEWINGTON.

M. J. NOLAN.

EVAN POWELL.

HENRY RAYNER.

GEO. H. SAVAGE.

G. E. SHUTTLEWORTH.

R. PERCY SMITH.

J. BEVERIDGE SPENCE.
ROTHSAY C. STEWART.
DAVID G. THOMSON.

T. SEYMOUR TUKE.

ALEX. R. URQUHART.

E. B. WHITCOMBE.

ERNEST W. WHITE.

H. WOLSKLEY-LEWIS (Sect/.).
T. OUTTERSON WOOD.
DAVID YELLOWLEES.

THEO. B. HYSLOr.

J. CARLYLE JOHNSTONE.
ROBERT JONES.

A/VP. W. MACDONALD.

T. W. McDOWALL

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PRINCETON UNIVERSITY

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EDUCATIONAL

FLETCHER BEACH.

W. BEVAN-LEWIS (ex officio).

J. 8. BOLTON.

C. HUBERT BOND (ex officio).

LEWIS C. BRUCE.

JAMES CHAMBERS.

THOS. S. CLOUSTON.

MAURICE CRAIO.

WILLIAM R. DAWSON.

J. O’C. DONELAN.

THOS. DRAPES.

REGINALD EAGER.

F. A. ELKINS.

J. A. EWAN.

JAMES J. FITZGERALD.

EDWIN GOODALL.

W. GRAHAM.

R. D. HOTCKIS (ex officio).

THEO. B. HYSLOP.

J. CARLYLE JOHNSTONE.

ROBERT JONES.

WALTER S. KAY.

N. T. KERR (ex officio).

R. R. LEEPER (ex officio).

P. W. MACDONALD.

THOS. W. McDOWALL.

S. R. MACPHAIL.

COMMITTEE.

HAMILTON C. MARR.

WILLIAM F. MENZ1ES.

C. A. MERCIER (Chairman).
JAMES MIDOLEMASS.

ALFRED MILLER.

H. HATES NEWINGTON.
MICHAEL J. NOLAN.

DAVID ORR.

L. R. OSWALD.

BEDFORD PIERCE.

WILLIAM R.4WE8.

HENRY RAYNER.

GEORGE M. ROBERTSON.

R. G. ROWS.

GEORGE H. SAVAGE.

R. PERCY SMITH.

J. BEVERIDGE SPENCE.
ROBERT H. STEEN.

W. H. B. STODDART (Secretary).
FREDERIC R. P. TAYLOR.

D. G. THOMSON

T. SEYMOUR 'l'UKE.

ADAM R. TURNBULL.

EDMUND B. WHITCOMBE.
ERNEST W. WHITE.

T. OUTTERSON WOOD.

DAVID YELLOWLEES.

COMMITTEE.

I HENRY DEVINE.
BERNARD HART.
HENRY RAYNER.

T. OUTTERSON WOOD.

LIBRARY

FLETCHER BEACH.

W. BKVAN-LEWIS (ex officio).

C. HUBERT BOND (ex officio).

R. H. COLE.

LIST OF CHAIRMEN.

1841. I)r. 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, Hamvell.

1852. Dr. Wintle, Warneford House.

LIST OF PRESIDENTS

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

1855. J. Thurnam, M.I)., Wilts County Asylum.

1856. J. Hitchmxn, M.I)., Derby County Asylum.

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

1858. John Conolly, M.I)., County Asylum, Hanwell.

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

1860. J. C. Bucktiill, M.I)., Devon County Asylum.

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

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

1863. David Skae, M.I)., Royal Edinburgh Asylum.

1864. Henry Munro, M.I)., Brook House, Clapton.

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

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

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

1868. W. H. O. Sankey, M.D., Sandywell Park, Cheltenham.

1869. T. Layeoek, M.I)., Edinburgh.

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

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

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PRINCETON UNIVERSITY

Ill

1S72. Sir James Coxe, M.D., Commissioner in Lunacy for Scotland.

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

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

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

1876. W. H. Pursey, 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 Tuke, M.D., London.

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

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

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

1885. J. A. 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. Clouston, M.D., Royal Edinburgh Asylum.

18S9. H. Hayes Newington, M.R.C.P., Ticehurst, Sussex.

1890. David Yellowlees, M.I)., 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. McDownll, M.D., Morpeth, Northumberland.

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

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

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

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

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

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

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

Square, London, W.

1905. T. Ontterson Wood, M.D., F.K.C.P., 40, Margaret Street, Cavendish

Square, London, VV.

1906. Robert Jones, M.D., F.R.C.P., F.R.C.S., Claybury Asylum, Woodford

Bridge, Essex

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

1908. Chas. A.Mercier, H.D., F.R.C.P., F.R.C.S.,34, Wimpole Street, London, W.

1909. W. Bevan-Lewis, M.Sc., L.R.C.P.

HONORARY MEMBERS.

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

Regius Professor of Pliy.-tic, Univ. Camb., St. Rudegund’s, Cambridge.
1881. Benedikt, Prof. M., Franciskaner Platz 5, Vienna.

1907. Bianchi, Prof. Leonardo, Mauicomio Provinciale di Napoli. (Carr. Mem.,
1896.)

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

1900. Bresler, Johannes, M.D., Oberartzt, Lublinitz, Silesia. (Corr. Mem.
1896.)

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

1876. Browne, Sir J. Crichton-, M.D Edin., LL.D., F.R.S., Lord Chancellor’s
Visitor, R lyal Courts of Justice, Strand, W.C. (Pbesidrnt, 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.

1909. Collins, Sir William J., D.L., M.P., M.D., M.S., B.Sc.Lond., F.R.C.S.
Eng., 1, Albert Terrace, Regent’s Park, N.W.

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PRINCETON UNIVERSITY

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iv Honorary and Corresponding Members.

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

1872 f Courtenay, Maziere, B.A., M.B., M.Ch.Uuiv. Dubl., Inspector of
ibqi'i Lunatics in Ireland, Lunacy Office, Dublin Castle. {Secretary for
JByl - 1 Ireland, 1876-87.)

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

1896. Ferrier, David, M.A., M.D., LL.D., F.R.S., F.R.C.P., 34, Cavendish

Square, London.

1872. Fraser, John, M.B., C.M., F.R.C.P.E., Commissioner in Lunacy, 13,
Heriot Row, Edinburgh.

1898. Hine, George T., F.lt.I.B.A., 35, Parliament Street, London, S.W.

1881. Hughes, C. II., M.D., St. Louis, Missouri, United States.

1909. Kraepelin, Dr. Emil, Professor of Psychiatry, The University, Munich.
1887. Lentz, Dr., Asile d’Alienes, Tournai, Belgique.

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

1866.1 Mitchell, Sir Arthur, K.C.B., M.A., M.D., LL.D., 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 dc 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,
VV. (President, 1887.)

1909. Obersteiner, Dr. Heinrich, Professor of Neurology, The University,
Vienna.

1891. O’Farrell, Sir G. P., M.A., M.D., Univ. l)ubl., Inspector of Lunatics in
Ireland, 19, Fitzwilliam Square, Dublin.

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

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

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

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

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

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

1904. Tuke, Sir John Batty, M.P., M.D., D.Sc., LL.D., F.R.C.P., 20, Charlotte
Square, Edinburgh.

CORRESPONDING MEMBERS.

1904 Bierao, Caetano, 48, Itua Formosa, Lisbonne, Portugal.

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

1904. Caroleti, Wilfrid, Mauicomia de Sta. Crur, St. Andreo de Palauiar,
Barcelona, Snain.

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

1902. Estense,Benedetto Giovanni Selvatico, M.D., 116, Piazza Porta Pia, Rome.
1907. Ferrari, Giulio Cesare, M.D., Director of the Manicomio Provinciale,

Iinola, Bologna, Italy.

1904. Koenig, William Julius, Deputy Superintendent, Dalldorf Asylum, Berlin.
1880. Komfeld, Dr. Hermann, Hotel Kepherta, Frume, Austria.

1889. Kowalowsky, Professor Paul, Kharkoff, Russia.

1896. Lindell, Emil Wilhelm, M.D., Sweden.

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

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

1897. Nacke, Dr. P., Huhertusberg Asylum, Leipzig.

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

1909. Pilcz, Dr. Alexander (Professor of Psychiatry in the University of
Vienna), Superintendent Landcssanatorium furNervcn und Geistes-
krauke Steinliof, Vienna.

1890. R£gis, Dr. E., 64, Rue Huguerie, Bordeaux.

1898. Semelaigne, Dr. Rene, Secretaire des Stances de la Society M&lico-

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 1865.

1900. Abbott, Heury Kingsmill, M.D.Dublin, D.P.H.Ireland, Medical Superin¬
tendent, Hants County Asylum, Farebam.

1891. Adair, Thomas Stewart, M.D., C.M.Edin., Medical Superintendent,
Stortlies Hall Asylum, Kirkburtou, near Huddersfield. (Hon. Sec.
N. and M. Division since 1908.)

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

1868. Adams, Josiuh O., M.D.Durb., F.R.C.S.Eng., 117, Cazcnove Road, Clap¬

ton, N.E.

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

1905. Alcock, Benjamin James, M.A., M.B.Aberd., Cb.B., James Murray’s Royal
Asylum, Perth.

1869. Aldridge, Chas., M.D.Aber., L.U.C.P., Plympton House, Plympton, Devon.
1905. Alexander, Edward Heury, M.B., M.R.C.S., Physician Superintendent,

Ashbourne Hall Asylum, Dunedin, New Zealand.

1899. Alexander, Hugh de Maine, M.D., Medical Superintendent, Aberdeen
City District Asylum, Kingseat, Newmachar, Aberdeen.

1890. Alexander, Robert Reid, M.D.Aber., 25, Lingfield Avenue, Kingston-

on-Thames.

1882. Alliott, A. J., M.D., Ferndale, St. John’s Hill, Sevenoaks.

1899. Allmaun, 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.

1908. Anderson, James Richard Sunner,M.B.,Ch.B.Glas.,Senior Assistant Medi¬

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

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

near Hull.

1909. Anderson, John Theodore, L.R.C.P.AS.Edin., L.F.P.S Glasg., Senior

Assistant Medical Officer, Hospital for the Insane, Perth, Australia.

1901. Andersou, 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. Arcbdall, Mervyn Thomas, L.S.A.Lond., L.R.C.P.&S.Edin., Brynn-y-

Nenadd Hall, Llunfairfechan, N. Wales.

1910. Aubrey, Gilbert Kennedy, L.M.&S., S.A., Assistant Medical Officer,

Darenth Asylum, Hartford, Kent.

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

tendent, County Asylum, Cotford, near Taunton, Somerset. (Hon.
Sec. for S. W. Division since 1905.)

1909. Bagnall, Robert George Archibald, M.B., Cb.B.Edin., Newcastle City
Asylum, Gosfortb.

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

Southall, Midd.

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

1909. Bain, John, M.A., M.B., B.Ch.Glasg., Assistant Medical Officer, North¬
ampton County Asylum, Berrywood.

1906. Baird, Harvey, M.D., Cb.B.Edin., Senior Assistant Medical Officer,

City Mental Hospital, Whitchurch, Cardiff.

1876. Baker, Robert, M.D.Edin., St. Paul’s Square, York. (President, 1892.)
1878. Baker, H. Morton, M.B.Edin., Assistant Medical Officer, Leicester Borough
Asylum, Humberstone, Leicester.

1888. Baker, John, M.D., Deputy Supt., State Asylum, Broadmoor, Berks.
1909. Ballard, Ernest Fryer, M.B., B.S.Lond., Assistant Medical Officer,
Somerset and Bath Asylum, Wells.

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

Asst. Medical Officer, London County Asylum, Long-Grove, Epsom.

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vi Members of the Association.

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

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.

1901. Baskin, J. Lougheed, L. lt.C.P.&S.Edin., L.F.P.S.Glas., Fisherton

House, Salisbury.

1902. Bnugh, Leonnrd D. H., M.B., C.M., G art loch Asylum, Gartcosli, Glasgow,

N.B.

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

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

St. Andrew’s Hospital, Northampton.

1907. Bazalgette, Sidney, M.lt.C.S., L.R.C.P.Loud., Assistant Medical Officer,

Fishponds Asylum, Bristol.

1874. Beach, Fletcher, M.B., F.R.C.P.Loud.,/omer7y Medical Superintendent,
Darenth Asylum, Dnrtford; Chaudos Lodge, Alton, Hants.
(General Secretary, 1889—1896. President, 1900.)

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

1902. Beale-Browne, Thomas Richard, M.lt.C.S.Eng., L.R.C.P.Loud., Medical
Staff, South Nigeria, West. Africa.

1896. Beamish, George, L.R.C.S.I., L.R.C.P.E., L.M., c/o New Club, 4, Grafton

Street, New Bond Street, W.

1909. Beeley, Arthur, M.Sc.Leeds, M.B., B.S.Lond., D.P.H.Cainb. ( Assistant
Medical Officer, E. Sussex Educational Committee), 14, Park
Avenue, Keigbly, Sussex.

1899. Beresford, Edwyu II., M.R.C.S., L.R.C.P.Loud., Medical Superintendent,

Tooting Bee Asylum, Tooting, S.W.

1879. Bevan-Lewis, William, M.Sc.Leeds, M.R.C.S., L.R.C.P.Loud., Medical

Superintendent, West Riding Asylum, Wakefield. (President,
1909-10.)

1894. Blacliford, James Vincent, M.D., B.S.Durham, 87, Belvedere Road,

Upper Norwood, S.E.

1908. Blackmore, Humphrey, P., M.D., Physician, Salisbury Infirmary.

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

1867. Blandford, George Fielding, M.D.Oxon., F.lt.C.P.Lond., Woodlands,
Camden Park, Tunbridge Wells. (President, 1877.)

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

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

1908. Blandy, Gurth Swinnerton, M.B., Ch.B.Edin., Assistant Medical Officer,
Middlesex County Asylum, Napshurv, Herts.

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.

19CO. Bolton, Joseph Shaw, M.I)., B.S., B Sc.Lond., Senior Assistant Medical
Officer, County Asylum, Rainhill, Liverpool.

1892. Bond, Charles Hubert, D.Se., M.I)., Ch.M.Ediu., Medical Superintendent,

London County Asylum, Long-Grove, Epsom. (Hon. General
Secretary since 1906.)

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

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

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

Borough Asylum, Ivvbridge, Devon.

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

1896. Boycott, Arthur N., M.D.Lond., M.R.C.S.Eng., L.R.C.P.Loud., 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.

1883. Boys, A. H., L.R.C.P.Edin., The Grange, St. Peter’s Street, St. Albans.

Google

Original from

PRINCETON UNIVERSITY

Members of the Association. vii

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

Superintendent, County and City Asylum, Powick, Worcester.

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

1895. Briscoe, John Frederick, M.R.C.S.Eng., Resident Medical Superintendent,
Westbrooke House Asylum, Alton, Hants.

1905. Brown, Harry Egerton, M.D., M.P.C., West Koffies Asylum, Pretoria,
S. Africa.

1904. Brown, Josephine, M.B.Lond., c/o Mrs. Barnett, Dockinfield Manor,
near Farnham, Hants.

1908. Brown, Robert Cunyngham, M.D.Durh., Deputy Medical Officer, H.M.
Prison, Pnrkhnrst, Isle of Wight.

1908. Brown, R. Dods, M.D., M.R.C.P.Edin., D.P.H., Senior Assistant, West
House, Morningside, Edinburgh.

1908. Brown, Relf, M.K.C.S., L.R.C.P.Lond., The Hall, Headcorn, Kent.

1893. Bruce, Lewis C., M.D.Edin., Druid Park, Murthly, N.B. ( Hon. Sec.

for Scotland 1901-1907.)

* Brushfield, Thomas N., M.D.St. And., The Cliff, Bndleigh Salter ton, Devon.

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

Bristol.

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

Superintendent, Flower House, Catford.

1907- Burpitt, Harry Reginald, M.D.Brux, M.R.C.S., L.R.C.P.Lond., Llan-
arthney, Newport, Mon.

1904. Burrell, Arthur Ambrose, M.B., B.Ch., Carrick Manor, Monkstown, 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,
Newcastle-on-Tyne.

1894. Campbell, Alfred Walter, M.D.Edin., Macquarie Chambers, 183, Mac¬

quarie Street, Sydney, New South Wales.

1909. Campbell, Donald Graham, M.B., Ch.M.Edin., Medical Officer, District

Asylum, Elgin.

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

1897. Campbell, Robert Brown, M.B., C.M.Edin., Medicul Superintendent,
Stirling District Asylum, Larbert.

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

1905. Carre, Henry, L.R.C.P., L.M., Woodilee Asylum, Leuzie, Glasgow.

1891. Carswell, John, L.R.C.P.Edin., L.F.P.S.Glusg., Certifying Medical Officer,

Barony Parish, 5, Royal Crescent, Glasgow.

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

1888. Chambers, James, M.A., M.D., The Priory, Roehampton. ( Co-Editor of
Journal since 1905, Assistant Editor 1900-05.)

1865. Chapman, Thomas Algernon, M.D.Glns., L.R.C.S.Edin., lletula, Reigate.
1907. Chislett, Charles G. A., M.B., Ch.B.Glasgow, Blomgate House, Lanark.
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. Sec. 2V. and M. Division , 1897—1901.)

1907. Clarke, Geoffrey, M.D.Lond., Assistant Medical Officer, London County
Asylum, Long-Grove, Epsom.

1910. Clarke, James Kilian, M.B., B.Cli., B.A.O. (R.U.I.), North Eastern

Hospital, St. Ann’s Road, Tottenham, N.

1907- ClaTke, Sidney Herbert, M.A., M.B., B.C.Cantab., M.R.C.S.,

L.R.C.P.Lond., Leicestershire and Rutland Asylum, Narborough,
near Leicester.

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Digitized by

viii Mevibers of the Association.

1901. Cleland, William Lennox, M.B., B.Ch.Edin., Park Side, Adelaide, South
Austral in

1862. Clouston, T. S., M.D., LL.D.Edin., F.R.C.P., F.R.S.E., 26, Heriot Row.

Edinburgh. (Editor of Journal, 1873—1881.) (President, 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., 25, Upper Berkeley

Street, W.

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

1906. Collen, Edward Victor, M.D., B.Ch., B.A.O.Dubl., Killycomain House,
Portsdown, Ireland.

1906. Collier, Walter Edgar, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, Kent County Asylum, Maidstone.

1903. Collins, Michael Abdy, M.B., B.S., M.R.C.S., L.R.C.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.Eug., Commissioner in Lunacy,
69, Onslow Square, S.W.

1909. Cooke, John Benson, L.R.C.S.&P.Edin. (H.M. Prison Service), Love

Lane, Wakefield.

1910. Coombes, Percival Charles, M.R.C.S., L.R.C.P.Lond., Assistant Medical

Officer, Surrey County Asylum, Nethern, Mersthum.

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

1903. 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., 37, 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,
Bishopston, Bristol.

1893. 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.

1893. Craig, Maurice, M.A., M.D., B.C.Cautab., F.R.C.P.Lond., 54, Welbeck

Street, W.

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

Sussex Asylum, Hellingly, Sussex.

1906. Creighton, John Alexander, M.B., C.M., West Riding Asylum, Wakefield.
1897. Cribb, Harry Gifford, M.R.C.S.Eug., L.R.C.P.Lond., Senior Assistant

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

1909. Crichton, Crawfurd S., M.B., Ch.B.Edin., Mansfield, Arbroath, N.B.

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

Huddersfield.

1909. Crowther, Sydney Nelson, M.R.C.S., L.R.C.P.Lond., Senior Assistant
Medical Officer, Netherne County Asylum, Surrey.

1894. Cullinan, Henry M., L.R.C.P.I., L.R.C.S.I., Resident Medical Superin¬

tendent, Portrane House, Donabate, Co. Dublin.

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

Co. Tipperary, Ireland.

1907. Daniel, Alfred Wilson, B.A., M.D., B.C.Cautab., M.R.C.S., L.R.C.P.Lond.

Senior Assistant Medical Officer, London County Asylum, Hanwell, W.

1905. Darbyshire, Harold Stewart C., M.R.C.S.Eug., L.R.C.P.Lond., Grosvenor
House, West Ealing, W.

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PRINCETON UNIVERSITY

Members of the Association. ix

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

1891. Davis, Arthur N., L.R.C.P., L.H.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.)

1883. De Lisle, Samuel Ernest, L.R.C.P., L.R.C.S.I., Three Counties Asylum,

Stotfold, Herts.

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

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

Asylum, Long-Grove Asylum, Epsom, Surrey.

1904. Devon, James, L.ll.C.P. A S.Edin., 6, Cathedral Square, Glasgow.

1903. Dickson, Thomas Graeme, L.lt.C.P. & S.Edin., Medical Superintendent,
Wye House, Buxton.

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

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

Asylum, Arlesley, Hitchin.

1909. Dobson, Margaret Bernard, M.D.Lond., 75, Eaton Rise, Ealing, W.

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

1908. Donald, Robert, M.B., Ch.B.Glas., Ashton, Plains, Airdrie, N.B.

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

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

Superintendent, County of London Manor Asylum, Epsom, Surrey.

1892. Donelan, John O’Conor, L.R.C.P.I., L.R.C.S.I., M.P.C., Medical Super¬

intendent, Richmond Asylum, Dublin.

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

1902. Douglas, Archibald R., L.R.C.P.&S.Edin., L.F.P.S.Glas., Royal Albert

Asylum, Lancaster.

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

Gondhurst.

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

1897. Dove, Emily Louisa, M.B.Lond., Wycombe Abbey, High Wycombe,

Bucks.

1903. Dow, William Alex., M.D., B.S.Durli., M.R.C.S., L.R.C.P., D.P.H., H.M.

Prison, Lewes.

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

corthy, Ireland.

1905. Drew, Cnpt. Charles Milligan, M.A., M.B., Ch.B.Glas., R.A.M.C., c jo
Messrs. Holt & Co., 3, Whitehall Place, S.W.

1907. Dryden, A. Mitchell, M.B.,Ch.B.Edin.,City Asylum, Gosforth, Newcastle-
on-Tyne.

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

Medical Officer to the Egyptian Asylum, Abbassia, Cairo, Egypt.
1899. Dudley, Francis, L.R.C.P.&S.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.Loud., Medical Superintendent, West

Koppies, Pretoria.

1907. Dwyer, Patrick J., M.B., B.Ch., R.U.I., Salisbury House, Rathgar,
Dublin.

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

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PRINCETON UNIVERSITY

Digitized by

x Members of the Association.

1903. Eady, George John, M.D., M.R.C.P.Edin., M.R.C.S.Eng., 6, Roland
Houses, S. Kensington, S.W.

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

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

County Asylum, Exminster.

1873. Eager, Wilson, L.R.C.P.Lond., M.R.C.S.Eng., St. Aubyn’s, Woodbridge,
Suffolk.

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

1891. Earls, James Henry, M.D., M.Ch., Claremont, Loughton, Essex.

1903. East, Guy Rowland, M.B.Durli., Northumberland County Asylum,
Morpeth.

1907. East, Wm. Norwood, M.D., Loud., M.R.C.S., L.R.C.P., 2, North Road,

Clapham Park, S.W.

1895. Easterbrook, Charles C., M.A., M.I)., F.R.C.P.Ed., Physician Superin¬
tendent, Crichton Royal Institution, Dumfries.

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., Loudon County Asylum,

Horton, Epsom, Surrey.

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

Asylum, Leavesden.

1898. Ellerton, Henry B., M.RC.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.Ediu., 31, Belvedere Road,
Upper Norwood, S.E.

1908. Ellis, Edward, M.D.Durh., L.R.C.S.& P.Edin., Craven House, Halifax,

Yorks.

1890. Ellis, William Gilmore, M.D.Brux., M.R.C.S.Eug., L.S.A., Superinten¬

dent, Government Asylum, Singapore.

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

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

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. Eurich, Frederick Wilhelm, M.D., C.M.Edin., 4, Marlborough Road,
Bradford.

1894. Eustace, Henry Marcus, M.D., B.Cli., B.A.T.C.l)., Assistant Physician,
Hampstead and Highfield Private Asylum, Glasnevin, Dublin.

1909. Eustace, William Neilson, L.ll.C.S.&P.Irel., L.M., Hampstead, Glisnevin,

co. Dublin.

1909. Evans, George, M.B.Lond., Assistant Medical Officer, London County
Asylum, Bexley.

1897. Everett, William, M.I)., The Headlands, Kettering, Northamptonshire.

1891. Ewan, John Alfred, M.A.St. And., M.D.Edin., 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.

Grindlny & Co., 54, Parliament Street, S.W.

1907. Exley, John, L.R.C.P.I., L.M., M.R.C.S., Medical Officer.H.M. Prison,

Grove House, New Wortley, Leeds.

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

Google

Original from

PRINCETON UNIVERSITY

Members of the Association.

1907. Farries, Johu Stoddart, L.R.C.P., L.R.C.S.Edin., Medical Superintendent,

Saudwell Hall, Handswortli, near Birmingham.

1908. Faulks, Edgar, M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer,

London County Asylum, Bexley.

1903. Fennell, Cliarles Henry, M.A.. M.D.Oxou, M.R.C.P.Lond., Senior
Assistant Medical Officer, East Sussex Asylum, Hellingly, Sussex.
1908. Fenton, Henry Feliu, M.B., Ch.B.Edin., Assistant Medical Officer,
County and City Asylum, Powick, Worcester.

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

Officer, Fife and Kinross Asylum, Cupar, Fife.

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

Edit)., Medical Superintendent, Bethel Hospital, Norwich.

1906. Fielding, Saville 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., Orchnrdstede, Arterburry Road,
Wimbledon, S.VV.

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

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

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

Sheffield.

1903. Fitzgerald, Alexis, L.R.C.P. A 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 Merriou Street, Dublin.

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

1908. Fitzgerald, James Francis, L.R.C.P.AS.Irel., L.M., Assistant Medical

Officer, District Asylum, Clonmel, Ireland.

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

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

Officer, District Asylum, Cork. •

1907. Fleming, Geo. A., L.R.C.P.AS.Irel,, Assistant Medical Officer, 100,

Piccadilly, W.

1904. Fleming, Wilfrid Louis Iiemi, M.R.C.S., L.R.C.P., Suffolk House, Pir-

bright, Surrey.

1894. Fleury, Eleonora Lilian, M.D., B.Cli., ll.U.l., Assistant Medical Officer,
Richmond Asylum, Dublin.

1908. Flynn, Thos. Aloy.iius, L.R.C.P.AS.I., Assistant Medical Officer, Port-

rane Asylum, Donabate.

1902. Forde, Michael J., M.D., M.Ch., Ii.U.I., Assistant Medical Officer, Port-

rune Asylum, Ireland.

1902. Forster, Hermann Julius, L.R.C.P.I., L.S.A., Assistant Medical Officer,
Brighton Borough Asylum, Hayward's Heath.

1906. Forster, R. A., M.B.. Ch.U.Aber., The Asylum, Graham’s Town, Cape
Colony, S. Africa.

1906. Fortune, John, M.B., Ch.B.Edin., Senior Assistant Medicnl Officer,
Ladywell Sanatorium, Salford.

1909. Foulerton, Alexander Grant Russell, F. R.C.S.Eng., L.R.C.P.Lond.,

D.P.H.Cantab. (County Medical Officer of Health for E. Sussex),
Middlesex Hospital, W., and Haywards Heath, Sussex.

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., Kensington Palace Mansions, De Vere
Gardens, W.

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

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PRINCETON UNIVERSITY

xii Members of the Association.

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

Dorset.

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

Inebriates Reformatory, East Hading, Norfolk.

1906. Gane, Edward Palmer Steward, M.R.C.S.Eng., L.R.C.P.Lond., Borough
Asylum, Ryehope, Sunderland.

1890. Gaudin, Francis Neel, M.R.C.S., L.S.A., M.P.C., Medical Superintendent,
The Grove, St. Lawrence, Jersey.

1906. Gavin, Noel John Hay, M.B., Ch.B.Edin., West Riding Asylum, Wake¬
field.

1885. Gayton, Francis C., M.D.Aberd., M.R.C.S.Eng., County Asylum,

Netherne, Merstham, Surrey.

1908. Geale, William James, L.R.C.P., L.F.P.S., Assistant Medical Officer,

Scalebor Park, Burley -in- Wharfdale, Yorks.

1896. Geddes, John W., 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., Cli.B., Herrison, Dorchester.

1910. Gibson, Rae, M.B., Ch.B.Edin., M.R.C.S., Assistant Physician, Royal
Asylum, Morningside, Edinburgh.

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

1910. Gilfillan, William, M.B., Ch.B.Glasg., Assistant Medical Officer,
Woodilee, Leuzie.

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

1904. Gillespie, Daniel, M.B. (R.U.I.), 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.

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

1909. Gloyne, Stephen Roodhouse, M.B., B.Ch. Leeds, D.P.H.Lond. (Assistant

Medical Officer, East Sussex Educational Committee), Elener,
The Avenue, Lewes.

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

Pencaitland, N.B.

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

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

1899. Gordon, James Leslie, M.B., Ch.B., Tooting Bee Asylum, Tooting,

Loudon, S.W.

* Gordon, William S., M.A., M.B., T.C.D., District Asylum, Mullingar.

1905. Gordon-Munn, John Gordon, M.D., F.R.S.E., Heigham Hall, Norwich.
1901. Gostwyck, C. H. G., M.B.,Cli.B., Stirling District Asylum, Larbert.
1894. Graham, Samuel, L.R.C.P.Lond., Assistant Medical Officer, District

Asylum, Antrim.

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

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

Officer, Somerset and Bath Asylum, ueur Taunton.

1909. Greene, Thomas Adrian, L.R.C.S.Irel., L.M., R.C.P.Irel., Medical

Superintendent, District Asylum, Carlow.

1886. Greenlees, T. Duncan, M.D., Fenstanton, Christ Church Road, Streatham

Hill, S.W.

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Members of the Association. xiii

1904. Griffin, Ernest Harrison, B.A.Cantab., L.S.A.Loud., c/o H.B.M. Consul,

Cuidad, Boliria, Venesuela, S.A.

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., Boothani 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.

1903. Hanbnry, Lang ton Fuller, M.R.C.S.Eng., 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.

1903. Hankin, Chella Mary, M.B.Durh., 14, Elms Avenue, Muswell Hill, W.

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

Northampton County Asylum, Berry Wood, Northampton.

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

Private Asylum, Tonbridge, Kent.

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

Woodford Bridge, Essex.

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.Eng., Long-Grove Asylum, Epsom,

Surrey.

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

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

1891. Havelock, John G., M.D., C.M.Edin., Physician Superintendent, Montrose
Royal Asylum.

1890. Hay, Frank, M.B., C.M., Inspector-General of Asylums for New Zealand,
Government Buildings, Wellington, 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. Henderson, George, M.A., M.B., 94, Fitzwilliam Street, Huddersfield.

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

1903. Hewitt, David Walker, M.B., B.Ch., R.U.I., Surgeon R.N., H.M.S.
Powerful, Australia.

1877. Hewson, R. W., L.R.C.P.Ediu., 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.

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

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

1909. Hodgson, Harold West, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, Barnsley Hall Asylum, Bromsgrove, Worcestershire.

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xiv Members of the Association.

1908. Hog£, Archibald. M.B., Ch.B.Glas., Alexandra Infirmary, Paisley.

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. Hotclikis, Robert D , M.A., M.D., Renfrew Asylum, Dykebar, N.B.

1907. Howard, S. Carlisle, M.B., Ch.B.Aberd., Assistant Medical Officer, Horton

Asylum, Epsom.

1900. Hughes, Percy T., M.B., Ch.M.Edin., D.P.H.Lond., 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.

1897. Hunter, David, M.A., M.B., B.C.Cantab., Medical Superintendent, West

Ham Borough Asylum. Goodmayes, Ilford, Essex.

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

Royal Albert Asylum, Lancaster.

1904. Hunter, Percy Douglas, M.R.C.S., L.R.C.P.Lond., East Sussex County

Asylum, Hellingly, Sussex.

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.

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

1908. Inglis, J. P. Park., M B., Ch.B.Edin., Metropolitan Asylum, Caterham,

Surrey.

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

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

1908. Jeffrey, Geo. Rutherford, M B., Ch.B.Glas., Senior Assistant Physician,
Crichton Royal Asylum, Dumfries.

1907. Jex-Blake, Bertha, M.B., Ch.B.Edin., Assistant Medical Officer, County

and City Asylum, Hereford.

1910. Johnson, Cecil, M.B., Ch.B.Vict., 6, Palewell Park, East Sheen, S.W.
1905. Johnson, Smeeton, M.B.Lond., L.R.C.P.,M.R.C.S., Langlands, Cleobury

Mortimer, Salop.

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.

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

District Asylum, Melrose.

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

1882. Jones, Robert, M.D.Lond., B.S., F.R.C.P., F.R.C.S., Medical Superinten¬
dent, London County Asylum, Claybury, Woodford, Essex. (Gen.
Secretary from 1897 to 1906. President 1906-7.)

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., Bangour Village, Uphall, Linlithgowshire.

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Members of the Association.

1899. Keegan, Lawrence Edward, M.D., Medical Superintendent, Lnnatic
Asylum, St. John’s, Newfoundland.

1909. Keith, William Brooks, M.B., Ch.B.Aberd., Assistant Medical Officer,
Kent County Asylum, Maidstone.

1909. Kellas, Arthur. M.B., Ch.B., D.P.H.Aberd., Senior Assistant Physician,
Royal Asylum, Aberdeen.

1908. Kelly, Richard, M.B., B.Ch., B.A.C.Dub., Assistant Medical Officer,
Storthes Hall Asylum, Kirkburton, near Huddersfield.

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

1907. Keene, George Henry, M.D. (T.C.D.), Camberwell House, Peckham Road.

1899. Kennedy, Hugh T. J., L.R.C.P.AS.L, L.M., Assistant Medical Officer,

District Asylum, Enniscorthy, Wexford.

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

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

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

District Asylum, Hartwood, Shotts, N.B.

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

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

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., 15, Blackbeath Rise,

Lewisham, S.E.

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

shire.

1899. Kirwan, James St. L., B.A., M.B., B.Ch., B.A.O.Roy. Univ. Irel.,
Medical Superintendent, District Asylum, Ballinasloe, Ireland.

1908. Kirwan, Richard, R., M.B., B.Ch., B.A.O., R.U.I., Assistant Medical

Officer, District Asylum, Castlebar.

1903. Kougli, Edward Fitzadain, M.B., B.Ch., County Asylum, Gloucester.

1898. Labey, Julius, M.R.C.S., Medical Superintendent, Public Asylum, Jersey.
1902. Langdon-Down, Percival L., M.A., M.B., B.C.Cantab., Dixland, Hampton

Wick, Middlesex.

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

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

etc.). Red House, Ardgovan Street, Greenock.

1902. Laval, Evariste, M.B., C.M.Edin., Langho, nr. Blackburn.

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

House, Bath.

1899. Law, Charles D., L.R.C.P.AS.Edin., L.F.P.G.S., 117, Wilderspool Road,

Warrington.

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.

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

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

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

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xvi Members of the Association.

1906. Le Fanu, Hugh, M.B., C.M.Abcr., “ Victoriaborg,” Accra, West Africa.

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,
Royal Asylum, Sunnyside, Montrose.

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

Court of Chancery, 42, Merrion Square, Dublin.

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

1859. Lindsay, James Murray, M.D.St.And., F.R.C.S. nnd F.R.C.P.Edin.

53, Victoria Road, Aldershot. (President, 1893.)

1908. Littlejohn, Edward Salteine, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, London County Asylum, Hanwell, W.

1903. Logan, Thomas Stratford, L.R.C.P.&S.Edin., L.F.P.S.Glas., County of

London Epileptic Colony, Ewell, Surrey.

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 Asvlum, Melton,
Suffolk.

1898. Lord, John R., M.B., C.M., Medical Superintendent, London County

Asylum, Horton, Epsom. (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.&S.Edin., Leicester Borough Asylum,

Leicester.

1906. Lyell, John Hepburn, M.D.Glasg., 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, Jesmond Road, Newcastle-on-Tyne.

1906. Macarthur, John, M.R.C.S., L.R.C.P.Lond., The Hut, Manor Road,
East Molesey.

1899. Macartney, William H. C., L.R.C.P.&S.I., Riverhead House, Sevenoaks.
1880. MacBryan, Henry C., L.R.C.P. & S. Edin., Kingsdown 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. McConaghey, John C., M.B., C.M.Edin., Parkside Asylum, Macclesfield,

Cheshire.

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

head, Paisley, N.B.

1884. MacDonald, P. W., M.D., C.M., Medical Superintendent, Dorset

County Asylum, Herrison, Dorchester. (Pbebident, 1907-8 ; Hon.
Sec. S.W. Division 1894 to 1905.)

1905. MacDonald, William Fraser, M.B., Ch.B.Edin., Olive Lodge, Polworth

Terrace, Edinburgh.

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

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

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

Officer, County Asylum, Hatton, nr. Warwick.

1870. McDowall, Thomas W., M.D.Edin., L.R.C.S., Medical Superintendent,
Northumberland County Asylum, Morpeth. (President, 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., Ch.B.Edin., Assistant Medical Officer, County

Asylum, Bridgend, Glam.

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1906.
1905.

1909.
1899.
1891.

1903.

1908.
1899.

1910.

1909.

1907.
1901.

1904.
1898.

1882.

1896.

1886.

1901.

1902.

1908.

1894.

1865.

1908.

1903.
1896.

1905.
1908.
1896.
1908.
1907.

Members of the Association. xvii

Macllraith, Alex. Robert MacIntyre, Holly House, Rawteustall, Lancs.

Macllraitb, W. MacLaren, L.K.C.P. <fc S.Edin., L.F.P.S.Glasg.,
L.D.S.R.C.S.Edin., Holly House, Rawtenstall, Lancs.

McIntyre, Alex. Gray, M.D.Ediu., Mansfield, Moncrief Avenue, Lenzie,
N.B.

McKelvey, Alexaiuler Niel, L.&M.P.C.P.&S.L, The Asylum, Auckland,
New Zeulaud.

Mackenzie, Henry J., M.R., C.M.Edin., M.I’.C., Assistant Medical Officer,
Tbe Retreat, York.

Mackenzie, Theodore Charles, M.B., Ch.B.Edin., District Asylum,
Inverness.

MacKenzie, William Tuach, M.D., Medical Superintendent, Royal and
District Asylums, Dundee.

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

McKillop, Alexander Cameron, M.B., Ch.B.Edin., Assistant Medical
Officer, District Asylum, Inverness.

Maclachlan, John Thomson, M.D.Glasg. (Assistant Physician, Glasgow
Soyal Infirmary), 310, Renfrew Street, Glasgow.

MacLeod, John A., M.B., C'h.B., Assistant Medical Officer, Locbtnore,
Lairg, Sutherlandshire.

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

Macnamara, Eric Danvers, M.A., M.B., 54, Wellr'ck Street, W.

Macnaughton, George W. F., M.I)., F.R.C.S.Edin., M.R.C.P.Lond.,
33, Lower Belgruve Street, Eaton Square, London, S.W.

McNaughton, John, M.D., 4, Corunna Street, Sandyford, Glasgow.

Macphail, S. Rutherford, M.D.Ediu., Derby Borough Asylum, Kowditch,
Derby.

Mncpherson, Charles, M.D.Glas., Deputy Commissioner in Lunacy, 15,
Rutland Square, Edinburgh.

Macpberson, John, M.D., F.R.C.P., Commissioner in Lunacy, 8, Darnaway
Street, Edinburgh.

McRae, G. Douglas, M.D.Edin., F.R.C.P., Medical Superintendent,
District Asylum, Ayr, N.B.

Macrae, Kenneth Duncan Cameron, M.B., Ch.B.Edin., Lynwood,
Murrayfield, Edinburgh.

McWalter, Willinm H., M.B., Ch.M.Glas., Medical Officer, H.M. Con¬
vict Prison, Peterhead.

McWiliiam, Alexander, M.A., M.B., C.M.Aber., Waterval, Odiham,
Winchfield, Hants.

Manning, Henry J., B.A.Lond., M.R.C.S., Laverstock House, Salisbury.

Mapother, Edward, M.D., B.S.Lond., Assistant Medical Officer, London
County Asylum, Long-Grove, Epsom.

Marnan, John, M.B., B.Ch., City and County Asylum, Fishponds,
Bristol.

Marr, Hamilton C., M.D.Glasg.Univ., Medical Superintendent, Woodilee
Asylum, Lenzie. (Hon. Sec. Scottish Division since 1907.)

Marshall, Robert Macnab, M.D., Ch.B.Glasg., 21, Maxmill Drive,
Pollokshields, Glasgow.

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

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

Martin, James Ernest, M.B., B.S.Lond., M.K.C.S., L.R.C.P., Assistant
Medical Officer, London Couuty Asylum, Long-Grove, Epsom.

Martin, Mary Edith, L.R.C.P.AS.Edin., L.F.G.S.Glas., L.S.A.Lond.,
3, Pulmeria Terrace, Hove, Brighton.

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xviii Members of the Association.

1910. Masson, Charles Armit, M.A., M.B., Ch.B.Abcrd., Assistant Medical
Officer, Inverness District Asylum.

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

1907. Meek, Andrew Alexander Robertson, M.B., Ch.B.Glas., 185, Dalmarnoch

Road, Glasgow.

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

tendent, Stafford County Asylum, Cheddleton, near Leek.

1891. Mercier, Charles A., M.D.Loud., F.R.C.P., F.R.C.S.Eng., Lecturer on

Insanity, Westminster Hospital ; 34, Wimpole Street, W. (Pbesi-
dent, 1908-9.)

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

Asylum, Hull.

1871. Mickle, William Julius, M.D., F.R.C.P.Lond., 69, Linden Gardens, Bays-
water, W. (President, 1896-7.)

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

1910. Middlemiss, James Ernest, M.R.C.S.Eng., L.R.C.P.Lond., Assistant
Medical Officer, Gartloch Asylum, Glasgow.

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

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

1904. Miller, James Webster, M.B., Ch.B.Aberd., Wonford House, Exeter.
1893. Mills, John, M.B., B.Ch., and Diploma in Mental Diseases, R.U.I.

District Asylum, Balliuasloe, Ireland.

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

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

intendent, County Asylum, Cane Hill, Coulsdon, 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.Irel.,Banstead Asylum,Sutton,Surrey.

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

Sanatorium, Virginia Water, Surrey.

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

intendent, County and City Asylum, Burghill, Hereford.

1910. Morton, Hugh, M.B., Ch.B.Glasg., Assistant Physician, Royal Asylum,
Edinburgh.

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

1896. Mott, F. W., M.D., B.Sc., B.S., F.R.C.P.Lond., F.R.S., Pathological
Laboratory, London County Asylum, Claybury, Essex.

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

Yorks.

1897. Mould, Philip G., M.R.C.S.Eng., L.R.C.P.Lond., Molyneaux, Brow

Station, near Manchester.

1908. Muirhcad, Winifred, L.R.C.P., L.R.C.S.Edin., Assistant Medical Officer,

Royal Asylum, Morningside, Edinburgh.

1907. Mules, Bertha Mary, M.B., B.S.Durh., Court Hall, Kenton, S. Devon.
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.R.C.P.Lond., Banstead Asylum,

Sutton, Surrey.

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

1905. Murrell, Christine Mary, M.D.Lond., B.S., Royal Free Hospital, 86,

Porchcster Terrace, Hyde Park, W.

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1909.

1903.

1880.

1910.
1903.
1875.
1873.
1909.
1869.
1893.
18S8.
1909.

1885.

1903.

1904.

1901.

1892.

1886.

1868.

1907.

1902.

1899.

1890.

1899.

1905.
1907.
1898.

1898.

1899.

1892.

Members of the Association. xix

Myers, Charles Samuel, M.A., M. I).Cantab. (University Lecturer in
Experimental Psychology), Great Shelford, Cambridgeshire.

Navarra, Norman, M.R.C.S., L.R.C.P., City Asylum, Stone, Hartford.

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

Neill, Alexander W., M.B., Ch.B.GIusg., Assistant Physician, Moruing-
side Royal Asylum, Edinburgh.

Nelis, William ¥., M.D.Durh., L.ll.C.P.Edin., L.F.P.S.Glasg., Newport
Rorotigh Asylum, Caerleon, Mon.

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

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

Nicol, James, M.D., Cu.M.Kdin., D.P.H.Loud. (Senior Assistant Medical
Officer, Caterhum Asylum), The Pines, Upper Caterhaiu. Surrey.

Nicolsou, David, C.B., M.D., C.M.Aber., M.R.C.P.Edin., F.S.A.Scot.,
201, Royal Courts of Justice, Strand, W.C. (Pkksixiknt, 1895-6.)

Nobbs, Atbelstane, M.l>., C.M.Kdiu., Lux ton House, Putney, S.W., mid
261, Upper Richmond Road, Putney, S.W.

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

Norman, Hubert James, M.B., Cli.B.Edin., D.P.H.Edin., Assistant
Medical Officer, Camberwell House Asylum, S.E.

Oaksbott, James A., M.D., M.Cli. (R.U.I.), Medical Superintendent,
District Asxluni, Waterford, Ireland.

O’Dolierty, Patrick, B.A. and M.B.irel., District Asylum, Omagh.

O’Downey, Augustine Francis, L.R.C.P. & S. Ediu., Salop aud Mont¬
gomery County Asylum, Bictuu Heath, nr. Shrewsbury.

Ogilvy, David, B.A., M.D., B.Cb., L.M.Duk., Senior Assistant Medical
Officer, Loudon County Asylum, Horton, nr. Epsom, Surrey.

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

O’Neill, Edward D., M.R.C.P.I., Medical Superintendent, i lie Asylum,
Limerick.

Orange, William, M.D.Heidelb., F.R.C.P.Lond., C.B., Oakhurst,
Godalining, Surrey. (Puksidunt, 1883.)

O’Reilly, Arthur Edward, L.R.C.S. & P.I., L.M., Hopetown, Cape Colony.

Orr, David, M.B., C.M.Edin., Pathologist, County Asylum, Prestwick,
Lancs.

Oiburne, Cecil A. P„ F.R.C.S.Edin., L.R.C.P.Fdin., The Grove, Old
Catton, Norwich.

Oswald, Laudel It., M.B., M.P.C., Physician Superintendent, Royal
Asylum, Gartuavel, Glasgow.

Owen, Corbet W., M.B., C.M.Edin., 31, Victoria Place, High Street,
Bangor, North Wales.

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

Parker, James, L.R.C.S.&P. aud L.M.Irel., Assistant Medical Officer,
West Riding Asylum, Wakefield.

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

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

Paton, Robert N., L.R.C.P., L.U.C.S.Kdiu., Medical Officer, H.M. Prison,
Wormwood Serubbs, London, W.

Patrick, John, M.B., Cli.B., District Asylum, Belfast.

Patterson, Arthur Edward, M.D., C.M.Aber., Senior Assistant Medical
Officer, City of Loudon Asylum, Hartford.

z,§

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PRINCETON UNIVERSITY

xx Members of the Association.

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

1907. Peachell, George Ernest, M.B., B.S.Lond., M.R.C.S., L.R.C.P., Assistant
Medical Officer, West Sussex County Asylum, Cliicliestor.

1903. Pearce, Francis H., M.A., M.B., B.C.Cantab., M.R.C.S., L.R.C.P., Earls-
wood Asylum, Redhill, Surrey.

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.I)., C.M. Queen’s Univ. Irel., F.Il.G.S.
(Address uncommunicated.)

1875. Philipson, Sir George Hare, M.D. and M.A.Cautab., F.R.C.P.Lond., 7,
Eldon Square, Newcastle-ou-Tyne.

1908. Phillips, John George, M.B., B.S.Lond., M.R.C.S., L.R.C.P., Assistant
Physician, Bethlem Royal Hospital, Lambeth, S.E.

1906. Phillips, Nathaniel Richard, M.R.C.S., L.R.C.P.Lond., Assistant Medical
Officer, County Asylum, Abergavenny, Monmouthshire.

1905. Phillips, Norman Routli, M.D.Brux., M.U.C.S., L.R.C.P., St. Andrew’s
Hospital, Northampton.

1891. Pierce, Bedford, M.D.Loud., F.R.C.P., Medical Superintendent, The
Retreat, York. {Son. Secretary If. and M. Division 190 -8.)

1888. Pietersen, J. F. G., M.R.C.S., Ashwood House, Kingswiuford, near
Dudley, Stafford.

1896. Planck. Charles, M.A.Cnmb., 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. Ediu., L.F.P.AS.Glasg.,
Medical Superintendent, Somerset and Bath Asylum, “ Westfield,”
near Wells, Somerset.

1909. Potter, Scott, L.R.C.S.&P.Irel., Senior Assistant Medical Officer, Fisherton
House, Salisbury.

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

1908. Prentice. Reginald Wickham, L.M.S.S.A.Lond., Beanworth Manor,
Arlesford, Hants.

1904. Pringle, Archibald Douglas, M.B., Ch.B.Aberd., Government Asylum,
Pietermaritzburg, Natal, South Africa.

1875. Pringle, Heury T., M.D.Glasg., Hawtree, Ferndown, Wiuiborne.

1901. Pugh, Robert, M.D.Edin., Cli.B., Medical Superiutendeut, Brecon and
Radnor Asylum, Talgarth, S. Wales.

Race, John Percy, M.R.C.S., L.R.C.P., L.S.A., Joint Counties’Asylum
Carmarthen.

Ruins, George Hooper, L.S.A.Lond., 10, Grove Park, Redlands, Bristol.
Rainsford, F. E., M.D., B.A.Dubl., Resident Physician, Stewart Institute,
Palmerston, co. Dublin.

Rambaut, Daniel F., M.A., M.D.Univ. Dubl., Salop and Montgomery
Asylum, Bicton Heath, Shrewsbury.

Rankine, Roger Aiken, M.B., B.S.Lond., M.R.C.S., L.R.C.P., Assistaut
Medical Officer, Earlswood Asylum, Redhill.

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

Raw, Nathan, M.D., B.S.Durh., L.S.Sc., F.R.C.S.Edin., M.R.C.P.Loud.,
66, Rodney Street, Liverpool.

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

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

Rayner.Henry, M.D.Aberd.,M.R.C.P.Edin.,16,Queen Anne Street,London,
W. (Phesident, 1884.) {General Secretary, 1878-89.) {Co-
Editor of Journal since 1895.)

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

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

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

1904.

1908.

1899.

1894.

1910.

1902.
1889.
1893.
1870.

1903.
1899.
1887.

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PRINCETON UNIVERSITY

Members of the Association. xxi

1886. Revington, George, M.A., M.D., B.Ch.Dubl., M.P.C., Medical Superin¬
tendent, Central Criminal As\)uui, Dundruiu, Ireland.

1907. Reynolds, Ernest Septimus, B.Sc.Vict., M.D., F.R.C.P.Lond.,
2, St. Peter’s Square, Manchester.

1899. Rice, David, M.D.Brux.,M.R.C.S., L.U.C.P.,Medical Superintendent, City
Asylum, Uillesdon, Norwich.

1897. Richard, Willium J., M.A., M.B., C.M.Glusg., Medical Officer, Govun
Parochial Asylum, Merrytlats, Govun.

1899. Richards, John, M.B., C.M.Edin., F.R.C.S.E., Joint Counties Asylum,
Carmarthen.

1905. Ridley, Edward Hope, M.D.Edin., The Asylum, Portsmouth.

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

1907. Rivers, William Gregory, M.B., Ch.B.Ediu., Assistant Medical Officer,

Cornwall County Asylum, Bodmin.

1S93. Rivers, William H. R., M.A.Cantab., M.D.Lond., F.R.C.P., E.R.S., e/o
C. H. Rivers, Esq., 11, Queen Victoria Street, E.C.

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

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

1887. Robertson, Geo. M., M.B., F.R.C.P.Ediu., Physician-Superintendent,

Royal Asylum, Morningside, Edinburgh.

1908. Robertsou, George Dunlop, L.R.C.S.& P.Edin., Assistant Medical Officer,

District Asylum, Hurtwood, Lanark.

1910. Robertson, Jane I., M.B., Ch.B.Glasg., Assistant Physician, Royal
Asylum, Gartnuvel, Glasgow.

1895. Robertson, William Ford, M.D., C.M., 48, Northumberland Street,
Edinburgh.

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

1900. Robinson, Harry A., M.D., Cli.B.Vict., 57, Canning Street, Liverpool.
1908. Rodgers, Frederick Millar, M.B., Cli.B.Vict., D.P.H., Senior Medical
Officer, County Asylum, Winwick, Lancs.

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

1908. Rolleston, Charles Frank, B.A., M.B., Cli.B., B.A.O.Dub., Assistant
Medical Officer, County of Loudon, Manor Asylum, Epsom.

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

1879. Ronaldson, J. B., M.D.St.And„ F.R.C.S. & L.R.C.P.Edin., D.P.H.,
Ennerdale, Haddington, N.B.

1879. Roots, William H., M.R.C.S., Caubury House, Kingston-on-Thames.

1899. Rorie, George Arthur, M.D., Ch.B.Ediu., Senior Assistant Medical
Officer, Dorset County Asylum, Dorchester.

1860. Rorie, James, M.D.Edin., L.R.C.S.Ediu., 4, Roxburgh Terrace, West
Park Road, Dundee. (Late Mon. Secretary for Scottish. Division.)

1888. Ross, Chisholm, M.D.Syd., M.B., Ch.M.Ediu., 147, Macquarie Street,

Sydney, New South W'ales.

1905. Ross, Sheila Margaret, M.D., Cli.B.Edin., Assistant Medical Officer of

Health, 42, Cavill Drive, Fallowtield, Manchester.

1899. Rotherham, Arthur, M.A., M.B., B.C.Cautab., Medical Superintendent,
Darenth Asylum, Hartford, Kent.

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

Derby County Asylum, Mickleover.

1884. Rowe, Edmund 1.., L.R.C.P.&S.Edin., Medical Superintendent, Borough
Asylum, Ipswich.

1883. Rowland, E. D., M.B., C.M.Edin., The Public Hospital, George Town,
Deiuerura, British Guiana.

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PRINCETON UNIVERSITY

xxii Members of the Association.

1902. Rows, Richard Oundry, M.D.Lond., L.R.C.P., Pathologist,

County Asylum, Lancaster.

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

1907. Rutherford, Henry Richard Charles, L.R.C.P.&S.Irel., L.M., District
Asylum, Ballinasloe, Co. Galway.

I860. Rutherford, James, M.D.Edin., F.R.C.P.Edin., F.F.P.S.Glas., Mountain-
hall, Dumfries. (Hon. Secretary for Scottish Division, 1876-86.)
1896. Rutherford, James Mair, M.B., C.M., F.R.C.P.Edin., Brisliugton House,
Bristol.

1907. Rutherford, James Whigliam, L.R.C.P.&S.I., L.M., Assistant Medical

Officer, Catford Asylum, Taunton.

1896. Rutherford, Robert Leonard, M.D. (R.U.I), Medical Superintendent,
Digby’s Asylum, Exeter.

1908. Ruttledge, W. E., M.R.C.S., L.R.C.P.Loud., County Asylum, Powick,

Worcester.

1902. Sail, Ernest Frederick, M.R.C.S.Eng., L.R.C.P.Loud., Medical Super¬
intendent, Borough Asylum, Canterbury.

1908. Summon, William Dougins, L.R.C.S.&P., L.M.lrel., 15, Prince Patrick
Terrace, North Circular Road, Dublin.

1908. Samuels, William Frederick, L.M.&L.S.Dubl., Anguilla, Leeward

Islands, W. Indies.

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

* Sankey, R. H. Heurtley, M.R.C.S.Eng., 3, Marstou Ferry Road, Oxford.
1873. Savage, Geo. H., M.D.&F.R.C.P.Loud., 26, Devonshire Place, W.

(Late Editor of Journal.) (President, 1886.)

1906. Scanlan, John J., L.Ii.C.P.&S.Edin., L.F.P.S.Glasg., D.P.H., 2b, Hyde
Park Mansions, W.

1896. Scott, James, M.B., C.M.Edin.. Governor’s House, H.M. Prison, Hollownv,
N.

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

I860. Seccombe, George S., M.R.C.S., L.R.C.P., c/o Messrs. H. S. King and
Co., 65, Cornhill, E.C.

1879. Seed, William Hy., M.B., C.M.Edin., The Poplars, 110, Waterloo Road,
Ashton-ou-Itibble, Preston.

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

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

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

1909. Shaw, Capt. William Samuel J., M.B., B.Ch.Irel., I.M.S., c/o Messrs.

Grindlay Sf Co., 54, Parliament Street, S.W.

1905. Shaw, Charles John, M.D., Ch.B., F.R.C.P.E., Medical Superintendent,
Argyle and Bute Asylum, Lochgelhead.

1891. Shaw, Harold B., B.A., M.B., D.P.H.Camb., Medical Superintendent,
Isle of Wight County Asylum, Whitecroft, Newport, isle of Wight.
1904. Shaw, Patrick, L.It.C.P.&S.Ediu., Medical Officer, Hospital for the
Insane, Kew, Victoria, Australia.

Shaw, T. Claye, M.D.Lond., F.It.C.P.Loud., 30, Harley Street, London, W.
1882. Sheldon, Thomas S., M.B.Loud., M.R.C.S., Medical Superintendent,
Cheshire County Asylum, Parkside, Macclesfield.

1909. Shepherd, George Ferguson, L.R.C.S.&P.Irel., Assistant Medical Officer,
St. Edmundsbury, Lucan.

1900. Shera, John E. P., M.D.Brux., L.R.C.P. AS.Irel., Somerset County Asylum,
Wells, Somerset.

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

Lond., Parkliolme, East Sheen, S.W- ( Late Medical Superin¬
tendent, Royal Albert Asylum, Lancaster.)

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Members of the Association. xxiii

1899. Sibley, Reginald Oliver, M.B.Loud., M.R.C.S., L.R.C.l*., Assistant

Medical Officer, Loudon County Asylum,Caue Hill, Coulndon,Surrey.
1901. Simpson, Alexander, M.A., M.B.Aber., Medical Superintendent, County
Asylum, VViuwick, N'ewton-le-Willows, Lancushire.

1905. Simpsou, Edward Swan, M.B., Ch.B.Edin., East Riding Asylum,
Beverley, Yorks.

1888. Sinclair, Eric, M.D.Glasg., Riclmiond Terrace, Denial n, Sydney, New
South Wales.

1891. Skeen, James Humphry, M.B., C.M.Aber., Medical Superintendent,
Kirklands Asylum, Bothwell.

1898. Skeen, William St. John, M.B., C.M., County Asylum, Winterton, Ferry -

hill, Durham.

1900. Skiuucr, Ernest W., M.D., C.M.Edin., Manstleld, Rye, Sussex.

1901. Slater, George N. O., M.B.Loud., M.R.C.S., L.R.C.P., Assistant Medical

Officer, Essex County Asylum, Breutwood.

1897. Smalley, Herbert, M.D.Durh., L.R.C.l*., M.R.C.S., l’risou Commission,

Hume Office, Whitehall, S.W.

1907. Smith, Ch. Mollysou, M.B., Cn.B.Aberd., Assistant Medical Officer,
County Asylum, Prestwich, Manchester.

1905. Smith, George William, M. B., Ch.M.Ediu., Hullowny Sanatorium, Virginia

Water, Surrey.

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

1899. Smith, John G., M.B., Ch.M.Ediu., Herts Couuty Asylum, Hill End, St.

Albuns, Herts.

1885. Smith, R. Percy, M.D.,B.S.Lond., F.R.C.P.,M.P.C.,36, Queen Aune,Street,
Cavendish Square, W. (General Secretary, 1890-7.) (l’nKslDKin,
1904-5.)

1884. Smith, W. Beuttie, F.li.C.S.Edin., L.lt.C.P.Edin., 4, Collins Street,

Melbourne, Victoria.

1903. Smith, William Maule A., M.U., ChB.Edin., M.R.C.l’.Edin., Senior
Assistant Medical Officer, Worcester Couuty Asylum, Barnsley
Hull, Bromsgrove.

1901. Smyth, Robt. B., M.A., M.B., Cli.B.Bubl., Senior Assistant Medical Officer,
Couuty Asylum, Gloucester.

1899. Smyth, Walter S., M.B., B.Ch., K.U.I., Assistant Medical Officer, County-
Asylum, Autrim.

1885. Soutar, James Grieg, M.B., Ch.M.Ediu., Baruwood House, Gloucester.

1906. Spark, Percy Charles, M.R.C.S., L.R.C.l*.Loud., Medical Superintendent,

The Colony, Ewell, Surrey.

1883. Spence, John Buchan, M.B., Ch.M.Ediu., L.R.C.l*.AS., The Asylum,
Colombo, Ceylon.

1875. Spence, J. Beveridge, M.B., M.C.Queen’s Univ., Medical Superintendent,
Burntwood Asylum, near Lichfield. (President, 1899-1900,
formerly Registrar.)

1891. Staustield, T. E. K., M.B., C.M.Edin., Baldwyu’s Park, Bexley, Kent.
1901. Starkey, William, M.B., B.Cli., B.A.O.Roy. Univ. Irel., Assistant Medical
Officer, Lancashire Couuty Asylum, Prestwich, near Manchester.

1907. Steele, Patrick, M.D., Ch.B.Edin., Assistant Medical Officer, Bungeur

Village, Declimont, Linlithgowshire.

1898. Steen, Robert H., M.B.Loud., Medical Superintendent, City of London

Asylum, Stone, Bartford. (Hon. Sec. S.R. Division since 1905.)
1909. Steward, Sidney John, M.B., B.C.Can tali., M.R.C.S., L.R.C.P.Lond.,
Assistant Medical Officer, St. Mary's Infirmary, higligHte Hill, N.
1907. Stewurt, Helen C., M.B., Ch.B.Birin., 33, Park Square, Leeds.

1868. Stewart, James, F.R.C.P.Edin., L.R.C.S.lrel., J unior Constitutional Club,
Piccadilly, S.W.; 48, South Hill Park, Hampstead Heath.

1887. Stewart, Rutlisay C., M.R.C.S., Leicestershire and llutlaud Asylum,
Narborougli, near Leicester.

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XXIV

Members of the Association.

1905. Stilwell, Henry Francis, L.ll.C.P.&S.E., Baruwood House, Gloucester.

1899. Stilwell, Reginald J., M.lt.C.S., L.lt.C.P., Moorcrolt House, Hillingdon,

Middlesex.

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

1897. Stoddart, William Henry Butter, M.l)., B.S.Loud., M.R.C.S.Eng.,

M.R.C.P.Lond., Bethlein Royal Hospital, London, S.E.

1909. Stokes, Frederick Ernest, M.B., Ch.B.Glusg., D.P.H.Cantab., Assistant
Medical Officer, Borough Asylum, Portsmouth.

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

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

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

Willows, Lancashire.

1908. Stuart, Francis Arthur Knox, B.A., L.S.A.Loud., Assistant Medical Officer,

West Sussex Asylum, Chichester.

1909. Stuart, Frederick J., M.R.C.S., L.R.C.P.Lond., Senior Assistant Medical

Officer, Northampton County Asylum, Beirywood.

1900. Sturrock, James Praiu, M.ASt.Aud., M.D., C.M.Edin., H.M. Prison,

Perth, N.B.

1886. Stiffern, Alex. C., M.D., M.Ch. (R.U.I.), Medical Superintendent, ltuberry

Hill Asylum, near Bromsgrove, Worcestershire.

1894. Sullivan, William C., M.l). (R.U.I.), 440, Camden Road, N.

1898. Sutcliffe, John, J.P., M.lt.C.S., L.K.C.P., Royal Asylum, Cheudle, near

Manchester.

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

Scotsburu Road, Tain, Scotlaud.

1877. Swanson, George I., M.D.Edin., The Pleasuunce, Heworth Moor, York.
1908. Swift, Eric W. 1)., M.B.Lond., Medical Superintendent, Orange River
Colony Govt. Asylum, Bloemfontein.

1901. Sykes, Arthur, M.lt.C.S., L.lt.C.P., Oak Villas, Barkerhouse Road,

Nelson, Lancs.

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

Ediu., D.P.H.Edin., It.C.P.S.Edin., F.P.S.Glasg., Medical Superin-
teudeut. Hospital for Insane, St. John’s, Newloundland.

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

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

1910. Taylor, Arthur Loudoun, B.Sc., M.B., Ch.B.Ediu., Assistant Medical
Officer, Lanark District Asylum, llartwood.

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,
Helliugly.

1908. Thomas, Joseph D., B.A., M.B., B.C.Cantab., Northwoods House, Winter¬
bourne, Bristol.

1904. Thompson, Alexander D., M.B., Ch.B.Glasg., Fulbourn Asylum, Cam¬

bridge.

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

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

1905. Thomson, James Hutcbcou, M.B., Ch.li.Aberd., Powick Asylum,

Worcester.

1905. Tidbury, Robert, M.D., M.Ch. (lt.U.l.), L.M., The Borough Asylum,
Ipswich.

1901. Tighe, 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. (Travelling.)

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XXV

Members of the Association.

1903. Topham, J. Arthur, 11.A.Cantab., >1.It.C.S.&P.Lond., County Asylum,

Cliartham, Kent.

1696. Townsend, Aitbur A. 1)., M.D., B.Ch.Birin., M.R.O.S., L.R.C.P., Assistant
Medical Officer, Hospital for Insane, liarnwood House, Gloucester.

1904. Treadwell, Oliver Fereiia Naylor, M.K.C.S.Eng., L.S.A., H. M. Prison,

l'arkburst, I. ot W.

1903. Tredgold, Alfred F„ M.R.C.S., L.R.C.P., 6, Dapdune Crescent, Guild-
foid, Surrey.

1902. Trevelyan, Edmund Fauriel,B.Sc., M.D.Lond.. F.K.C.P.Loud., M.K.C.S.,

Assistant Physician to the LeedsGeneral 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., Kcsideut Physician,

Saughton Hull, Edinburgh; Linden Lodge, Loanbead, Midlothian.
1885. Tuke, T. Seymour, M.A., M.B., B.Ch.Oxou., M.K.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 lion . Secretary for
Scotland .) (Phk61DEMT-Ei.KCT.)

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

1909. Turnbull, Robert Cyril, M.D.Lond., M.R.C.S., L.R.C.P., Assistant
Medical Officer, Londou County Asylum, Coluey Hatch, N.

1889. Turner, Alfred, M.D., C.M.Edin., Piyiupton House, Plymptou, S. Devon.
1906. Turner, Prank Douglas, M.B.Lond., M.lt.C.S., L.R.C.P., Medical Officer,

Eastern Counties Asylum lor 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., St. Saviour’s Road, St. Leonards-

ou-Sea, Sussex.

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

James Murray’s Royal Asylum, Peitli. (Co-Editor oj Journal since
1894.) (Mon. Sec.for Scotland, 1886-94.) (Pkk81I>knt, 1898-9.)
1909. Urquliart, Annie Davidson, M.B., B.Ch.Edin., Assistant Medical Officer,
County Asylum, Morpeth, Northumberland.

1908. Vidler, Albert Edward, M.lt.C.S., L.R.C.l’.Lond., L.S.A., Medical Officer,
Ashford District, Staines Union, Studholmc, Asblord, Middlesex.

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

St. Ann’s Asylum, Trinidad, B.W.l.

1894. Viuceut, William James, M.B., B.S.Durb., M.R.C.S., L.lt.C.P., Assistant

Medical Officer, Wadsley Asylum, mar Sheffield.

1908. Wallace, John Andrew Leslie, M.D., Ch.B.Ediu., M.l’.C., Assistant
Physician, Crichton Royal Institution, Dumtries.

1908. Walker, Harry Victor, L.R.C.P.L, L.M., L.S.A., 2, Acres Street,
Wandsworth Common.

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

1896. Walker, William F., L.K.C.S.AL.M.Edin., L.S.A.Lond., l’las-yu-Dinas,
Dinas Mawddwy, Merionethshire.

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

1895. Waterston, Jane Elizabeth, M.D.Brux., L.R.CP.l., L.R.C.S.Edin.,

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

1902. Watson, Frederick, M.B., C.M.Edin., The Grange, East Finchley,
Londou,N.

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

1908. Watson, H. Ferguson, L.R.C.P., L.R.C.S.Eoiu., L.F.P.S.Glaag., Assistant
Medical Supt., Rent re w District Asylum, Dykebar, Paisley, N.B.
1885 W at son, William Riddell, L.R.C.S. aud L.R.C.P.Ediu., Govan District

Asylum, Hawkhead, Paisley.

1897- Welsh, Gilbert Aitken, M.D., C.M.Edin., The Crescent, Garliestown, N.B.

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xxvi Members of the Association.

1880. West, George Francis, L.lt.C.P.Edin., Medical Superintendent, District
Asylum, Kilkenny, Ireland.

1872. Whiteombe, Edmund Bancks, M.Sc., M.B., B.Ch.Birm., M.R.C.S.Eng.,
Medical Superintendent, Winson Green Asylum, Birmingham.
(President, 1891.)

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

Shrewsbury. {Hon. Sec. South-Eastern Division, 1897-1900.)
(President 1903-4.)

1905. White, Robert George, M.A., M.B., B.Sc., Ch.B.Ghtsg., Pathological
Department, School of Medicine, Cairo. Egypt.

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

1905. Whittington, Richard, M.A., M.D.Oxon., M.lt.C.S., L.R.C.P., 1, Sill-
wood Place, Brighton, Sussex.

1889. Whitwell, James Richard, M.B., C.M., Medical Superintendent, Suffolk
County Asylum, Melton Woodbridge.

1903. Wigan, Charles Arthur, M.D.Durh., M.R.C.S.Eng., Deepdeue, Portis-

head, Somerset.

1883. Wiglesworth, Joseph, M.D., F.R.C.P.Lond., Raiuhill Asylum, Lancashire.
(President, 1902-3.)

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

1900. Wilkinson, H. B., M.R.C.S., L.R.C.P., Assistant Medical Officer,
Plymouth Borough Asylum, Blackadon, Ivy-bridge, South Devon.
1887. Will, John Kennedy, M.A.,M.D.,C.M„ Bethnal House,Cambridge Rd.,N.E.
1907. Williams, Charles E. C., M.A., M.D., B.Ch.Dubl., Assistant Medical
Officer, Holloway Sanatorium, Virginia Water, Surrey.

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

1909. Williamson, George Scott, L.lt.C.S.&P.Edin., Pathologist, West Riding
Asylum, Wakefield.

1904. Wilson, Geoffrey Plumpton, M.R.C.S., L.R.C.P.Lond., Kestcvcn Asylum.

Sleaford, Lines.

1897. Winder, W. H„ M.lt.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., 29, lielsizc Square,
S. Hampstead, N.W.; and Little Combe, Charlton.

1899. Wolseley-Lewis, Herbert, M.D.Brux , F.lt.C.S.Eng., Medical Superin¬

tendent, Kent County Asylum, Harming Heath, Maidstone.

1904. Wood, Martin Stanley, M.B., Ch.B.Viet.,Royal Asylum, - Cheudie, Cheshire.
1869. Wood, T. Outterson, M.l)., M.R.C.P.Lond., F.ll.C.P., F.lt.C.S.Edin.,
40, Margaret Street, Cavendish Square, W. (President, 1905-6.)

1885. Woods, J. F., M.l)., M.lt.C.S., 7, Harley Street, Cavendish Square, W.

1900. Worth, Reginald, M.B., B.S.Durh., M.lt.C.S., L.R.C.P., Middlesex

Asylum, Tooting, S.W.

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

Ordinary Members . 673

Honorary Members . 32

Cobuestonding Members . 17

Total. 722

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

C. Hubert Bond, the Honorary General Secretary, 11, Chandos Street,
Cavendish Square, London, IV., and in duplicate to the Printers of the
Journal, Messrs. Adlard and Son, 22J, Bartholomew Close, London,
E.C.

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PRINCETON UNIVERSITY

XXVll

OBITUARY.

Members.

1883. Blair, Robert, M.D., of Bracfort, Crookston, Paisley.

1896. Bubb, William,M.It.C.S., L.R.C.P.Lond.,of Clovcrdale Lawn,Cheltenham.
1905. Ferris, William, M.D., B.S.Lond., of Tooting’, S.W.

1888. Graham, Thomas, M.D.Glasg., of Garthhiud Place, Paisley.

1871. Ireland, William W., M.D.Edin., of Victoria Terrace, Musselburgh, N.B.
1903. Rhodes, John Milson, M.D.Brux., L.R.C.P.AS.Edin., of Ivy Lodge,
Barlow Moor, Didsbury, Manchester.

1908. Roscoe, Henry, M.R.C.S., L.R.C.P., D.P.H.Vict., of Choddlcton Asylum,
Staffs.

1862. Stilwell, Henry, M.D.Edin., M.R.C.S.Eng., of Compton St., Eastbourne.

Digitized by

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PRINCETON UNIVERSITY

xx vm

Digitized by

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.

Certif.) to their names.

Adamson, Robert O.

Adkins, Percy, R.

Aiuley, Fred Shaw.

Ainslie, William.

Alexander, Edward H.
Anderson, A. W.

Anderson, Bruce Arnold.
Anderson, John.

Andriezen, W.

Armour, E. F.

Attegalle, J. W. S.

Aveline, H. T. S.

Ballantyne, Harold S.

Barbour, William.

Barker, Alfred James Glanville.
Bashford, Ernest Francis.

Begg, William.

Belben, F.

Bird, James Brown.

Blachford, J. Vincent.

Black, E. J.

Black, Robert S.

Black, Victor.

Blackwood, John.

Blandford, Henry E.

7 Bond, C. Hubert.

Bond, R. St. G. S.

Bowlau, Marcus M.

Boyd, James Paton.

Bristowe, 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, Allred 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.
Clayton, Thomas M.

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.

11 Devine, Henry.

Distin, Howard.

Dixon, J. F.

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, A. R.

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

Ferguson, Robert.

Findlay, G. Landsborougli.
Fitzgerald, Gerald.

Fleck, David.

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PRINCETON UNIVERSITY

XXIX

Fortune, J.

Fox, F. G. T.

Fraser, Donald Allan.

Fraser, Thomas.

Frederick, Herbert John.

Gaudin, Francis Neel.

Gawn, Ernest K.

Gemmell, William.

Genney, Fred. S.

Gibb, H. J.

Gibson, Thomas.

Giles, A. B.

Gill, J. Macdonald.

Gilmour, John R.

Goldie, E. M.

Goldschmidt, Oscar Bernard.
Goodall, Edwin.

Graham, Dd. James.

Graham, F. B.

Grainger, Thomas.

Grant, J. Wcmyss.

Grant, Lacklan.

Gray, Alex. C. E.

Griffiths, Edward H.

Hall, Harry Baker.

Hoisted, H. C.

Haslam, W. A.

Haslett, William John Handheld.
Hassell, Gray.

Hector, William.

Henderson, Jane B.

Henderson, P. J.

Hennan, George.

Hewah, Matthew L.

Hewitt, D. Walker.

Hicks, John A., jun.

Hitcliings, Robert.

Holmes, William.

Horton, James Heury.

Hotchkis, R. 1).

Howden, Robert.

Hnghes, Robert.

Hutchinson, P. J.

2 Hyslop, Thos. B.

Ingram, Peter R.

Jeffery, G. R.

Jagannadlmn, Annie W.

Johnston, John M.

Kelly, Francis.

Kelso, Alexander.

Kelson, W. H.

Ker, Claude B.

Kerr, Alexander L.

Keyt, Frederick.

King, David Barty.

King, Frederick Truby.

I<aing, C. A. Barclay.

Doing, J. H. W.

Daw, Thomas Bryden.

Lecper, Richard R.

Leslie, R. Murray.

Livesay, Arthur W. Bligh.

Livingstone, John.

Lloyd, R. H.

Low, Alexander.

McAllum, Stewart.

Macdonald, David.

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

Macdonald, W. F.

Macevoy, Henry Johu.
McGregor, George.

Maclnncs, lan Laniont.
Mackenzie, Henry J.

Mackenzie, John Cumining.
Mackenzie, T. C.

Mackenzie, William H.
Mackenzie, William L.

Mnckic, George.

McLean, H. J.

Macmillan, John.

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

Macphcrson, John.

Macvean, Douald A.

Mallannah, Srcenagula.

Marr, Hamilton C.

Marsh, Ernest L.

Martin, A. A.

Martin, A. J.

Martin, M. E.

Martin, Wtn. Lewis.

Masson, James.

Meikle, T. Gordon.

Melville, Henry B.

Middleuiass, James.

Miller, R.

Miller, R. H.

Mitchell, Alexander.

Mitchell, Charles.

Moffett, Elizabeth J.

Mouteith, James.

Moore, Edward Erskine.

1 Mortimer, Johu Desmond Ernest.
Munro, M.

Murison, Cecil C.

Murison, T. D.

Myers, J. W.

Nair, Charles R.

Nairn, Robert.

Neil, James.

Nixon, Johu Clarke.

Nolan, Michael James.

Norton, Evcritt E.

Orr, David.

Orr, James.

Orr, J. Fraser.

Oswald, Landcl R.

Owen, Corbet W.

Paget, A. J. M.

Parker, William A.

Parry, Charles P.

Patterson, Arthur Edward.
Patton, Walter S.

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PRINCETON UNIVERSITY

XXX

Digitized by

Paul, William Moncricf.

Pearce, Walter.

Pcnfold, William James.

Pliilip, James Farquhar.

Philip, William Marshall.

Pieris, William C.

Pilkington, Frederick W.

Pitcairn, John James.

Porter, Charles.

Price, Arthur.

1’ring, Horace Reginald.

Rainy, Harry, M.A.

Ralph, Richard M.

Rannie, James.

4 Raw, Nathan.

Reid, Matthew A.

Renton, Robert.

Rice, P. J.

Itigden, Alan.

Ritchie, Thomas Morton.

Rivers, W. H. R.

3 Robertson, O. M.

Robson, Francis Win. Hope.

Roric, George A.

Rose, Andrew.

Rowand, Andrew.

Rudall, James Ferdinand.

Rust, James.

Rust, Montague.
lORutherford, J. M.

Sawyer, Jas. E. H.

Scott, George Brebner.

Scott, J. Walter.

Scott, William T.

Senwright, H. G.

Sheen, Alfred W.

Simpson, John.

Simpson, Samuel.

Skac, F. M. T.

Skeen, George.

Skeen, James H.

Slater, William Arnison.

Slattery, J. B.

Smith, Percy.

Smyth, William Johnson.

Snowball, Thomas.

1 To whom the Gaskell

2 To whom the Gaskell

3 To whom the Gaskell

4 To whom the Gaskell

5 To whom the Gaskell

6 To whom the Gaskell

7 To whom the Gaskell

8 To whom the Gaskell

9 To whom the Gaskell

10 To whom the Gaskell

11 To whom the Gaskell

Soutar, James G.

Sproat, J. H.

Stanley, John Douglas.

Staveley, William Henry Charles.
Steel, John.

Stephen, George.

Stewart, William Day.

Stoddart, John.

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

Strong, D. R. T.

Stuart, William James.

Symes, G. D.

Thompson, A. D.

Thompson. George Matthew.
Thomson, Eric.

Thomson, George Felix.

Thomson, James II.

Thorpe, Arnold E.

Trotter, Robert Samuel.

Turner, W. A.

Umney, W. F.

Walker, James.

Wallace, J. A. L.

Wallace, W. T.

Wardc, Wilfred B.

Wutcrston, Jane Elizabeth.
Watson, George A.

Welsh, David A.

West, J. T.

Whitwell, Robert R. H.
Wickham, Gilbert Henry.

Will, John Kennedy.

Williams, I). J.

Williamson, A. Maxwell.

4 Wilson, G. R.

Wilson, James.

Wilson, John T.

Wilson, Robert.

Wood, David James.

Wright, Alexander, W. O.

Yeates, Thomas.

Yeoman, John B.

Young, D. P.

Younger, Henry J.

Zimmer, Carl Raymond.

Prize (1887) was awarded.

Prize (1889) was awarded.

Prize (1890) was awarded.

Prize (1892) was awarded.

Prize (1895) was awarded.

Prize (1896) was awarded.

Prize (1897) was awarded.

Prize (1900) was awarded.

Prize (1901) was awnrded.

Prize (1906) was awarded.

Prize (1909) was awarded.

Google

Original from

PRINCETON UNIVERSITY

THE

JOURNAL OF MENTAL SCIENCE

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

No. 232 [To 8 "" 8 ] JANUARY, 1910. Vol. LVI.

Part I.—Original Articles.

The Causes of Insanity , with Especial Reference to the
Correlation of A ssigned Factors: A Study of the
Returns for 1907. By Sidney Coupland, M.D.,
F.R.C.P., Commissioner in Lunacy.

The revised scheme of registration put forth by the Medico-
Psychological Association three years ago and officially adopted
by the Commissioners in Lunacy is a noteworthy attempt to
impart greater accuracy and precision to the record of facts
relating to the insane. An important feature of this revision was
a full and carefully designed schedule, compiled by a special
committee, intended to replace the long-established list of the
“causes of insanity,” which, whilst doubtless reflecting the
knowledge of the middle of last century, lacked scientific pre¬
cision and had become obsolete. The new schedule aimed at
greater definiteness, and being framed on the teachings of
experience by those most competent to the task, may well be
considered to fairly embrace the whole field of aetiological
inquiry. It is with the object of showing what may be learnt
from its use that I have ventured to lay before the Association
the results of a study of the records of the institutions for the
insane in England and Wales during 1907—the first year of the
adoption of the revised system—in so far as these refer to
patients suffering from their first attack of insanity.

The number of first attack cases in 1907 was, males 6,035,
females 6,202. In a certain proportion of such cases, esti¬
mated ( 2 ) to amount to males 1,208, females 1,214, no causal

LVI. 1

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2 THE CAUSES OF INSANITY, [Jan.,

factor could be ascertained or positively assigned. Only one
such factor was definitely determined in the cases of males 3,456,
females 3,499. The residue—males 2,433, females 2,475, or a
total of 4,908 individuals—comprises those whose cases have
furnished the material upon which this paper is based, for in
each of them inquiry yielded information of two or more of the
antecedents enumerated in the schedule.

The Groups of /."Etiological Factors.

The number of scheduled factors amounts to 46 for the male
and 50 for the female sex, and they are grouped under 11 head¬
ings, namely:

Group a. Heredity.

,, B. Mental instability.

,, c. Deprivation of special sense.

,, D. Critical periods.

,, E. Child-bearing.

,, F. Mental stress.

,, G. Physiological defects and errors.

,, H. Toxic.

„ 1. Traumatic.

,, k. Diseases of the nervous system.

,, l. Other bodily affections.

The comprehensive character of this list is shown by the fact
that not one of the setiological factors named therein has gone
unrecorded, whilst of the number of instances entered under
the large Group h only 2 per cent, are to be found assigned to
other than the specified toxins. Such a result bears testimony
to the care and foresight of the compilers.

In order to dispense with a dreary recital of figures, which
may more suitably be remitted to an appendix to this paper, I
have endeavoured to indicate graphically the proportionate fre¬
quency with which the several factors and their groups were
found to recur. One of these diagrams (and Table I) represents
these ratios amongst all the instances recorded, whether isolated
or combined ; the other deals only with those where the factors
were associated ( 2 ). There is not much difference in the general
result of the two reckonings, and such as there is may pro¬
bably be explained by the preponderant recurrence of certain
causes owing to their multiple association.

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BY SIDNEY COUPLAND, M.D.

Table Showing Proportionate Distribution of Groups of ^Etiological

Factors.

All instances (alone or combined). Combined instances only.

Group.

Males.

Females.

Males.

Females.

A .

20'2

. 24 - 2

24*2

. 27*1

B .

2-8

3'5

3-8

C .

• 0-5

0*5

. o’6

D .

. 9*2

I7'4

7*9

. 14*6

E .

. —

. 6 - o

. —

4-2

F .

• I4-5

18-6

n*3

14-9

G .

4'5

3'°

5*2

H .

• 29-5

ii-8

27-5

ii-8

4*3

r 4

4'°5

i'3

K .

. 8*2

6*3

7*i

6’i

L .

. 6-4

8-o

8-65

n’8

Briefly these charts show in

the first place

that of all the

setiological groups in the male sex the toxic is the most fre¬
quently met with, whereas in the female it is relegated to the
fourth place. Then comes the heredity group, which furnished
more instances in the female than in the male sex ; then mental
stress, followed by the group of critical periods, both considerably
more frequent in females. Then diseases of the nervous system,
other bodily affections, and physiological defects, which yielded
a larger proportion of instances in males than in females.
Child-bearing takes the seventh place in women, the traumatic
group the eighth place in men and the tenth in women, mental
instability taking the place below traumatism in males, but
above it in females; and lastly deprivation of special sense,
which in either sex yielded comparatively few instances, occur¬
ring in the full list in the ratio of 5 per 1,000.

The ^Etiological Factors.

The number of instances in which the various factors were
met with either singly or in association amounted to 9,831 in
males and 10,062 in females. Their relative distribution will
be seen in the diagrams, and since it is clearly impossible
and would also be unprofitable to deal with each individual
item in turn (no small proportion occurring so rarely as to be
useless for reliable analysis), I have selected for my purpose the
thirteen factors which recur most frequently in the returns.

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Taken in the order in which they appear in the schedule, and
affixing to each its assigned symbol, they are :

Males

Females

per cent.

a. Insane heredity (a i) .

. I4’2

. 17-4

b. Alcoholic heredity (a 5)

• 3'9

3’9

c. Puberty and adolescence (d i) .

• 2-5

3 ’ 1

d. Climacteric (r> 2)

. 0 - I

6-4

e. Senility (d 3)

. 6’6

7’9

/. Puerperal state (e 2) .

. —

3’9

g. Sudden mental stress (f i)

. 2’9

4*9

h. Prolonged mental stress (f 2)

. 116

• 137

i. Alcohol (hi)

. iy8

k. Influenza (h 5) .

• 2-5

2*1

1 . Syphilis (acquired) (h 8)

• 7 ' 1

1*0

m. Epilepsy (k 3)

• 4‘9

3’5

n. Cardio-vascular degeneration (l 2)

• 3 ' 1

The remaining 33 factors amongst the males anc

37 factors

amongst the females divide between them the 22'8 per cent.
and 23*1 per cent, remaining respectively after the deduction of
the above figures.

It will be seen that the predominance of heredity as a factor
in the tetiology of insanity is mainly due to the strain of mental
derangement in the family, other inherited defects, such as
are evidenced by epilepsy or other neurotic manifestations
and eccentricity, accounting for only 2‘i and 2*9 per cent, in
males and females respectively, whilst a history of alcoholism
in the family was met with in 3^9 per cent, in each category.
Similarly in the personal history of the patient by far the most
common toxic agency recorded was alcohol, a fact which must
of course be set alongside with the vastly preponderant liability of
exposure to the effects of this agent over that of any others on the
list. It may be of interest to note that the drug habit (h 2 ) was
only recorded in the proportion of 2 and 1 per 1,000 instances
in males and females respectively. To judge from these returns
sudden mental stress is apparently by no means so liable to
unbalance the mind as the wearing influence of prolonged stress,
and the mental failure of old age accounts for the fact of
senility being the most common of the critical periods of life to
be associated with such derangement.

Again, comparing the sexes one finds that there was a higher

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BY SIDNEY COUPLAND, M.D.

proportion of insane inheritance amongst females than amongst
males, whilst a family history of alcoholism occurred in exactly
the same proportions in each sex. In these returns the critical
period of puberty and adolescence was a more disturbing
factor amongst females, as also was senility, whilst obviously the
climacteric perturbation, well recognised in its mental aspect,
was, as a factor in insanity, almost wholly limited to women.
That the mental stability of women is less balanced than that
of men would further appear from the fact that as regards both
forms of mental stress the proportion of instances in which they
preceded the attack was higher in the former than in the
latter sex. These relative proportions are markedly reversed in
the records of personal alcoholic intemperance as a factor in the
previous history of the insane, for in the returns its incidence
on males was nearly thrice as high as on females, possibly
denoting the relative proclivity to such indulgence between the
two sexes in general. Influenza occurred in about the same
proportion as an antecedent in the two sexes, but acquired
syphilis was more than seven times as common amongst the
males as amongst the females, a fact which may be compared
with a similar disproportion in respect to general paralysis of
the insane.

Of the total number of instances recorded about one-third
were returned as the sole ascertainable factors in the history of
the cases bearing on the insanity, the cases yielding them being
nearly half as numerous again as those in which two or more
factors were combined. It is possible that as years go by and
more penetrating inquiry is made that this proportion of
“ isolated ” causes will tend to diminish. Suffice it to note
that of the thirteen selected factors here dealt with the most
numerous of such “ single ” causes was prolonged mental stress,
the next alcohol, then insane heredity, senility, and epilepsy,
the climacteric and puerperal state in females and syphilis in
males being also fairly prominent in the list.

It is not, however, upon the simple question of the relative
frequency of assigned causes nor of their possible isolated
sufficiency to induce mental derangement that I wish espe¬
cially to dwell, but rather on the more subtle question of the
combination or correlation of two or more factors in the
aetiology of insanity, of which the main, if not the sole, object
of study must be to discover its bearing on the prevention of

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THE CAUSES OF INSANITY,

[Jan.,

disease. I turn, therefore, to this subject, premising that at
the present stage one can do little more than indicate the
directions in which inquiry may be most usefully directed.

The Correlation of Causes.

The correlation table, if it may be so termed, initiated by the
Association and adopted in the Commissioners’ Annual Report
(63rd Report, App. A, Tables XVII and XVIII), is, I believe,
a novel departure in statistical inquiry, and one possessing
peculiar interest and value, provided that correct deductions
can be drawn from it. It is based on the recognition of the
obvious fact that in mental, as in physical disease, many
differing conditions or circumstances may co-operate in deter¬
mining an illness, some no doubt of more importance than
others, although not seldom it may be impossible to decide
w'hich of many factors has been the most essential to the result.
It must, I think, be admitted that there is no warrant for
establishing a close parallel between body and mind in this
respect. If there were ground for belief in what is at present a
pure hypothesis, then it would not be difficult to go farther and
accept the assumption that the principal cause of insanity in
general is of the nature of a toxaemia, due possibly to a microbe,
as was seriously advanced a few years ago in the columns of the
Times by an anonymous medical correspondent. I perhaps may
add that the same thesis was maintained with equal gravity by a
lady whom I had occasion to visit in my official capacity, who
not only averred that she had seen the microbe of insanity
crawling up the walls of the institution, and obligingly, at my
request, made me a sketch of it, but declared she had witnessed
its contagious influence transmitted from one inmate to another!
Even admitting this possibility, there would, however, still
remain for inquiry the ascertainment of the circumstances
of inheritance, environment, and habits of the individual,
which might favour the operation of the essential cause
and explain the fact of proclivity. It would be quite analo¬
gous to the fact that the ubiquitous Bacillus tuberculosis
requires for its propagation a favourable soil prepared for it
by an inherited feebleness of tissue-resistance, life and work
in an impure and sunless atmosphere, defective nourish¬
ment, exposure and the like. Therefore, whatever view may be

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held as to the essential cause of insanity, it is of the highest
importance for its prevention that there should be as accurate
knowledge as possible of all the conditions to which the
individual has been subjected, which may perchance have
contributed to his derangement; and if it can further be
shown how these several factors are combined or cor¬
related one with another, the sphere of protection may be more
clearly indicated.

It is not unlikely that this line of inquiry would enable us
to establish a definite relationship between the character of
the precursory circumstances and the type of the mental
disorder; but for this purpose a very large collection of data
would be necessary. Indeed, I feel that it is somewhat pre¬
mature to raise the question at all, even in its wider bearings,
with only the returns of a single year before one.

The principle upon which the table is drawn up is perfectly
simple. It consists merely in a series of columns corresponding
to the various scheduled factors, in which the number of
recorded instances of each associated factor is indicated. This,
which necessarily involves the duplication of the numbers of
the latter, enables the calculation to be made as to the
proportionate frequency with which any given factor has been
associated with any other in the list. The total instances of
combination dealt with were males 9,490, females 9,678
(v. Table II).

Having utilised for this purpose the several vertical columns,
the completed analysis supplies a horizontal series of ratios
indicating the proportionate frequency of correlation of any
given factor to the total number in each successive column.
Thus (excluding Group D 2 on account of its small total), insane
heredity (a i) amongst males is found to have been associated
with 42 other factors, the total number of its correlations being
1,403, the individual items ranging from 308 in the case of one
of them to 1 in that of 4, yielding therefore a percentage-rate
of 2i’3 in the one instance and one of 07 in the others. But
in the full analysis the 1,403 instances in which insane heredity
is in association will show that leading factor to appear in each
series in proportions ranging from 28 to 3 per cent., the mean
rate of its correlation-frequency being 157 per cent.

The thirteen selected factors yield the following rates:

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Correlation of ^Etiological Factors.

Males.*

Females.t

Asso¬

ciated

factors.

Total

instances.

Mean

correlation

rate.

Asso¬

ciated

factors.

Total

instances.

Mean

correlation

rate.

a. Insane heredity

•403

'57

1612

'93

b. Alcoholic heredity .

c. Puberty and adoles-

575

578

cence

267

4-6

306

4'i

d. Climacteric

—

3<5

574

7'3

e. Senility .

473

520

/. Puerperal state
g. Sudden mental

—

““

224

3°

stress

h. Prolonged mental

195

404

stress

868

106

1033

103

i. Alcohol .

1497

'57

615

k. Influenza

igO

2*5

172

2’4

l. Syphilis .

674

122

m. Epilepsy

n. Cardio-vascular de-

375

274

generation

454

5' *

387

* Exclusive of d 2 . f Exclusive of I 3 .

The simplest way to indicate the relationship existing between
these several factors will be to select those instances where
the correlation-frequency rate has surpassed the mean, as
pointing to such a combination of antecedents as may possibly
be of greater significance than those where the rate is lower
than the mean.

Taking them in order and noting as one proceeds wherein
the sexes differ in respect to these correlations, it may be
observed from the diagrams (and Tables III and IV) that (a)
a family history of insanity predominated in both sexes in respect
to the period of puberty and adolescence, mental stress (whether
sudden or prolonged) and influenza. That in the male sex
such predominance occurred with a family and personal history
of alcoholism and with epilepsy, and in the female sex with the
climacteric and puerperal state.

Next we find that ( b ) an alcoholic heredity is associated with
a personal addiction to alcohol in both sexes, and also with
epilepsy; whilst in males the mean rate is exceeded, notably in
association with an insane inheritance, influenza and syphilis,
and in females with the puerperal state.

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In both sexes the mean rate is exceeded by (c) the period
of puberty and adolescence when correlated with an insane
heredity, sudden mental stress and epilepsy.

The (d) climacteric period in women as a predisponent is
found to be mainly correlated with insane heredity, mental
stress (both sudden and prolonged), alcoholic intemperance
and influenza.

(e) Senility in each sex was mainly linked, as may naturally
be anticipated, with cardio-vascular degeneration, and to a far
smaller degree in the female with prolonged mental stress
and influenza.

The (/) puerperal state is characterised by the preponderance
of the factor of heredity, with which may be conjoined an
alcoholic heredity and mental stress.

( g ) Sudden mental stress may be associated with insane
heredity and personal alcoholism in males, and to a lesser
degree with such conditions as influenza, epilepsy and puberty;
whilst in females it was found largely associated with insane
heredity, with puberty, the climacteric, the puerpera and
influenza.

(/t) Prolonged mental stress in each sex was correlated with
insane heredity, intemperance and influenza, in males also with
syphilis; in females with the climacteric and less markedly
with senility and the puerperal state.

(*) Alcoholic excess in each sex shows marked correlation with
prolonged stress, alcoholic heredity, syphilis, and cardio-vas¬
cular degeneration, and in women with the climacteric.

( k) Influenza has similar marked association with insane
heredity, mental stress, the climacteric, and the puerperal
state.

(/) Syphilis in both sexes was mainly correlated with alco¬
holism in the subject; in males also with an alcoholic heredity,
prolonged stress, and cardio-vascular degeneration.

(m) Epilepsy in each sex was chiefly combined with an
alcoholic heredity, with adolescence, and with vascular deterio¬
ration, and to a lesser degree with an insane heredity.

In each sex (») cardio-vascular degeneration was mainly cor¬
related with senility, and also with alcoholism, syphilis, and
epilepsy.

These few selected analyses only bring us to the fringe of the
subject, for, as has been stated, the actual numbers of other

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io TIIE CAUSES OF INSANITY, [Jan.,

factors with which the 13 are really correlated range from 45 to
28, and it maybe accepted that in one half or at least one third
the correlation frequency rates were above the mean rates. A
considerable proportion of the instances recorded are, however,
far too few in number to be subjected to comparison, and must
perforce be entirely set aside. Nevertheless, some of them may
fairly be introduced as they are conditions of importance, and
recurred with moderate, if not striking, frequency. I have
therefore prepared a list into which 14 additional factors are
admitted, and have ranged in order of correlation-frequency
(together with those already treated) such of them as yielded a
marked correlation with the 13 selected factors. These
additional factors were met with in association with others in
numbers ranging from 289 to 80, as follows:

Epileptic heredity (a 2 )

No. of instances.
Males. Females.

156 . igO

Neurotic heredity (A3).

130

. 172

Congenital mental deficiency (b 2)

251

. 289

Pregnancy (e 1) .

—

. 80

Lactation (e 3)

—

. hi

Privation and starvation (g 2)

177

. 197

Masturbation (g 4)

162

. —

Sexual excess (g 5)

—

Tuberculosis (H 4)

. 83

Injuries (1 1) .

287

—

Lesions of brain (k 1) .

163

• 139

Hysteria and allied neuroses (k 4)

—

• 137

Anaemia, etc. (l 1)

. —

. 210

Valvular disease of heart (l 3)

105

. 184

In the subjoined list the associated conditions are enumerated
in the order of their frequency of correlation with each of the
13 selected factors in turn, the newly introduced ones being
indicated by italics. The actual figures will be found in the
appendix (Tables V and VI). In several series a few further
additional factors are given whenever the total of their instances
seemed to justify their inclusion.

a. With Insane Heredity: Males. —1, Masturbation ; 2,
puberty and adolescence ; 3, sudden mental stress ; 4, prolonged
mental stress; 5, alcohol; 6, influenza; 7, tuberculosis ; 8, val¬
vular heart disease-, 9, heredity—alcoholism; 10, injuries', 11 epi-

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leptic heredity ; 12, epilepsy; 13, sexual excess. Also physical
strain, renal and digestive disorders, and sunstroke.

Females.— 1, Puerperal state; 2, pregnancy ; 3, puberty and
adolescence ; 4, influenza ; 5, lactation ; 6, sudden mental stress ;
7, prolonged mental stress; 8, tuberculosis ; 9, climacteric; 10,
hysteria, etc. Also masturbation, physical strain, neurotic and
digestive disorders.

b. With Alcoholic Heredity: Males.—1, Neurotic heredity,

2, alcohol (personal); 3, tuberculosis; 4, epilepsy ; 5, influenza ;

6 , epileptic heredity ; 7, congenital mental deficiency ; 8, insane
heredity ; 9, syphilis ; 10, valvular heart disease. Also surgical
operations and moral deficiency.

Females.— 1, Alcohol (personal): 2, epileptic heredity-, 3,
puerperal state; 4, epilepsy ; 5, lesions of brain ; 6, congenital
mental deficiency ; 7, neurotic heredity ; 8, puberty and adolescence.
Also moral deficiency, neurotic and digestive disorders.

c. With Puberty and Adolescence : Males.—1, Masturba¬
tion-, 2, congenital mental deficiency, 3, epileptic heredity ; 4, sexual
excess ; 5, insane heredity; 6, epilepsy; 7, sudden mental stress.
Also anaemia, surgical operations, and moral deficiency.

Females.—1, Congenital mental deficiency-, 2, hysteria, etc.;

3, ancemia ; 4, epilepsy ; 5, epileptic heredity; 6, insane heredity ;

7, sudden mental stress; 8, tubcrcidosis. Also over-exertion,
impaired nutrition, moral deficiency, masturbation, and neurosal
disorders.

d. With Climacteric: Females.— 1, Prolonged mental
stress; 2, influenza; 3, valvular heart disease-, 4,alcohol; 5, insane
heredity; 6, sudden mental stress. Also surgical operations,
renal and certain general diseases.

e. With Senility: Males.— 1,Cardio-vascular degeneration ;
2, valvular heart disease ; 3, lesions of brain ; 4, privation. Also
respiratory, renal, and digestive diseases.

Females.— 1, Cardio-vascular degeneration; 2, lesions of
brain-, 3, valvidar heart disease ; 4, influenza; 5, privation. Also
injuries and respiratory disorders.

/. With Puerperal State: Females.— 1, Tubcrcidosis-, 2,
insane heredity; 3, pregnancy ; 4, neurotic heredity ; 5, privation-,
6, alcoholic heredity; 7, epileptic heredity ; 8, ancemia. Also
malnutrition, neuroses, and toxins.

g. With Sudden Mental Stress: Males.— 1, Insane
heredity; 2, puberty and adolescence; 3, influenza. Also
physical strain, surgical operations, renal disease, anaemia, etc.

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Females. —i, Pregnancy; 2, influenza; 3, hysteria, etc.; 4,
puberty; 5, insane heredity; 6, amentia ; 7, climacteric; 8,
lactation; g, congenital mental deficiency ; 10, neurotic heredity; 11,
puerperal state. Also physical strain, malnutrition, neurosal
and renal diseases.

h. With Prolonged Mental Stress: Males. — 1, Tuber¬
culosis; 2, influenza; 3, insane heredity; 4, neurotic heredity ;
5, syphilis ; 6, privation ; 7, alcohol. Also over-exertion, renal
and gastro-intestinal diseases, and anaemia.

Females. —1, Lactation; 2, climacteric; 3, pregnancy; 4,
privation; 5, insane heredity; 6, neurotic heredity; 7, ancemia;
8, senility; g, alcoholic heredity; 10, influenza; 11, hysteria;
12, puerperal state ; 13, alcohol. Also over-exertion, moral de¬
ficiency, respiratory and general diseases, and injuries.

i. With Alcohol : Males. —1, Sexual excess; 2, syphilis ;

3, alcoholic heredity; 4, privation; 5, insane heredity; 6, pro¬
longed mental stress ; 7, injuries ; 8, cardio-vascular degenera¬
tion ; g, sudden mental stress ; 10, senility ; 11, valvular heart
disease. Also moral deficiency, sunstroke, drug habit, specific
fevers, renal disease.

Females. —1, Syphilis; 2, alcoholic heredity ; 3, climacteric;

4, cardio-vascular degeneration; 5, lesions of brain. Also the
drug habit, sexual excess, diseases of spinal cord and nerves,
moral deficiency, neurosal and renal affections.

k. With Influenza: Males. — 1, Epileptic heredity; 2, pro¬
longed mental stress ; 3, tuberculosis ; 4, sudden mental stress ;

5, insane heredity. Also operations, over-exertion, and organic
diseases.

Females. —1, Lactation ; 2, sudden mental stress : 3, climac¬
teric; 4, insane heredity; 5, senility; 6 , pregnancy.

l . With Syphilis: Males. —1, Sexual excess; 2, alcohol;
3, privation; 4, cardio-vascular degeneration; 5, prolonged
mental stress ; 6, tuberculosis; 7, lesions of brain ; 8, alcoholic
heredity. Also sunstroke, fevers, malnutrition, diseases of
spinal cord and nerves.

Females. —1, Lesions of brain; 2, alcohol; 3, epileptic
heredity; 4, neurotic heredity; 5, cardio-vascular degeneration.
Also moral deficiency, sexual excess, diseases of cord and
nerves.

in. With Epilepsy : Males. —1, Epileptic heredity; 2, in¬
juries ; 3, congenital mental deficiency ; 4, neurotic heredity;

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5, senility; 6, cardio-vascular degeneration ; 7, alcoholic

heredity.

Females.—1, Epileptic heredity ; 2, congenital mental deficiency ;
3, neurotic heredity ; 4, puberty ; 5, alcoholic heredity ; 6, cardio¬
vascular degeneration. Also injuries and operations.

n. With Cardio-vascular Degeneration : Males.— i,
Senility; 2, lesions of brain ; 3, epilepsy; 4, syphilis ; 5, priva¬
tion ; 6, alcohol. Also renal, respiratory and nervous diseases,
injuries and malnutrition.

Females. —i, Senility; 2, lesions of brain ; 3, privation ; 4,
syphilis ; 5, epilepsy; 6, alcohol; 7, valvular heart disease. Also
renal and nervous diseases.

Some indication of the relative importance of the above-
named conditions as aetiological factors may perhaps be obtained
by noting the frequency with which they recur in the several
series of correlations. On this basis, heredity,—insane, epileptic
and alcoholic, the toxic agent,—alcohol, and sudden mental
stress predominate in both sexes, whilst in males privation and
tuberculosis, and in females the climacteric and influenza, would
appear to be comparatively frequent factors. On the other
hand, the least frequent and most restricted in respect to
variety of correlation were in both sexes the period of adoles¬
cence, in the male sex that of senility, and in the female
syphilis and prolonged stress, in spite of the fact of the high
total of instances which are recorded under the last-named
heading.

A few further comments on the foregoing lists are necessary.
The high place taken by insane heredity amongst the males in
whom there was a history of masturbation, is accounted for by
the fact that out of a total of 162 returned under the latter
head, no fewer than 48 were in subjects of inherited taint,
yielding a relative proportion nearly twice that of the mean
rate (15*8). It will be noticed that very many conditions
show an excessive rate of insane inheritance, both amongst
males and females, the puerperal state, as already pointed out,
being in this respect far in advance of any other factor.

Puberty and adolescence are naturally to be found largely asso¬
ciated with feeble-mindedness, as with epilepsy in both sexes,
masturbation in the male, hysteria and anaemia in the female.

In addition to what has already been pointed out, the
climacteric perturbation in the history of insanity is found

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14 THE CAUSES OF INSANITY, [Jan.,

sometimes associated with the effects of surgical operations
and with bodily disorders.

Then as regards senility, almost any bodily affection,
especially cardiac and cerebral disease, and also privation are
correlated conditions, which have certain significance, but one
far less than the cardio-vascular degeneration before men¬
tioned.

The high position assigned to tuberculosis as an associated
factor with the puerperal state would be misleading without
explanation. It is solely due to the paucity of total instances
recorded, namely 83, so that the 5 which are returned as in
correlation with the puerpera give a ratio of 6'o per cent .—
considerably higher than the mean rate (2’g) of the 32 instances
of factors with which the puerperal state is stated to have
combined.

Sudden mental stress as a factor was apparently more variously
correlated with others in proportions above the mean in women
than in men, including such conditions as pregnancy, hysteria,
anaemia and lactation, but here again the small total makes it
doubtful if the position accorded to the first-named is the
correct one.

With regard to prolonged stress, beyond the 13 factors dealt
with previously it will be seen that tuberculosis and lactation
again have high positions, which may not represent their real
correlation-frequency, and more importance may be attached
to the inclusion of privation as a correlated factor.

In addition to the factors already noted, the extended
analysis shows that alcoholism is also preponderant in respect
to its correlation with sexual excess, privation and traumatism
in males and in females with brain disease. Its association with
neuritis also appears from the figures in these returns.

In males influenza was obviously markedly associated with
tuberculosis, surgical operations and physical over-exertion,
and in females with lactation, pregnancy and neurosal
disorders.

Syphilis has a predominant correlation with diseases of the
central and peripheral nervous system in each sex, and with
tuberculosis and privation in males, besides the correlations
before mentioned.

The addition of injuries and of surgical operations as factors
in high correlation with epilepsy is noteworthy.

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i 9 io.]

BY SIDNEY COUPLAND, M.D.

Lastly, certain bodily diseases, notably of the brain, may be
included in the conditions with which cardio-vascular degenera¬
tion is correlated.

In regard to the correlations that have been thus singled
out, it must not be forgotten that they by no means comprise
all that could be mentioned in the series dealt with where the
correlation-rate was above the mean, but these being in the
highest proportion are to be regarded as combinations that are
the most likely to recur. But the table does not enable us to
ascertain how often groups of more than two particular factors
recurred. It is obvious, too, that very many of the associations
named are just those which would be likely to occur apart
from any question of their influence in producing mental
disorder, as will be seen, for instance, in those series in which
alcohol and syphilis, youth and age are the leading factors.
But apart from such combinations there are others that are
more or less novel, and it is perhaps to these that one may
look with most hope as enabling an attack of insanity to be
warded off by taking measures to protect the individual from
their influence.

The factor of inherited taint appears to dominate the whole
position, and not the least value of these returns is the demon¬
stration they afford of its influence. Nor is this surprising,
since it is quite conceivable that influences operating on the
cerebral mechanism which may leave the mind unshaken where
there is no such transmitted tendency may, be they severe or
slight, transient or lasting, suffice to unbalance it when that
tendency exists. The preponderance of alcoholism amongst
the toxic factors, especially in males, ought not to be unduly
emphasised considering the widespread consumption of alcohol
in the community, and the recognised fact that inebriety is
probably as frequently concomitant, or consequent, as antece¬
dent to mental defect. Nevertheless it is surely wise to infer
from such returns as these that abstinence from this, as from
any other intoxicant, in the case of one whose family history
show's a possible proclivity to mental or nervous disorder,
would be of foremost importance in prophylaxis.

In respect to mental stress, which also stands out so promi¬
nently in these records, may I be permitted to express my own
conviction that the psychical and emotional states comprised
under this phrase cannot be ignored in the aetiology of insanity.

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16 THE CAUSES OF INSANITY, [Jan.,

Whatever view may be taken of the meaning and nature of
mind, the history of numberless cases, as these records clearly
show, do convey evidence of the fact, explain it as one may,
that the mind can give way under “ strain, 0 as the old phraseo¬
logy had it; and just as in the case of a toxin like alcohol, so
in the case of a less tangible influence, the reason why one
individual succumbs under a stress which another easily with¬
stands must be found once more in the inherent, inscrutable,
yet necessarily existing quality of cerebral or mental constitu¬
tion, which neither psychologist nor neurologist has yet been
able to appraise or demonstrate.

In venturing to bring before this Association the results of
this statistical study I feel bound to emphasise their purely
provisional character. I do not think that positive or definite
conclusions ought to be drawn from them, and have, therefore,
abstained from any such attempt. We must patiently await
the accumulated material of many years’ careful observation
and record before attempting to dogmatise from analogous
results. My aim has been far less ambitious. It was to en¬
deavour to awaken interest in the subject of the correlation of
causes, and above all to demonstrate the importance of full
and accurate records, in order that the collective investigation
of these facts may be as complete and thorough as possible.
It is difficult, indeed, I should think it very often impossible, to
obtain information which can be utilised for this purpose;
reticence and evasion in respect to such intimate matters as
family disease or personal habits are only too likely to operate
when the matter of inquiry is so sinister a one as insanity.
We may trust that education will eventually overcome the
prejudice that still surrounds the subject, and that many
obstacles to the ascertainment of the whole facts may thus be
removed.

May I finally mention what must be apparent to all, that
every such collective inquiry is imperfect by reason of the very
fact that it is collective. No two recorders can be of precisely
the same opinion in their estimation of evidence or the import
of a fact; there are bound to be differences, not only as to the
value of a fact in life-history, but even in such matters as the
precise significance to be applied to such terms as “ sudden,”
“ prolonged,” “ intemperance,” “ privation,” and the like. But
when due allowance is made for such differences, and when

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igio.]

BY SIDNEY COUPLAND, M.D.

time has, by the accumulation of data, tended to attenuate
those that do exist, we may hope eventually to elicit what we
are all seeking—the truth.

A ppendix.

The following tables contain all the data upon which the
paper has been based. Table I shows the total number of
instances in each sex in which separate Eetiological factors were
returned, including both those which occurred as the sole
ascertainable conditions in the history of the case, and those
which were in association with one or more other factors.
The relative frequency of the occurrence of these factors and
their groups is indicated by their percentage distribution, which
is also shown in the diagrams. Table II is limited to those
factors which were in correlation, the total instances correspond¬
ing to the totals of each of the columns in the correlation table
(6 yd Report Commissioners in Lunacy, Tables XVII and XVIII).
Tables III and IV give the correlated instances and their relative
frequency (correlation-rate) to the total instances of each of
eleven and thirteen factors in the male and female sex respec¬
tively. These tables are also illustrated in the diagrams, where
the unshaded figure in each series indicates the mean rate of
correlation of the factor concerned with respect to the total
number of groups in which its instances occurred ( 3 ). Tables V
and VI constitute an extension of the same analysis, so
as to include for each sex an additional number of factors and
their correlations with the selected factors.

(') Precise figures are unavailable; the estimate is based on the ratio of the
first attacks to total direct admissions.—( s ) This diagram has not been repro¬
duced; the detailed figures are given in Table II.—(■*) These mean rates differ
from those given above in the text, as in calculating them it was deemed advisable
to exclude all the figures assigned to Group C, owing to their comparative paucity.

LVI.

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18 THE CAUSES OF INSANITY, [Jan.,

Relative Frequency of Causes (or Antecedents) of
Insanity (First Attacks).

Table I.— Etiological Factors Alone and in Combination.

Groups of xtiological factors.

Total instances.

Percentage distribution.

Males.

Females.

Males.

Females.

a. Heredity:

I. Insane heredity (a)

1390

1739

142

174

2. Epileptic heredity

122

1*2

3. Neurotic heredity

»35

0-9

r 3

4. Eccentricity....

5. Alcoholism (b)

379-1979

387—2432

39 —20‘2

39 —242

b. Mental instability .-

1. Moral deficiency .

0*2

2. Congenital mental deficiency

197

217

3. Eccentricity....

34— 268

36— 281

0‘3 — 27

04 — 28

C. Deprivation of special sense :

1. Smell and taste .

—

2. Hearing ....

0'2

3. Sight .

26— 46

19— 49

0’3 — °‘5

0-2 — 0'5

D. Critical periods :

I. Puberty and adolescence (c)

248

310

2'5

3'I

2. Climacteric (d) .

638

3. Senility (e) .

650— 909

797—>745

66 — 92

79 —> 7'4

E. Child-bearing:

1. Pregnancy ....

—

2. Puerperal state (/)

—

390

—

3. Lactation ....

— —

122 — 609

- -

12 — 60

F. Mental stress:

I. Sudden mental stress ( g)

285

495

2. Prolonged mental stress ( h).

1144 — 1429

1370—1865

1 r6 — 14-5

137 — 18-6

G. Physiological defects and errors:

1 . Malnutrition in early life

o'i 5

2. Privation and starvation

>43

178

i '4

3. Over-exertion (physical)

065

4. Masturbation

162

i*6

0-3

5. Sexual excess

66— 447

22— 303

07 — 4'5

02 — 30

H. Toxic:

1. Alcohol (*) ....

1752

671

178

2. Drug habit ....

0 2

O'l

3. Lead and other such poisons

0-3

006

4. Tuberculosis

o*8

064

5. Influenza (k)

249

208

2'5

2*1

6. Puerperal sepsis .

—

025

7. Other specific fevers .

4 i

4 «

°'4

8. Syphilis, acquired (/) .

697

7 'J

095

9. Syphilis (congenital) .

0-15

10. Other toxins

32—2913

48 — 1189

03 —295

045—11'8

1 . Traumatic:

1. Injuries ....

332

3’4

2. Operations ....

°'3

0'6

3. Sunstroke ....

57 — 419

11— 144

06 — 43

o'1 — 1 - 4

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Original from

PRINCETON UNIVERSITY

i 9 io.]

BY SIDNEY COUPLAND, M.D.

Table I— continued.

Groups of aetiological factors.

Total instances.

Percentage distribution, i

Males.

Females.

Males.

Females, j

K. Diseases of nervous system :

I. Lesions of the brain

197

*47

205

|'5

2. Lesions of spinal cord and

nerves ...

3. Epilepsy (m)

479

350

4. Other defined neuroses fhys-

teria, etc.) ....

106

O'S

1*0

5. Other neuroses in infancy

or childhood

5 — 79 ^

12— 643

005— 8'2

01 — 63

L. Other bodily affections :

1. Anaemia, etc.

15 *

025

*'5

2. Cardio-vascular degenera-

tion (n) ....

304

244

3 '*

3. Valvular heart disease

13°

4. Respiratory system

5. Gastro-intestinal system

045

0*6

6. Renal and vesical system .

7 *

7. Generative system (exclud-

ing syphilis)

o «5

8. Other general affections, as

diabetes, myxeedema, etc. .

45— 625

69— 802 o'45— 6 4

Total ....

983 «

10062

IOO'O

100*0

Table II .—Combined ^Etiological Factors.

Groups of etiological factors.

Total instances.

Percentage distribution.

Males.

Females.

Males.

Females.

A. Heredity:

166

1. Insane heredity (a)

1404

1615

148

2. Epileptic heredity

'56

190

i*6

2*0

3. Neurotic heredity

• 3 °

172

*'4

i 8

4. Eccentricity

o '3

5. Alcoholism {b)

575—2297

578—2621

6-1—24'2

6‘o —27-1

B. Mental instability :

1. Moral deficiency .

0-4

2. Congenital mental deficiency

25 *

289

2*6

3. Eccentricity

35 — 338

37 — 363

0-4— 3'5

°'4 — 3 ’ 8

c. Deprivation of special sense:

1. Smell and taste .

—

0*02

2. Hearing ....

046

3 - Sight.

29— 57

22— 69

o'3— 0'6

0'22— 07

D. Critical periods:

1. Puberty and adolescence (c)

267

306

3'2

2. Climacteric (d) .

Z I

576

0*1

6*0

1 Senility [e) .

473 — 75 *

520—1402

5 0- 7 9

5'4 —*46

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20 THE CAUSES OF INSANITY, [Jan.,

Table II— continued.

Groups of setiological factors.

Total instances.

Percentage distribution.

Males.

Females.

Males.

Females.

E. Child-bearing :

I. Pregnancy ....

0-8

2. Puerperal state (/)

—

224

—

3. Lactation ....

- -

Ill— 415

- -

1*1 — 4*2

F. Mental stress :

1. Sudden mental stress (g)

196

404

2. Prolonged mental stress (h)

871—1067

1034—1438

9-2—11-3

10 7 —149

G. Physiological defects and errors:
I. Malnutrition in early life

0-25

2. Privation and starvation

177

197

185

3. Over-exertion (physical)

7 '

4. Masturbation

162

o ’3

5. Sexual excess

S9— 500

30— 368

09— 52

03 — 37

h. Toxic:

1. Alcohol (i) .

'497

615

15-8

2. Drug habit ....

0*2

0*1

3. Lead and other such poisons

0-3

0*1

4. Tuberculosis

5. Influenza (k)

190

172

i-8

6. Puerperal sepsis .

—

015

7. Other specific fevers .

8. Syphilis, acquired (/) .

674

122

7 »

I'2

9. Syphilis, congenital

01 5

10. Other toxins

39—2603

61—1149

°' 4 — 2 7'5

06 —ir8

I. Traumatic:

1. Injuries ....

287

3 ‘o

2. Operations ....

o -35

3. Sunstroke ....

63— 334

8— 127

07— 405

01 — 13

K. Diseases of nervous system :

1. Lesions of the brain

163

'39

i ’4

2. Lesions of spinal cord and
nerves .....

3. Epilepsy (m)

375

274

4 '°

4. Other defined neuroses (hys¬
teria, etc.) ....

5. Other neuroses in infancy or
childhood ....

'37

' - 4

8— 672

20— 599

O'l— 7-1

02 — 61

L. Other bodily affections :

1. Anaemia, etc.

210

o '35

2*2

2. Cardio-vascular degenera¬
tion («) ....

456

387

4-8

3. Valvular heart disease

105

184

I I

4. Respiratory system

5. Gastro-intestinal system

6. Renal and vesical system

116

1*2

7. Generative system (exclud-
ing syphilis)....

l 7

0*2

°'5

8. Other general affections, as
diabetes, myxoedema, etc.

49— 821

74—1127

05— 8-65

08 —ir8

Total ....

9490

9678

1000

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Original from

PRINCETON UNIVERSITY

Table III. Combinations of Selected Aitiological Factors.

Males.

1910 .]

BY SIDNEY COUPLAND, M.D,

2 I

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Table IV .—Combinations of Selected JEtiological Factors.

Females.

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22 THE CAUSES OF INSANITY, [Jan.,

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Original from

PRINCETON UNIVERSITY

Table V. —Further Combinations of Selected Factors.

Males.

1910 .]

BY SIDNEY COUPLAND, M.D,

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PRINCETON UNIVERSITY

IOOO IOOO i IOOO i IOOO IOO'O 100*0 IOOO 100*0 IOOO 100*0

Table VI._ Further Combinations of Selected Factors.

Females.

THE CAUSES OF INSANITY. [Jan.,

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PRINCETON UNIVERSITY

0.001 0.001 0.0011 0.001 0.001 0.001

i 9 io.]

ALCOHOLIC INSANITY.

Alcoholic Insanity (Korsakow's Polyneuritic Psychosis):
Its Symptomatology and Pathology. By John
Turner, M.B., Senior Assistant Medical Officer, Essex
County Asylum.

Introduction.

(1) Definition of Alcoholic Insanity.

There are certain persons who, having taken alcohol to
excess, develop a form of insanity characterised by distinctive
features, clinical and pathological. [This is the form which I
mean by “ alcoholic insanity.”]

There is a far larger number of persons in whom various
forms of insanity are associated with drinking habits ; but these
forms present no characteristic features either clinically or histo¬
logically, and unless the fact of indulgence in alcohol can be
established by inquiries into the personal history of the patient,
it would be impossible from a study of the case alone, in my
opinion, to adduce alcohol as the causative factor.

It is this larger class which I am unable to look upon as of
alcoholic origin in the sense that alcohol was the causative
factor.

What are the distinctive symptoms in a case of alcoholic
insanity ?

In my opinion it is only when a case presents the symptoms
described by Korsakow as polyneuritic psychosis that we are
justified in asserting that we are dealing with a case of alcoholic
insanity. I know that it is generally asserted that Korsakow’s
disease is only one of the forms by which alcohol displays its
deleterious action on the nervous system, and further that
Korsakow’s disease is not necessarily the result of alcohol.

As regards the first of these points, if it be allowed that
alcohol is capable of producing a definite form of insanity, a
form which can be diagnosed without a reference to past habits,
and which can be recognised after death by characteristic
appearances, then in default of these criteria the burden of
proving that alcohol may also cause various forms of insanity,
which we frequently meet with in persons in whom one can

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26 ALCOHOLIC INSANITY, [Jan.,

with certainty exclude this factor, rests with those that make
the assertion.

As regards the second, my experience fully bears out
Ascherson’s (i) statements that “hard drinking has a share
in the aetiology of Korsakow’s disease in an overwhelming
majority of the cases,” and “ a more careful investigation of
the histories of the non-alcoholic cases would only serve to
swell the number of the alcoholic at their expense. In typical
cases alcohol can never be excluded.”

I can recall one case of polyneuritic psychosis in a young
woman suffering from pulmonary tuberculosis, apparently, from
her own account, a model of propriety and sobriety, and with
none of the physiognomical stigmata of alcohol, and unless I
had been fortunate enough to obtain from a trustworthy source
the true state of affairs, which was a life of drunkenness and
immorality, this would have been included under the head of
polyneuritic psychosis of non-alcoholic origin, and probably as
due to tubercle.

(2) The Relationship of Alcohol to Insanity.

This appears to be of a three-fold nature :

(1) Coincidental .—That such a relationship should occur in
many cases appears to be unavoidable when we consider the
very large number of people who consume alcoholic drinks in
some one or another form.

(2) Sequential .—The drinking of alcohol in most people
produces a momentary pleasurable sensation, followed by a
more remote feeling of well-being. So that it can easily be
perceived why those in whom the highest inhibitory powers are
deficient will be especially prone to over-indulgence. Under
this heading come the Jane Cakebreads, who spend their time
between the gin-shop and the prison, weak-minded persons
or moral imbeciles unable to resist the attractions of alcohol,
under the action of which they become a nuisance to the com¬
munity. With such the alcohol is not the cause of the insanity,
but the insanity is the cause of the drinking habits.

(3) Causal .—Here the drinking habits produce in certain
predisposed cases a series of characteristic symptoms and a
specific lesion of the nervous system, and from my point of
view unless these symptoms or histological appearances can be

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i 9 io.]

BY JOHN TURNER, M.B.

2 7

shown one is not justified in labelling every case where over-
indulgence in alcohol can be proved as alcoholic insanity.

Numbers I and 2 make up by far the larger bulk of the
cases in which alcohol is related to insanity, and account for the
large percentage of cases of insanity which are wrongfully
attributed to alcohol. As a matter of fact, as a causal factor
in insanity it plays a comparatively insignificant role , 3 to 4
per cent, in women, and probably about the same proportion or
rather less in men I find in the Essex County Asylum, whilst
Dawson (2) puts the percentage of mental disease really attri¬
butable to alcohol at about 10 per cent.

As regards the various forms which authors describe as
alcoholic psychoses, acute hallucinosis, chronic hallucinosis,
alcoholic paranoia, and pseudo-paresis, etc., there seems to be
very little accord among them as to what constitute diagnostic
symptoms. And those which some of them give as such
appear to me singularly inadequate.

Chotzen (3) emphasises the difficulty of differentiating the
alcoholic psychoses from others of non-alcoholic origin. Accor¬
ding to him the diagnostic features in acute hallucinosis are the
dominance of aural hallucinations, the absence of hypochon¬
driacal symptoms, and the tendency to recovery. Rut it is
probably within the experience of many who have had a large
acquaintance with lunatics that such a combination of charac¬
teristics may often arise without alcohol being a direct aetio-
logical factor.

Stoddart (4) describes a chronic hallucinosis, which according
to Chotzen is denied by some, at all events, as a sequel of acute
hallucinosis. This author also gives as the chief distinction
between alcoholic and true paranoia the absence of systematised
delusions in the former. None of these varieties, except per¬
haps some cases of so-called pseudo-paresis, which more pro¬
bably are cases of polyneuritic psychosis with gross brain
lesions the result of arterio-sclerosis, show any characteristic
pathological changes, and none, I contend, are capable of being
diagnosed as alcoholic in default of a previous knowledge of
alcoholic indulgence in the patient. No doubt in all these
forms alcohol may be the exciting cause, in the sense that it
has served to overturn an already tottering nervous system, but
what I contend is that it is not a specific but an accidental
stress, insomuch as such cases if subjected to other equally

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ALCOHOLIC INSANITY,

[Jan.,

powerful stresses would develop similar mental disturbances,
and therefore there is nothing in the nature of the symptoms
or in the pathological anatomy to point specially to alcohol as
the exciting cause ; whereas in true alcoholic insanity both the
symptoms and the pathological anatomy present characteristic
features.

In spite of the desire of ardent teetotallers to prove the
injurious effect of alcohol on the nervous system, the balance
of evidence is in favour of the view that it only in a very small
proportion of cases can produce permanent and demonstrable
effects on the nervous tissues, although, as is self-evident, it can
in anyone induce a temporary interference with the conduc¬
tion of nervous impulses.

In the majority of drinkers alcohol appears to exert grave
toxic effects on other viscera whilst sparing the nervous
system. The point of least resistance in most alcoholics is
not the brain but the kidneys, the liver, or the blood-vessels.

( 3 ) Alcohol unable to Initiate Insanity except in Certain Pre¬
disposed Subjects.

This is shown by the fact that although drinking to excess
is very common in the community, the percentage of cases
which develop insanity under the influence of this stress is
very small. Probably not one person in a thousand who drinks
to excess develops alcoholic insanity, but if alcohol was by
itself an effective toxic agent in this direction then all who
indulge in it to excess would suffer. Hence it is obvious that
among the cases which succumb to alcohol in the direction of
insanity we must seek for another—a predisposing factor.

We may postulate this other factor to be an initial or inborn
instability of the nervous system, or in other words a con¬
genital structural defect of this tissue.

When treating of the pathological appearances met with in
the brain in cases of alcoholic insanity, I shall point out that
in more than half the cases we can demonstrate a form of
nerve-cell which with great probability represents immaturity of
structure.

The deleterious effects of alcohol are far more liable as
previously mentioned to affect other viscera than the brain.
To take one instance, whilst outside asylums a certain form of

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BY JOHN TURNER, M.B.

cirrhotic liver is looked upon as almost pathognomonic(*) of
alcoholic excess, this lesion, as F. W. Mott (5) has pointed out,
is very rarely met with in insane alcoholics, so that Mott has
asserted that it is only persons with an inherently stable
nervous system who can drink long enough to acquire advanced
alcoholic cirrhotic liver.

(4) The Relationship of Delirium Tremens to Alcohol

Poisoning.

It is well recognised that delirium tremens is apt to
develop in heavy drinkers after the sudden deprivation of
alcohol, and also that it may appear in a case of alcoholic
insanity weeks or even months after residence in an asylum.
Ascherson (1) refers to the likelihood of symptoms of delirium
tremens appearing in a case of Korsakow’s disease during the
night at any time during the course of the case. There¬
fore it seems impossible that the toxic effects of alcohol can
account for this phenomenon.

Bonhoffer (6), Kraepelin (7) and S. Cole (8) believe that
delirium tremens and Korsakow’s disease are but different
forms of the same affection. There is a good deal to be said
for this idea, but as delirium tremens is, as its name implies, an
acute delirious condition, whilst alcoholic insanity is not
necessarily so and in very many cases runs a chronic course
without any acutely delirious episodes, I am disposed to
believe (in common with these authors) that delirium tremens
is set up by the accumulation of some toxin or toxins not
directly alcoholic, but produced and liberated under certain
conditions by the injurious effects of alcohol on the general
bodily metabolism, forming a common but not inevitable
accompaniment of alcoholic insanity in much the same way as
the congestive seizures in general paralysis.

Wassermeyer (9) does not favour the view that it is of this
nature, but looks upon it rather as an exacerbation of chronic
alcoholic poisoning.

It should be noted that delirium tremens is liable to occur
in cases which do not show any symptoms of insanity. These
are cases which lack, I believe, the inherent mental instability
necessary for the production of alcoholic insanity.

(*) From time to time doubts have been expressed as to the causal relation of
hob-nailed liver and alcohol. See a letter in Brit. Med. Journ., November 2nd,
1907, by Dr. H. B. Donkin.

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30 ALCOHOLIC INSANITY, [Jan.,

The occurrence of high temperature in delirium tremens
with no discoverable extra-cerebral cause was described by
Magilan and later by Alzheimer (10). I have met with two
cases myself. Unless these cases can be looked upon as
fulminating forms of polyneuritic psychosis, their existence
tends to show that delirium tremens of itself may be a fatal
disorder and that it is not necessarily associated with poly¬
neuritic psychosis.

(5) The Diapiostic Sign of Alcoholic Insanity — Neuritis.

The dominating features in the cases which I describe as true
alcoholic insanity are symptoms referable to an interference
with the passage of nerve impulses along the nerve-fibres,
either peripheral or central.

To these symptoms I would apply the term “ neuritic.”
Adolf Meyer (11) has already pleaded for an extension of the use
of the term to all degenerated conditions with decay of myelin
sheaths of any nerve-unit. And for the sake of convenience I
have termed all symptoms neuritic which point to an interfer¬
ence in the passage of nerve currents, whether this interference
is only temporary and not accompanied by histological changes
in the nerve-fibres, or permanent and histologically demon¬
strable ; and also whether it affects the peripheral nerve-tracts
(sensory or motor) or the central in the spinal cord and
cerebrum up to the highest associational tracts.

From this point of view I maintain that all cases of
alcoholic insanity are accompanied by—nay I would add, are
the result of—neuritic changes, and from a comparison of the
symptoms in alcoholic insanity with those observed transiently
in every attack of drunkenness the similarity between the two
is easily appreciated, and some further evidence is derived in
support of the contention that alcohol is responsible for these
symptoms in both cases.

Similarity between the Symptoms of Drunkenness and the Sym¬
ptoms of Alcoholic Insanity.

In the temporary alterations produced in the nervous
system during every attack of drunkenness are foreshadowed
the more permanent changes which occur in alcoholic insanity.
These are, on the physical side :

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BY JOHN TURNER, M.B.

(1) Thickness of speech. —The affected individual’s mental
sphere may be unclouded and he may be capable of making
strong but unavailing efforts to enunciate clearly. This con¬
dition indicates that the central apparatus, the nerve-cells pro¬
bably or the nerve-cell region, is in a condition to function, but
that the nerve-cell branches—the nerves—fail to convey the
cell impulses. I think we are justified in seeking for an ex¬
planation in interference with neural action and not muscular,
as w’e have no data to show that muscle actions under acute
alcoholic excess are in default, and we see that the involuntary
muscles still perform their duty naturally.

(2) Inco-ordination of gait. —Here also the symptoms may
be w'ell marked at a stage when the mental sphere is relatively
unclouded. The subject may be able to correctly appreciate
his condition, and to make strong efforts to overcome the
failure, but ineffectually. The striking parellelism between
this inco-ordination of gait and that which follows as a result
of polyneuritis w’ould appear to warrant our regarding both as
essentially similar in nature, only in one the interference in the
conduction of peripheral impulses is temporary and leaves on
its disappearance no discoverable histological alterations ; in
the other the interference is more or less persistent, and has a
definite and demonstrable histological basis.

(3) General blunting of sensation. —A later phenomenon which
co-exists with or follows the well-knowm psychical effects of
alcohol referred to by some French writers (Chapin, etc.) as
psycho-sensory anaesthesia. This phenomenon, including a
deadening of sense of fatigue as well as of pain, finds its
parallel in the frequency with which anaesthesia or analgesia is
found in alcoholic insanity and degenerative changes in the
posterior columns of the cord.

(3 a) Muscular hyperccsthesia. —Hill Buchan (12) notes the
frequency with w r hich in the acute stage of an alcoholic attack
there is a degree of sensitiveness to pressure in the calves which
often passes off in a few days.

(4) On the psychical side the analogy is continued in the
silly jocularity of one stage of drunkenness, the irascibility of
another, the excessively emotional condition of a third ; and
the paramnesic troubles of alcoholic insanity find their counter¬
part in the almost instantaneous forgetfulness which so many
drunkards display at some period of their debauch.

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32 ALCOHOLIC INSANITY, [Jan.,

This similarity in the symptoms between intoxication and
certain forms of insanity in which there is a history of alcoholic
excess, is in favour of the idea that alcohol is capable of pro¬
ducing a special form of insanity presenting the symptoms met
with in every attack of drunkenness. And further, in the absence
of these symptoms, we are entitled to doubt the validity of the
claim of alcohol as the causative factor in an attack of insanity
merely because the subject can be shown to be addicted to
alcoholic excess. We do not recognise special forms of insanity
of adverse circumstances, tobacco or puerperal insanity, etc., on
the sole ground that these stresses occur in association with
insanity affecting a numerous class.

In the same way I desire to eliminate from true alcoholic
insanity those cases in which alcohol as the exciting cause has
acted merely as a general stress and to include only those cases in
which it has been a specific stress, giving rise to characteristic
symptoms and characteristic changes in the nervous system.

Symptomatology.

The mode of onset is frequently sudden, that is, after perhaps
years given to excessive alcoholic indulgence. Ascherson (1)
found this to be the mode in 36 per cent, of the cases of
Korsakow’s disease which he investigated, and he found that
in the cases showing multiple neuritis the onset was more fre¬
quently gradual, and that the mental symptoms may either
precede or follow the neuritis. According to his figures the
mental symptoms succeeded the neuritis in 28, developed with
it in 21, and preceded it in only 7. In several of my cases
signs of peripheral neuritis were absent or, at all events, not
detected on admission to the asylum, but developed later on,
sometimes several months after the total deprivation of all
alcoholic drinks. Not infrequently (i6‘6 per cent, according to
Ascherson) the symptoms follow directly after an attack of
delirium tremens.

Epileptic or epileptiform attacks may precede the mental
symptoms or develop during the course of the disease. In 114
cases of mine they were noted in 11 instances (9‘6 per cent .)—
5 times preceding an attack and 6 times during an attack.

Ascherson found the onset was of an epileptic nature in 1 5
per cent, of the 126 cases he collected, and that in 20 per cent.
an epileptiform attack occurred during the course of the malady.

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BY JOHN TURNER, M.B.

A. Physical.

Physiognomy .—As a rule there is a characteristic alcoholic
countenance, but although this is familiar to both lay and pro¬
fessional observer, it is very difficult to place the finger on this
or that feature which forms or helps to form this type. Apart
from expression, the coarse capillary injection of the cheeks
and of the nose especially and a somewhat dusky livid hue of
the lips are very characteristic of the drinker. The general
expression in a great many is one of silly self-satisfaction with
a fatuous smile, which may be blended with a look of astonish¬
ment. A few, and generally the less typical cases, display an
expression of fear or apprehensiveness. I think, perhaps, the
most characteristic marks are centred around the mouth muscles;
there is a curious looseness and indecision of the lips, and in
instantaneous (-^ sec.) photographs the lower lip, whilst talk¬
ing, appears blurred owing to a fine tremor, which may often be
unappreciable to the unaided eye. Sometimes there is a slight
symmetrical ptosis giving a drowsy expression. Asymmetrical
conditions in the working of the muscles of expression, especi¬
ally in the upper zone of the face, are common.

The facies of the female subject of alcoholic insanity is much
more characteristic than that of the male.

Gait is only affected in subjects with peripheral neuritis of
the lower limbs, and with these it is unsteady and waddling,
with feet widely separated from the middle line, and a great
tendency to fall or stumble, especially in the act of turning.
With these conditions Rhombergism is almost always present
although the knee-jerks may not be absent.

Deep reflexes .—Very valuable information is obtained as to
the nature of the disease from the state of the tendon reflexes,
especially the knee-jerks, and at the outset it may be stated
that a case of insanity where the knee-jerks are absent or very
slight, without the association of persistent Argyll-Robertson
pupils, should always raise a suspicion of alcoholic causation in
the mind of the examiner. In 68 of my cases the knee-jerks
were present, normally or to an exaggerated degree, in only 2r.
In the remainder (70 per cent.) they were either very slightly
marked or absent (in 39, or 57*3 per cent.).

In most cases there is a parallelism between absence of knee-
jerks and inco-ordination of gait, generally with the accompani-

LVI. 3

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34 ALCOHOLIC INSANITY, [Jan.,

ment of alteration in the sensation of the lower limbs; but this
is a rule to which there are many exceptions. Thus in 13
instances where the knee-jerks were very slight or absent, the
gait and sensation were apparently unimpaired. On the other
hand, in 2 1 instances where the knee-jerks were present, in 8
the gait was unaffected, in 10 it was affected, and in 3 there is
no note as to its state.

In 9 cases the knee-jerks, absent on admission, gradually
returned to a normal condition after admission to the asylum,
and therefore after deprivation of alcohol, but in 3 cases a
reverse condition occurred. This tends to show that the
absence in all cases cannot be directly imputed to the alcohol ;
probably it may be a secondary result of vascular nature
(endarteritis of small arteries?).

In 8 cases the knee-jerks remained after a more or less
lengthy residence in the asylum, as on admission, absent, but
the gait, which had been affected, became normals It is not
uncommon to meet with temporary alterations, e.g., they may
be absent, re-appear, and again disappear.

Ankle-jerks. —Dr. R. T. Williamson (13) states that loss of
the ankle-jerks is one of the first signs of the injurious action
of alcohol on the peripheral nervous system, often disappearing
long before the knee-jerks. Since I saw this statement I have
from time to time tested all my cases for this symptom, but so
far I have notes only concerning 13. In 3 it was absent along
with absence of knee-jerks. In 3 it was absent when the knee-
jerks were present. In 2 it was present when the knee-jerks
were absent. In 4 it was present when the knee-jerks were
present, and in 1 case it was present in one foot only when
both knee-jerks were slight. These numbers are small, but so
far as they go they do not seem to any great extent to coincide
with Dr. Williamson’s results. Dr. A. Hill Buchan (12), in
alcoholic cases associated with neuritis, found the ankle-jerks
increased in 4 and absent in 19.

Pupils .—My experience quite coincides with Ascherson’s (1)
results. He found the most common condition was a sluggish
reaction to light, and remarks that the special feature of the
pupillary disturbance is that it is “ transitory and varies much
in intensity from day to day; a constant Argyll-Robertson
pupil is, in my opinion, never found, and should always lead to
a suspicion of tabes dorsalis or general paralysis.”

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The condition of the pupils in 68 of my cases was as follows :

(1) They were unequal in 26^4 per cent. \ sometimes the right,
sometimes the left was the larger, and sometimes the inequality
shifted on different days from side to side.

(2) They reacted either very slightly and sluggishly to light
or were rigid in 34*2 per cent ., but this condition was in most
cases only temporary. Thus in 8 cases where they appeared
at one time quite rigid to light the condition was temporary in
6 ; in i it developed after admission, and as the patient was
shortly removed to another asylum the further state could not
be recorded, and in the last case it was noted on admission,
but no further note as to the condition is made in the later
reports.

Sensation .—Testing for sensation among the insane is always
a somewhat difficult and unsatisfactory proceeding, as owing
either to mental dulness, defective intelligence, inability to fix
the attention, or excitement, there is always uncertainty as to
the accuracy of the replies, and this difficulty is most felt,
perhaps, in alcoholic cases, associated as they are with amnesic
troubles, great emotionality, and a great tendency to untruth¬
fulness. For these reasons the results obtained can only be
regarded as approximations to the truth.

The cases were tested for the temperature sense by hot and
cold tubes, for light contact by cotton-wool, for ordinary tactile
sense by the finger touch, for pain by pricking, and the accuracy
with which they could localise impressions was also noted, as
also the presence of anomalous subjective sensations. Nothing
abnormal was noted in 18 out of 48 cases ; in the remaining
30 (60 per cent.) some defect was encountered.

(a) The most commonly observed defect was some degree of
anaesthesia or analgesia, which was noted in 18 cases.

(b) Hyperaesthesia was noted in 10.

In a few cases where anaesthesia was found at one period,
hyperaesthesia was found later on, or vice versd.

( c ) Subjective sensations such as numbness, formication, pins
and needles, or tenderness in the calves were present in 9
cases, and in 2 besides a feeling of pins and needles was met
with in the hands only.

( d) The temperature sense was found to be unaffected in
all but one of the 21 cases tested, and in this case at one
period the cold tube was called hot but the hot tube was

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correctly appreciated, but at a later period no anomaly was
detected.

(e) The kinsesthetic sense was tested for in only 4 cases
and was normal in all of them.

Quinquaud described a sign observed by him in chronic
alcoholics in 1893. It is elicited by the patient placing
the extended ring and middle fingers so that their tips rest
with gentle pressure against the observer’s extended palm.
During the first few seconds nothing is noticed, but then one
feels slight taps as if the bones were striking against one
another and the observer’s palm.

Ftirbringer (14) and Hoffman (15), who investigated the
subject among large numbers of people, arrived at fairly con¬
cordant results, viz.:

(1) That people in whom it is absent are in all probabilities
not drinkers in the ordinary acceptation of the term.

(2) In a slight degree the presence of the sign does not
justify the assumption of alcoholic abuse.

(3) A strong degree of phalangeal crepitation points with
great probability to a drinker (in the proportion of 3 to 1 in
the opinion of Hoffmann).

(4) The sign is of more value diagnostically than either
tremor of the hands or tenderness of the calf muscles.

(5) It is less marked in women than in men.

Whilst Ftirbringer believed that the sounds were produced
in the finger-joints, Herz (16) believes that they are occasioned
by very slight separations of the digital flexors from their
sheaths, the tendons at the same time being in a state of
tension.

From my own limited experience of this test among women
I am not inclined to attach much importance to it alone, but
taken in conjunction with other suspicious signs it may help to
form a correct diagnosis in some doubtful cases. Whilst its
presence is suggestive of alcoholic abuse, its absence by no
means excludes this factor.

In 19 cases of alcoholic insanity I tested for it, usually
at different times during the progress of each case ; it was
absent in 8, well marked in 5, and slightly marked in 6.
Sometimes I could obtain it only in one hand, and sometimes
on different occasions of testing it would be the right and then
the left or vice versd. As some of the cases were not tested

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till after a more or less lengthy residence in the asylum,
varying from a few months to three years, and therefore
during all this period without alcohol, the large proportion of
cases in whom I failed to get it may not be surprising, but it
was well marked in some of those who had been longest here,
and on the other hand in a case of delirium tremens it was
absent on admission and when tested for twice later on. In
some it seemed to vary very capriciously, eg, it was only
slightly marked seven months after admission and absent the
following month in one woman who was shortly after discharged.
During her absence she drank heavily and was brought back
having severely cut her throat ; on re-admission the sign was
not obtainable, but four months later it was present in both
hands, and again four months later it was absent.

Blood-pressure .—According to my experience, which is at
variance with Ascherson’s on this point, the tendency is for the
blood-pressure to be raised, often to a very marked degree ; in
some it remains within normal limits and in a small minority it
is persistently low. There seems to be no definite relation
between the mood and the height of pressure, and the cases in
which the mood is continuously euphoric may be associated,
and generally are, with extremely high tensions.

This condition of the pressure is only what might be antici¬
pated considering the frequency of granular kidneys, cirrhotic
conditions of the liver and thickening of the walls of the blood¬
vessels, which are so often found at the autopsy in these cases.
I have records of the systolic pressure from 26 cases taken
daily for a week or fortnight and at different periods in
the disease. Twenty-one of these cases were between the ages
of thirty and fifty-nine, and in 12 (or 57 per cent.) the
average pressure was high (above 130 mm. Mg. up to 200 or
more). The mood was markedly euphoric in 9 out of these
12 ; in only one was it depressed. In 7 (33 per cent.)
the average pressure was within normal limits (1 10 to 1 30),
and the mood was euphoric in 6 of these. In only 2 was
the average pressure low (below 1 1 o).

In 5 cases sixty or more years of age the average
pressure was extremely high in 3 (191, 218, 284) and the
mood was euphoric in 2 and depressed in the third. In the
remaining 2, considering their age, the average pressure was
within the normal limits.

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Blood .—A differential count of the leucocytes was made in
nine typical cases, in each case for fourteen consecutive days.
The only difference from the normal standard appeared to be
a slight diminution in the number of polymorphs and increase
in the number of lymphocytes. But when these results were
compared with the differential count in six control cases, taken
from apparently healthy and sane women whom I had no reason
to suppose were addicted to alcoholic habits, there was found
also in these latter a high lymphocyte count, although not quite
so high as occurred among the cases of alcoholic insanity. In one
only of the nine was the polymorph count increased, varying
between 10,000 and 12,000 per c.mm., rising on one day to
20,000. This woman was somewhat anremic and had been
several years in the asylum.

Of the two whose lymphocyte count ranged highest, one had
been in the asylum for some years, the other had recently been
admitted.

In the annexed chart is shown the average curves in the
nine patients (continuous line) and those for the six controls
(dotted lines).

The result of these examinations adds no fresh testimony to
the view that confusional insanity of alcoholic origin is of an
auto-toxic nature ; only one case showed a polymorphonuclear
leucocytosis, and that not of a very marked character. The
lymphocytosis also when compared with the control cases is
too slight to have much significance, even if one were justified
in regarding lymphocytosis as evidence of chronic toxic
conditions.

Coagulation-rate .—In the same nine cases in which a blood-
count was made, the coagulation-rate was tested by Wright
and Paramore’s method ; and taking (at blood-heat) below 130
seconds as a quickened rate and between 130 and 150 as
normal, I found that it was slightly quickened in three and
normal in six. Lawson (17), who tested the blood in all
classes of alcoholic cases, found that in the great majority
there was no delay, but in a few cases with wet brain and
meningeal symptoms it was retarded.

Urine .—So far as my observations go the urine presents
nothing specially characteristic in alcoholic insanity ; it is
generally pale and with low specific gravity and contains a
trace of albumen in 57 per cent., but this percentage, although

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Chart i.

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40 ALCOHOLIC INSANITY, [Jan.,

it looks high, is not more than has been noted among the
insane generally. Ascherson found a trace of albumen in only
12 per cent, of his cases. The peculiar orange colour described
by Leopold Levi, and which this observer ascribes to an
excess of urobilin, Ascherson only found twice. French writers
appear to lay great stress on this character. I do not find any
mention of it in my notes, and, as I have just said, in the great
majority of cases the colour is pale.

The cerebrospinal fluid does not appear to show any
characteristic changes, but, so far as I know, too few cases have
been examined on this point to speak dogmatically. Wasser-
meyer records two cases where negative results were obtained,
the fluid being very clear and without lymphocytes. In two
cases of delirium tremens he found a slight opalescence but
no lymphocytosis. In two cases of mine, also, the fluid was
quite clear, devoid of cells, and, in fact, showed no departure
from the normal.

B. Mental.

The three cardinal symptoms are :

(1) Loss of memory.

(2) Disorientation to place, time and persons.

(3) Confabulation or pseudo-reminiscence,

and if these, or at all events the first two, are not present at
one time or another in the course of a case, one should be very
chary of diagnosing alcoholic insanity. Of very great diagnostic
significance also are the peculiarities of mood displayed by
subjects of this form of insanity.

I shall examine briefly these four symptoms in the order
named.

Loss of memory .—This is chiefly for recent events, and
according to Ascherson and others the defect usually coincides
with the duration of the patient’s illness; it is antero-grade as it
is called, and it is active, i.e., facts continue to be forgotten so
fast almost as they are acquired, and a very characteristic sign
of alcoholic insanity is shown by the inability of patients to
remember the date, which they have just been told and made
to repeat. If they do not instantaneously forget, it is only
necessary to divert their attention momentarily by plying them
with some other question. They cannot tell a few hours after

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what they have had for dinner, or what their occupation was
the previous day, or earlier in the present. They cannot find
their way about the building, or their own beds, months or
even years after residence in the asylum, and if asked to
perform some duty, probably forget all about it on their way
to carrying it out.

Wehrung calls attention to the fact that in Korsakow’s
disease (and he is speaking of the disease following alcohol),
total amnesia never occurs and isolated remnants of normal
memory are found.

In a very large number of cases the defect ultimately, after
a period varying from a few months to years, improves, or may
even apparently altogether disappear ; and also it should be
noticed that the defect may vary from day to day, so that on
some days it is difficult to detect, whilst on others it is very
pronounced. These peculiarities, besides serving to differentiate
it from the quite similar defect often noted in aged people,
senile amnesia, also point to the affection being at first a
functional one, although the small proportion of cases which
completely recover shows that it eventually takes on an organic
character, the length of time required for this change varying
in very wide limits in different cases. As Ascherson points
out, this condition of affairs coincides with the morbid anatomy
of the disease.

Disorientation in time and place or mental confusion. —The
patients have no idea where they are or whence they came ;
they cannot say how long they have been in the asylum, and
although they may only have come the preceding day, will tell
you that they have been there three or four months. Ofttimes
they cannot specify even approximately the time of day, and
will be talking of going to bed shortly after they have arisen,
or clamouring for their mid-day dinner late in the evening.
The disorientation as to place varies very much in different
cases : some imagine they are in a hospital or parish infirmary,
but in cases where the symptom is more marked they imagine
themselves to be still in the place from which they have just
come, or think they are still in their own home and speak of
having to get their husband’s dinner ready. Ascherson likens
this disorientation to a state of stupor or pathological sleep, or
rather to a very prolonged state of awakening from sleep.

Paramnesia - confabulation or pseudo-reminiscence. —I have

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42 ALCOHOLIC INSANITY, [Jan.,

notes of it in 42 out of 70 cases (60 per cent.), but it was
probably present in a larger proportion, for it is a symptom
very liable to be overlooked unless specially inquired for, and I
find that in my earlier cases which were not so strictly tested
for this point it is much less frequently noted than in the later
cases. Ascherson regards it as an essential feature of the
malady, and although he only records it in 70 per cent, of the
126 cases he collected, says that he has rarely seen an instance
of the disease in which it was absent.

Judging from my notes it most frequently takes the form of
erroneous accounts of recent visits to various places, or long
detailed accounts of shopping the day before, or allusions to
visits paid to public-houses, when the patient is very likely in
bed and unable to walk. References to having performed the
household duties that morning or the preceding day, getting
meals ready and attending to the children are very common.

Wehrung limits the term “ pseudo-reminiscence ” to the re¬
calling of imaginary events arising in conversation, when there
occurs to the patient some picture which he proceeds to
identify as an actual past experience—confabulation to the
fabrication which a patient uses to bridge over awkward gaps in
his memory.

It is very difficult to draw a sharp line of demarcation
between pure confabulation and ordinary delusions or halluci¬
nations. I can recall one case who, lying in bed and able to
enter into a connected conversation, would occasionally rap on
the wall, call out in a loud voice, “ Shop ! ” and then ask for
“ half a quartern of whiskey, please.” This difficulty is further
exemplified by the morbid ideas relating to sexual or maternal
instincts. No less than eleven women out of seventy (nearly I 6
per cent!) had erroneous ideas that they had babies or children in
bed with them, or that their husbands had been in bed with
them during the night and had just got up. All such instances
seem to me to partake largely of the nature of confabulation,
although they are generally classified under delusions.

Several hypotheses have been put forth to explain the dis¬
ordered nervous mechanism underlying paramnesia. Korsakow
suggested that owing to enfeeblement of mental power, external
impressions received and stored up in the memory cannot be
fully retained, but that traces of them remain ; the association
formed from these traces of memory, themselves imperfectly

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made, when again brought before consciousness in an act of
recollection constitute a false reminiscence.

Ascherson’s explanation is as follows : “ The stimulus
afforded by an impression from without alters the constitution
of those neurons which subserve the processes of ideation in
such a way that a free communication is opened up for the
passage of impulses from one of them to another ; thus an
association of ideas takes place and a concept is made. If the
original stimulus be sufficiently strong, it at the same time
incites into action certain higher neurones, whose function is to
control and inhibit ideation, and through the control so exer¬
cised communications are established only between a certain
fixed number of the lower neurons, and a limit is placed upon
the kind of association formed ; but if the original stimulus is
not strong enough to rouse the function of these higher
neurons, there is nothing to guide the impulses along any
definite paths, and either too few or too many communications
between the lower neurons are opened up. The associations
formed are therefore too scanty or too numerous and the
ideation faulty. These communications made at the time
between the lower neurons constitute paths of least resistance
for future mental operations ; therefore when a recollection
subsequently takes place it is a false one. The fundamental
fault is a failure of power, in this instance of power to control
or to inhibit the association of ideas.”

In accordance with my belief that the essential nature of the
lesion in alcoholic insanity is a blocking or impediment in the
passage of impulses along nerve-fibres, I venture to put forth
an explanation based on this assumption and on McDougall’s
(19) theory of inhibition by drainage. If we postulate that
there is an obstruction in the channels of communication
between the lower and higher neurons which Ascherson refers
to (or possibly between the higher neurons themselves), it will
result that an impulse arriving at the lower neurons finds its
further course upwards impeded by the obstruction before
mentioned, and it will tend consequently to spread along other
paths than those along which it normally does, and thus fresh
association paths are opened up and new and false concepts
ensue.

This explanation differs from both the preceding insomuch
as the fault is assumed not to lie in want of power in the initial

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impulse, but to an impediment in its course towards the higher
neurons. The following diagram will perhaps serve better
than long descriptions to make my meaning clearer. The dark
circles D , E, F, B, X, etc., represent a series of neurons on a

Chart 2.

lower level, and the clear circle C one on a higher level. The
impression from without sets free an impulse which normally
spreads to D and up to C. Although there are paths of com¬
munication with all the other neurons, yet because these paths
represent channels of greater resistance the impulse has origin¬
ally taken the path mentioned leading to D, and each repetition
of the impulse renders the resistance less and less along this
tract, and the path becomes more and more organised. The

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BY JOHN TURNER, M.B.

higher neuron C, which for the sake of clearness is represented
alone and which has communications on all sides like the lower
sends an impulse to the lower neuron E, because, as will be
explained further on, this happens to be the one which offers
least resistance, and the ultimate result of the impression is to
set up impulses along the efferent channels E and D, which
subserve the production of a normal concept. But supposing
there is a block in the channel between the upper and lower
neurons, then the impulse, instead of spreading upwards, flows
along the path of next least resistance to the neuron F, which
it discharges, and the final results of the impression in this case
are impulses flowing along the efferent channels D and F,
which subserve the production of an abnormal or false concept.

The theory of inhibition by drainage allows us to form a
conception why the initial impulse from B takes the path to D
rather than the other paths open to it. We must suppose that
D has recently been discharged, and during this process it
drains energy from all its branches towards the outgoing im¬
pulse along its axon, but this necessitates the lowering of the
resistance in (amongst others) the channel between B and D.
So that when B is discharged the impulse tends to spread along
the channel to D rather than along the other channels open to it.
And the same line of reasoning shows why a certain amount of
its energy is directed towards the higher neuron C, and why
from C a certain amount is sent to E.

The theory of inhibition by drainage supplies the only
physiological explanation which can at present be given to the
process of association, and it reduces all associations to ex¬
amples of association by contiguity.

Conduct and peculiarities of mood .—One half of my cases
presented euphoria, those in whom it was well marked dis¬
playing by their beaming expression and tendency to laugh at
everything their condition of entire self-satisfaction. Jocularity,
if one may use the word as a convenient one to express a
frame of mind which is continually, in season or out, pouring,
out silly and vulgar jokes and primed with all the popular
catch-words and phrases of the moment, is common, combined
with extreme garrulity. These cases are at the same time
highly emotional and easily moved to tears. Many are very
irascible, and apt on slight provocation to become rude,
impudent and abusive. It should be mentioned that Occasion-

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ally the euphoric mood is a late development, and may not
appear till some weeks or months after admission to the
asylum. Such cases may at the onset be acutely melancholic
or in a dull, heavy, lethargic condition. Finally there are
some who, although of a morose and sullen aspect, will often
surprise one by displaying a cynical humour of no mean
quality. It is true that the great majority of cases do not
give any special trouble in the asylum ; they can generally
attend to their personal wants. They are neat and show
considerable aptitude for work ; but nevertheless I cannot agree
with Ascherson that there is nothing in their conduct to justify
their being certified as insane. I am strongly of opinion that
asylum and prolonged treatment (in default of adequate special
inebriate homes) is the very best thing for them, as it certainly
is for their unfortunate relatives or offspring, and that they are
in every sense of the word certifiable lunatics. I would define
a lunatic, or at all events a certifiable lunatic, as anyone who
is more or less persistently and perniciously out of harmony
with his environment. And by the latter term I include all
those whose general conduct is prejudicial to themselves or to
the community.

All cases of alcoholic insanity come within the scope of this
definition. No one disputes the validity of a certificate which
consigns a person to an asylum solely because such a one is
actively suicidal. Much more, then, should there be no
cavilling at certificates which consign to an asylum persons
suffering from a form of mental disorder, not only harmful to
themselves and to their property, but demoralising to all those
with whom they have to live ; and a disorder which, unless so
treated, will almost inevitably go from bad to worse, resulting in
untold misery to children or other relatives, and not impro¬
bably injury or death to the subject. Ascherson refers to the
depressing and demoralising effect of asylum treatment. I
cannot speak on these points, because, notwithstanding a fairly
large experience of these cases, I have seen neither. And
although he considers that suicide is not likely to be appre¬
hended, one of the most determined suicidal patients I have
known was the subject of alcoholic insanity.

Although, as Ascherson remarks, in many cases there appears
to be a speedy restoration to sanity, at all events as regards
their behaviour, yet persons who are quickly discharged are

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almost sure to relapse when again exposed to temptation. The
histories which are often forthcoming in these cases show how
pernicious such people become when not properly looked after,
and the demoralising influence they must exert on young
children especially, in my opinion, would over-ride any sup¬
posititious demoralising influence which asylum surroundings
could exert on the subjects of this disease.

Psychiatric hospitals which Ascherson advocates for the
treatment of this complaint do not at present exist in England,
and if they did I do not believe they would lend themselves
for the favourable treatment of alcoholic insanity. The only
chance in my opinion to get lasting good results, and it is at
best a very slender one, is prolonged detention in an asylum
or inebriate home.

Before concluding this section on the symptomatology of
the disease I may add that Serbsky (20) has pointed out an
important characteristic which, according to him, serves to
differentiate Korsakow’s disease from other illnesses with like
symptoms, and this is the retention of the patient’s character
and personality.

Morbid Anatomy and Pathology.

One of the earliest, at all events among English authorities,
to deal exhaustively with the pathological anatomy of alcoholic
insanity was Bevan Lewis. It is evident, however, from his
clinical description of the disease that his conclusions are largely
based on cases which do not accord with the definition given in
the first part of this paper, and therefore, as is to be expected,
they do not to a large extent tally with the results that others
have obtained in Korsakovv’s psychosis nor with my own
observations.

Dr. Bevan Lewis (21) lays great stress on glial proliferation
(scavenger cells) in the first and lower layers of the cortex.
The brunt of the affection according to him falls on the nerve-
cells of the lower pyramidal and polymorphic layers, and takes *
the form of fatty degeneration, especially of the apices and
dendrites. He records an increase of nuclear elements around
the cells and vessels; atheroma and fatty changes in the
intima, small aneurysmal dilatations and plugging of the lumen
with emboli, and believes that the initial lesion is a vascular

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one—“ an extensive endarteritis of a most chronic and insidious
character.”

In the spinal cord it is in the region of the posterior columns
that changes are most manifest; these are increased vascularity,
thickening of vessel walls and collections of amyloid bodies.
The sclerosic change takes the form of a circular investment
“ originating in its investing membranes and creeping inwards
along the vascular tracts, and especially along the posterior
median raplu { ."

He regards the fatty changes in the nerve-cells as a more
acute process, and the sclerosic as the result of a much slower
and more gradual poisoning of the tissues.

Cole (8) has made a most careful and complete examination
of the nervous system, muscles, heart, etc., in three cases of
Korsakow’s disease. My results are practically in accord with
his, so that it will be unnecessary to quote from his description,
except on points in which his more thorough examination
included parts which I omitted to study.

I have examined the nervous system, liver and kidney in
twelve cases of the disease, and although my observations in
individual cases are much less complete than Cole’s, they cover
a wider range of cases, and if on this account alone possess a
value which observations, however thoroughly made on a very
limited number of cases, lack.

The naked-eye inspection of the brain shows, as a rule,
nothing of special interest. In eight cases there was more or
less marked atrophy, generally along the vertex and sometimes
implicating the parietal and frontal lobes in their entirety.
The membranes appeared natural to the naked eye in seven ;
in the other five there was slight opacity over the sulci, but in
no case was there adhesion to the cortex. The membranes of
one of the cases which appeared natural to the unaided eye
showed under the microscope endarteritis of its vessels.

The basal vessels were healthy in nine, atheromatous in two,
and calcified in one.

The routine microscopical examination of the cortex was
made from sections taken from the topmost part of the
ascending frontal, including the paracentral lobule. The tissues
were fixed in absolute alcohol, embedded in paraffin and stained
(in the earlier cases) by toluidine blue or Unna’s polychrome
blue. But in many cases sections from other parts of the

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JOURNAL OF MENTAL SCIENCE, JANUARY, 1910.

Fig. 1.

Fig. 2.

Fig. 4.

_. " > /~v, illustrate Mr

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John Turner's paper.

Fig. 5.

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BY JOHN TURNER, M.B.

cortex and from the cerebellum were also examined, and in
five cases the cortex was treated by a modified Marchi method
for changes in the tangential and other cortical and medullary
fibres, and for showing the presence of fatty degeneration in
the nerve-cells.

The ordinary Nissl preparations of the cortex show nothing
characteristic, not even the condition of the Betz cells or the
proliferation of nuclei around the nerve-cells and vessels. To
discover the lesions especially associated with alcohol we must,

1 believe, examine sections treated by methods which reveal
changes in the myelin sheaths, and we must carry out our
observations over a large area of the brain to get constant
positive results, because sometimes one area and sometimes
another is affected.

Meynert’s stria; are not interfered with. The first or outer
layer in seven cases showed a small spider-cell proliferation,
but not to anything like the extent either as regards numbers
or size of cells to that which is commonly seen in general
paralysis or cases of terminal dementia. In the sections stained
by osmic acid the body of these small cells was usually found
to be filled with small black stained (fatty) globules, and there
was either a marked diminution or total absence of the mye¬
linated tangential fibres. The second layer in five cases
appeared natural, the cells well formed and in good numbers,
but in one of these five some sections stained by osmic acid
showed that these apparently healthy cells were in a state of
well-marked fatty degeneration (Fig. i). This is not, however,
a general peculiarity in alcoholic cases, as other cases similarly
treated failed to show any such degeneration, and it is commonly
found in non-alcoholic toxic cases, e.g., acute delirious mania.
In the remaining seven cases changes were visible in the toluidin
blue or polychrome sections, which took the form of shrinking
and uniform dark staining with paucity in number. Such
changes, however, if one may judge from a single case stained
by osmic acid, were not associated with fatty degeneration.
The pyramidal cells (third layer) do not show any marked
structural changes, except where prolonged pyrexial conditions
or probable secondary toxaemic infection complicates the cases.
They are, however, often (six out of eleven of my cases) beset
with numerous little cells in their pericellular spaces (see fig. 2).
These little elements, the free nuclei, satellites or neuronophages
LVI. 4

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of different authors, differ in size and general appearance ;
many appear to be free nuclei, round or oval, densely stained
and 5 or 4 fx in diameter; many have a small quantity of cyto¬
plasm of a square or oblong shape attached to one side of the
nucleus, which stains with polychrome of a faint pinkish
tint (best seen by artificial light). The nuclei of these latter
cells are often somewhat larger and paler than the free nuclei,
and may show definite chromatin dots arranged around the
periphery or scattered irregularly throughout the nucleus. These
in all probability represent lymphocytes, and perhaps immature
forms of plasma-cells. A third variety is characterised by a
much larger (7 to 9/1) and clearer nucleus with a distinct
nucleolar dot and well-defined rim of cytoplasm. These I am
inclined to regard as endothelial nuclei, although, perhaps, some
of them represent the mesoglia cells of Ford Robertson.

The Bets cells .—Changes corresponding in appearance to a
state of axonal reaction were found in 7 of my 12 cases, and
in 2 out of 4 cases of delirium tremens. S. Cole found similar
changes in all 3 of his cases, and they have been observed by
Gilbert Ballet, Faure, Babinski, Chancellay, and others. Their
absence has been noted by H. W. Miller (22) in a case in
which a similiar change was present in the anterior horn cells.
Cole believes the change is brought about by the selective action
of secondary toxins. I (23) previously supposed that it was
a genuine axonal reaction secondary to neuritic changes in the
pyramidal tracts.

My further observations, however, on large numbers of all
forms of insanity lead me now to believe that both these as¬
sumptions are incorrect. I find (over 300 cases) that a similar
form occurs in 42 per cent. ; 70 per cent, in epileptics, 60 per
cent, in imbeciles (not epileptic), a similar proportion in cases
with marked melancholic symptoms, and only 20 per cent, in
general paralytics, and I have elsewhere stated my reasons for
regarding this form of cell as one indicating a condition of
defective development—an immature cell.

In my 12 cases of alcoholic insanity it was found in 7, or
5 8 per cent., a proportion therefore lower than it is met with
among epileptics, imbeciles, and melancholic cases, but higher
than the general average.

This form of change was also found in the anterior fore-
horn cells in 2 of the 9 cords examined, and in both of these

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it was only noted in the region of the lumbar enlargement.
The lower proportion here is quite in accord with my findings
concerning this form of cell in insanity in general, namely,
that it is much less commonly found in the fore-horn cells than
in the Betz cells.

The first 5 of my cases in which the cord w’as examined for
tract degeneration gave results which seemed in favour of the
view that the change was an early condition of axonal reaction,
for in the 3 cases where degeneration was found in the pyra¬
midal tracts the Betz cells showed this change, and in the 2
where no degeneration w-as found in the pyramidal tracts the
Betz cells did not show the change. In the 4 following cases,
however, although pyramidal tract degeneration was absent in
all, 2 of the brains showed the change in the Betz cells and 2
did not.

The strongest point against this being a true axonal reaction
is the comparatively early stage of what would constitute an
axonal change that they show in cases where it is known that
the pathological conditions are of old standing. When we get
a severance of the axon, as by haemorrhage into the centrum
ovale, in the course of fourteen or fifteen days the Betz cells
have passed into an advanced stage of alteration and are
shrunken, very pale, with no chromatoplasm, and a very small
shrivelled nucleus. So that it seems reasonable to expect that
an equivalent picture of advanced cell alteration would be met
with if a similar pathological condition {viz., destruction of the
axons) was at work in these alcoholic cases ; although the
probability must be borne in mind that an interference in
the continuity of the axon or its destruction remote from the
cell, as by pyramidal tract degeneration, may be followed by
slower and perhaps slighter changes than by a lesion of the
axon close to the cell. The experimental work on the pro¬
duction of axonal reaction has been chiefly done by plucking
out or cutting through the axons of the hypoglossal nerve quite
close to its cells of origin, and in haemorrhage into the centrum
ovale the lesion also would be quite close to the origin of the
axons of the Betz cells. I know that years after amputation
of a limb this change has been shown in the half of the cortex
corresponding to the limb movements, but the intrepretation
which has been put on this coincidence may need qualification
when it is seen how commonly a similar change is found in the
absence of amputation.

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The characters which constitute the immature form are
large, globose or swollen cells, with a finely granular condition
of the central chromatoplasm, whilst that in the dendrites, the
apex, and around the periphery of the cell-body retains its
usual character of large spindle-shaped bodies. The nucleus
is almost invariably displaced, lying either quite high up near
the apex or against one side of the cell, but it otherwise
appears to be in a normal condition. When we meet with cells
of this kind in which the structure of the nucleus is affected, so
that it is either small or crenated, dense or with ruptured
membrane, it is an indication that the immature cell has fallen
a victim to a super-imposed pathological change, and equally
so if the entire cell-body is small and of a pale ground-glass-
like aspect and the dendrites attenuated and lacking their
normal Nissl bodies, or if the whole cell-body and branches
stain deeply.

Although I believe that in the great majority of alcoholic
cases the axonal-like condition of the Betz or fore horn cells is
really an immature condition, the possibility must be admitted
that in those cases where morbid changes affecting the axons
of these cells are present, they may represent a real axonal
change. I am unwilling, however, to allow that degenerative
changes in remote parts of the axon are always effective in pro¬
ducing axonal reaction in the particular cells whose axons are
affected. A reference to the table on p. 56 shows that of the 9
cases where the cords and generally the posterior tibial nerves
were examined, in no less than 4 cases (Nos. 2, 5, 6, and 7)
there was no correspondence between the incidence of axonal-
like cells in the cortex and cord, and changes in the pyramidal
tracts or posterior tibial nerves. Cole also, it may be men¬
tioned, refuses to allow that the change is secondary to an axis-
cylinder affection.

In only 2 of my cases was the immature form uncomplicated
by added morbid modifications ; in one other, whilst on one side
the form was pure on the other it was not. And the most
common change found superadded to the initial defect of
structure was the darkly stained form which I described many
years ago as common in cases of acute delirious mania. This
was found in 6 cases. In 2 cases the cells were in the con¬
dition termed by Nissl “ acute cell change ” and by Marinesco
“ coagulation necrosis.”

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It has been asserted that the darkly stained cell referred to
above is also in this condition, but there is no justification for
such an assertion. In the experimental work on the production
of coagulation necrosis by subjecting animals to a high tempera¬
ture we in all likelihood get a pure form of this change, uncom¬
plicated, that is, by additional pathological factors, and as
Goldscheider and Flatau (24), two pioneers in this line of
research, show in their coloured plates and description, the
change is unaccompanied by any signs of dark staining. The
chromatoplasm forms into finer and fewer grains and loses to a
large extent its affinity for the stain, so that the cell appears
paler than normal, and finally the entire cell-body and even the
nucleus is stained a dull pale uniform blue or lilac (with poly¬
chrome). When as the result of pathological conditions
generally, but not always, associated with high fever, we find
coagulation necrosis in the human nerve-cells, a similar picture
is presented to that described in animals, but if, as sometimes
happens, they not only show an entire disappearance of visible
chromatoplasm but also stain deeply, we have here in all likeli¬
hood evidence that the morbid conditions giving rise to this
state of affairs are not simply those necessary to produce coagu¬
lation necrosis, but that in addition other and probably toxic
factors are at work.

In the change, however, which I termed dark staining of the
nerve-cells, and which occurs so often in these alcoholic cases,
the whole character of the alteration is distinct from coagu¬
lation necrosis, and in cells which prior to the alteration possess
normal Nissl bodies, these structures remain, so far as can be
seen, intact; the dark staining affects the between substance,
and may, and does, obscure the chromatoplasm, but there is no
appearance at any stage suggesting a disintegration or solution
of it. Thenucleus of the cell is increased in density up to complete
homogeneity with nearly black staining, and at the same time it
is shrunken generally in proportion to its density. The cells in
which prior to the dark staining change, there has been a defi¬
ciency of tigroid substance, as in immature forms, when they
become affected will of course show no appearance of Nissl
bodies in the darkly stained areas where it was originally
deficient, but they will be found apparently intact, but
obscured in the apex, dendrites, and periphery of the cell-
body. This darkly stained condition of the Betz cells was

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also found in one (perhaps two) of the four cases of delirium
tremens.

Dehio has described a dark staining of the nerve-cells in
experimental alcoholic poisoning (acute) in animals.

A large excess of pigment is often found, and in sections
stained by polychrome it usually appears of a bright yellow
colour, but in sections stained in osmic acid it generally
colours nearly or quite black, and is then probably of a fatty
nature.

The polymorphic cells show no constant or peculiar structural
changes, but around them is an even greater collection of
satellite cells than around the pyramidal cells.

Glia .—In none of the cases (excepting the very moderate
proliferation noted in a few cases in the first layer) was there
any increase in the glia. This corresponds with Cole’s experi¬
ence, but is markedly at variance with Bevan Lewis’s findings—
a discrepancy which I attribute to the inclusion among his
cases of many in which alcohol was only a coincidental or
sequential occurrence.

Vascular changes .—In 4 out of 11 there was a notable
increase in the perivascular cells. In 5 out of 11 the cortical
arteries were thickened and in 2 of these endarteritis was noted.
In 3 there were small cortical haemorrhages.

Before leaving the brain I may mention that two Italian
observers (25) have recorded an alteration of the corpus callosum
in alcoholic subjects ; the morbid process seemed to be one
characterised mainly by degeneration of the myelin sheaths,
with formation of granular cells and proliferation of neuroglia,
the axis cylinders being in greater part preserved.

Montesano (26) noticed plasma-cells in four cases in rabbits
given up to 12 c.cm. of absolute alcohol diluted with water,
but C. Reichlin (27), repeating these experiments, was not able
to discover them, and as this absence of plasma-cells agrees
with the findings of Nissl, Alzheimer, etc., he believes that an
intercurrent affection must have caused the death of Monte-
sano’s animals. I have never seen typical plasma-cells in
human brains from alcoholic cases, although one often comes
across cells which may well be early stages in a condition
toward plasma-cells, and which I believe to be lymphocytes.

The spinal cord was examined in nine cases. The condition
of the fore-horn cells has already been alluded to, but it may

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BY JOHN TURNER, M.B.

be further mentioned that in eight certainly, and probably in
all nine, there was a marked accumulation of pigment which
stained black with osmic acid and was probably of a fatty
nature. In neither of the two cases of delirium tremens in
which the cord was examined was any of this pigment observed.
In five of the cases there were no signs of tract degeneration.
In the other four there was both recent and old degeneration of
the exogenous fibres of the posterior columns, most marked in
the lumbar region in two, most marked in the cervical in one.
The pyramidal tracts were degenerated in three.

The posterior roots were degenerated in two, in one of these
in the intra-medullary region only, and the anterior roots were
degenerated in the intra-medullary region in one. On this
point of Marchi reaction in the roots Cole utters a warning
against the appearance being due to post-mortem damage,
which is very likely to occur in the intra-medullary part. It
is interesting to note that in the two cases where the lumbar
fore-horn cells showed an axonal or immature character, in one
the tract degeneration of the posterior columns was most
marked in the lumbar region and there was intra-medullary
(? artefact) Marchi reaction in the anterior roots. In the other
the tract degeneration in the posterior columns was least
marked in the lumbar region. In both cases the pyramidal
tracts were affected.

Nerves .—I examined the posterior tibial nerves in seven
cases and in all but one there was evidence of disease, patches
throughout the cross-section showing a marked disappearance
or even entire absence of myelin fibres (Figs. 3 and 5). In
one of the two cases where the popliteal nerves were also
examined the change was found to be much more marked in
the more peripherally situated posterior tibial than in the more
centrally situated popliteal. In two cases where marked
changes were found in the posterior tibials, the median was in
one unaffected and in the other showed very slight changes.
In a subacute case recorded by Cole, he similarly found
marked fibrotic atrophy in the posterior and anterial tibials
and much less change in the arm nerves. In an acute case he
records intense acute degeneration (Marchi reaction) with
multiplication of the neurilemma nuclei in leg and arm nerves
and slight affections in the left phrenic.

The following table correlates the state of the knee-jerks

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with the changes found in the posterior tibial nerves and spinal
tracts in the nine cases examined :

Knee-jerks.

Axonal-like
Betz cell.

Axonal-like

fore-horn

cells.

Neuritis.

Changes in spinal cord tracts.

Absent

Present

Lumbar

only

Present

Marked recent degeneration
in posterior columns and
slighter changes in pyrami¬
dal tracts.

Absent

Present

Marked degeneration in pos¬
terior columns only.

Absent

Not ex¬
amined for

No tract degeneration.

Absent

Present

Lumbar

only

Not ex¬
amined for

Marked degeneration of pos- ,
terior columns and pyrami¬
dal tracts.

Absent

Present

Absent

Not ex¬
amined for

No tract degeneration.

Ex¬

aggerated

Present

Absent

Present

Slight degeneration in pos- j
terior columns and pyrami¬
dal tracts.

Well

marked

Present

Absent

Present

No tract degeneration.

Normal

Absent

Not ex¬
amined for

No tract degeneration.

Ex¬

aggerated

Absent

No tract degeneration.

It will be observed that in two cases an exaggerated or well-
marked condition of the knee-jerks was associated with
extensive old neuritis ; on the other hand the general tendency
is for absent knee-jerks to be associated with changes in the
exogenous fibres of the posterior columns.

Spinal ganglia .—Several (five or six) of the cervical and
lumbar spinal ganglia were examined in three cases :

(1) Associated with well-marked degeneration of the exo¬
genous fibres of the posterior columns the chief change noted
in the cells was that resembling axonal reaction—marked
central chromatolysis ; the cells were plump but pallid, nucleus
eccentric. In the Nissl preparations not much pigment was
noted in the larger cells, but with osmic acid they were found
to contain a rather large amount of nearly black (? fatty)
pigment The small cells were heavily pigmented, this pig¬
ment showing in the Nissl preparations. There was marked
proliferation of the connective-tissue covering of the nerve-cells
and many clumps of small dark cells, representing probably the
sites of degenerated nerve-cells. In the Marchi preparations

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BY JOHN TURNER, M.B.

there did not appear to be any degenerative changes in the
myelin fibres either within the ganglia or at either pole, nor
did the anterior roots appear affected, but vacuolation of the
cells was noted.

(2) Also associated with posterior column degeneration the
ganglia cells were affected but in divers ways ; some showed
axonal characters, many were shrunken (especially in the
cervical ganglia) and darkly stained and distorted ; some were
loculated and with invading nuclei which appeared to have
partially destroyed them. The cells were heavily pigmented,
this pigment appearing of a nearly black colour with osmic
acid. There were many collections of dark nuclei representing
probably the sites of degenerated ganglia cells. Marchi
preparations showed no degeneration in the myelin fibres.

(3) This case was not associated with tract degeneration in
the cord. The majority of the cells were plump, closely fitting
their connective-tissue coverings ; they were very pale, with
only a few scattered grains of chromatoplasm and no peri¬
pheral ring of flakes. The nucleus was pale, sometimes
crenated, and appeared as if solid ; it was central and sur¬
rounded by a wide perinuclear space. There was a large
amount of pigment. The small cells were paler than normal
and with general chromatoplasm. No vascular or connective
changes were noted.

Liver .—In 6 of the cases the liver was cirrhotic, and in
2 of these it had a typical hob-nailed form. In one of the
cases of delirium tremens it was cirrhotic. Marked fatty
infiltration was ascertained in 2 by microscopic examination,
and was probably present in 2 others which were not
examined microscopically. Endarteritis was present in 1.

Kidneys were granular or showed evidence of more or less
marked interstitial changes in 8, and it should be observed
that none of the 4 in which this organ was stated to be
healthy were subjected to microscopical examination. In all
4 of the cases of delirium tremens they appeared natural, but
only one of these was examined microscopically.

Very marked endarteritis was noted in 2 of the cases of
alcoholic insanity.

Heart .—Excessive deposition of fat was noted in 2. In 8
the aorta was atheromatous (but in 3 only to any marked
degree). Cole found, microscopically, fatty degeneration of the

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58 ALCOHOLIC INSANITY, [Jan.,

heart muscle in 2 of his 3 cases, and noted also in 2 cases
extensive fatty degeneration without loss of transverse striation
of the voluntary muscles.

Pathology.

The only distinguishing feature in the pathological anatomy
of alcoholic insanity appears to be degenerative changes in the
nerve-fibres, peripheral and central. I have given reasons which
tend to show that the condition of the Betz and anterior horn-
cells, on which considerable stress has been laid by previous
observers, has no direct relation to either alcohol or to the
secondary toxins which its abuse may engender in the system.
The accumulation of free nuclei or satellite cells around the
nerve-cells and also in the peri-adventitial spaces is also in no
wise peculiar to this form of insanity, although it may reasonably
be regarded as a response on the part of the leucocytes, the
adventitial or glia elements, whichever they may be, to a toxin
either directly alcoholic or more probably a secondary toxin,
the result of a general perversion of metabolism. The fatty
degeneration of the nerve-cells and the dark staining may also
probably be similarly accounted for.

The neuritic lesion is evidently, as Cole points out, a de¬
generation of the nerve-fibre and not an inflammatory condition.
He, however, believes that the primary changes are the result
of pathological processes “ which partially impair the vitality
of the whole neuron, leading first to decay of its remotest
parts,” and that these changes are due not directly to alcohol,
but to secondary toxins, and he points to the changes noted
in the large nerve-cells as an evidence of this change in the
neurons.

I would suggest that alcohol itself exerts a prejudicial effect,
not primarily or necessarily on the cell bodies, but on the
myelinated branches of specially susceptible nerve-cells. The
almost universal opinion of physiological chemists now is that
alcohol has invariably a paralysing influence on the nervous
system (Schmeideberg, Binz, Bunge, Dixon, etc.). As Bunge
(28) puts it, “the stimulating action which alcohol appears to
exert on the psychical functions is also only a paralysing action.”
The cerebral functions first to suffer are judgment and reason,
and as a consequence emotional life comes into free play
unhampered by the guiding strings of reason.” These results

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appear to me to be best explained by the view that the para¬
lysing influence is exerted on the nerve-fibtes and not on the
nerve-cells (see p. 43 and diagram). This prejudicial effect
may be exerted directly on the nerve-fibre, or perhaps by a
vicious combination of alcohol with the myelin sheaths or
perhaps by both combined. I am led to this conclusion by the
absence of any constant or characteristic lesion in the cells
themselves, and to the frequency with which in the presence of
well-marked neuritic changes one fails to discover any morbid
character whatever in the nerve-cells. But although I regard this
to be the essential and primary lesion, I believe that subsequently
in the course of the disease secondary toxins come into play
to complicate the pathological process, and that these are
essential for the onset of delirium tremens. But the alcoholic
lunatic is no exception to the rule which obtains in all
other cases of so-called acquired insanity: he is born, not
made.

This hypothesis harmonises with the clinical features of
alcoholic insanity better than the idea of a primary change in
the nerve-cell body itself. In a large majority of cases rapid
improvement up to a certain point occurs after admission to an
asylum and therefore immediately following deprivation of
alcohol ; but in a certain proportion there are anomalous
features about some of the symptoms, such as alterations in the
knee-jerks and the accession of delirium tremens some time
after admission to an asylum, which point to the interaction
of a morbid agency other than alcohol.

And, moreover, in regard to the relationship of the axonal-
like Betz cells and the neurotic lesions, if, as some hold, the
cell change is a genuine axonal reaction, we should expect to
find evidence of lesions in the pyramidal tracts in all the cases
where this form of cell occurs, and equally, if the cell change
were due, as Cole and others believe, to a toxic action directly
exerted on the cell body, we should expect to find secondary
changes in the axons forming the pyramidal tracts; but
these conditions are not fulfilled, and often where we find
affected cells we find no evidence of change in the medullated
axons, and vice-versd. And on both suppositions we are driven
to invoke another morbid agency to account for either the cell
or fibre changes, a disadvantage which is avoided by the
assumption that the appearances observed in the cells are not

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the result of acquired morbid agencies, but of an inborn defect
in the cerebral structure.

A more extended examination of the spinal ganglia than
has hitherto been made will be necessary before we shall be in
a position to make definite assertions as to the relation of the
changes in the posterior columns of the cord and the cells of
the spinal ganglia. In my three cases the evidence, so far as
it goes, would seem to show that there is some connection, for
in the two cases where the cells showed axonal-like characters
there was found a degeneration in the exogenous fibres of the
posterior column, but in the third case where the cells did not
show this character the posterior columns were intact. But
after experimental division of the posterior roots, although
according to Koster (29) palpable changes are found in the cells
of the ganglia, these do not take the form of axonal reaction.

Although I cannot claim to have shown that neuritic changes
were present in all my cases of alcoholic insanity, seeing that 4
out of 12 failed to show any evidence of this nature in the
parts examined, yet as alcohol seems to be very capricious
in the selection of the part it will affect, and in view of the
generally positive results following more extended investiga¬
tion of the tissues, I am inclined to impute my failure to a
lack of thoroughness in the histological examination. Thus
in no less than 3 of my negative cases the peripheral nerves
were not examined. Wehrung, in this connection, states that
neuritis has been found in all the cases (Korsakow’s disease)
in which it has been looked for.

Many other views have been advanced to account for the
pathogenesis of polyneuritic psychosis. Korsakow himself
attributed the disease to the action of noxious substances in the
blood allied to Bouchard’s poisons.

In the opinion of the French school it is due to an auto¬
toxin arising from hepatic inadequacy, especially when there
is also an interference with the renal functions. Ascherson un¬
favourably criticises this latter view, because he only found
clinical evidence of liver affection in 64’5 per cent, of cases and
definite cirrhosis in 16 per cent., and the kidneys were suffi¬
ciently affected to cause albuminuria in only 20 per cent., and
symptoms pointing to joint lesions of both in only 16 per cent.
But of his cases only 5 came to autopsy, and among these the
liver was cirrhotic in 2, fatty in 2, and normal macroscopically

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6 I

in i ; the kidneys were fatty and cloudy in I, granular in i,
and healthy in 3. In reference to Ballet’s contention that
hepatic inadequacy sufficient to give rise to mental symptoms
may exist in the absence of macroscopical changes in the liver,
he cites a case of Korsakow’s disease in which the liver was
found to be healthy both to the naked eye and the microscope,
and in which the kidneys were but slightly diseased. These are
weighty objections, but they appear, with the single exception
of the last quoted instance, to rest entirely on macroscopical
examination. Unfortunately I only made microscopical exami¬
nations of the liver and kidney in 6 of my cases, but in all
these the liver was found to be affected (in 4 cirrhotic and in 3
also fatty), and in 5 the kidney showed interstitial changes, and
in 1 only it appeared natural. Of the remaining 6 in which the
liver and kidney were not examined by the microscope, in 2 both
organs appeared healthy ; in one the liver appeared healthy,
whilst there was evidence of interstitial changes (adhesions of
capsule) in the kidney. In 2 the liver was cirrhotic (hob¬
nailed) and the kidneys granular ; in the remaining 1 the liver
had appearances indicating fatty changes and the kidneys were
cystic. So that in no less than 10 (83 per cent.) there were
appearances of disease in these organs either separately or con¬
jointly. In my opinion even where a microscopical examina¬
tion of a tiny piece of such a large organ as the liver fails to
show any change, to conclude thereform that the organ in its
entirety is healthy is a very bold assumption. S. Cole, in all
three of his cases, also found changes in these organs ; fatty infil¬
tration or degeneration and cirrhosis of the liver ; fatty changes
alone or in combination with slight interstitial changes in the
kidneys, although in two of the cases this organ appeared
natural to the naked eye.

VVehrung supposes that in Korsakow’s disease there is the
production of an antitoxin the result of prolonged alcoholic
abuse, and he attributes the delay which so often occurs after a
bout of drinking before mental symptoms appear to the time
occupied for the neutralisation of the alcohol by the antitoxin ;
only when this is accomplished can the excess of antitoxin
exert its own influence upon the cortical structures. Tansi (31)
practically adopts this view in discussing the cause of delirium
tremens, but in the opinion of Hertz (quoted by Tansi) it is the
result of renal insufficiency—a symptom of alcoholic nephritis.

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Bonhoffer (30) in all cases of polio-encephalitis hemorrhagica
superior (by which term Wermeke in 1881 described certain
paralyses of the eye movements, accompanied by delirium, with
acute onset and fatal termination, the symptom-complex arising
on the basis of chronic alcoholism), found neuritis and amnesia
(Korsakow’s disease). But he believes that alcohol alone is
insufficient to cause the occurrence of the syndrome and that
there is always an additional toxic cause, and that the syndrome
in the great majority of cases is ushered in by delirium tremens.

According to him senile and arterio-sclerotic changes often
produce the syndrome in a very pure form, but here it is
preceded by apoplectic or minor attacks. He finds it also (but
rarely) in general paralysis.

References.

(1) Ascherson, W. L.—“ Mental State in Alcoholism,” Motfs Archives
of Neurology , iii, 1907. [In this paper will be found a good bibliography
up to date.]

(2) Dawson, YV. R.— Dublin Journ. of Med. Science, 1908.

(3) Chotzen, F.— Arch. f. Psych., 1906; Centralbl. f. Nervenh. u.
Psych., 1907.

(4) Stoddart, W. H. B.— Mind and its Disorders, 1908.

(5) Mott, F. YV.— Archives of Neurology, iii, 1907; Brit. Med. Journ.,
1907.

(6) Bonhoffer.—Quoted by Ascherson.

(7) Kraepelin.—Quoted by Ascherson.

(8) Cole, S. J.— Brain, 1902 ; Archives of Neurology, ii, 1903.

(9) YVassermeyer.— Arch. f. Psychiat. u. Nervenkrank., 1908.

(10) Alzheimer.— Centralbl. f. Nervenh. u. Psych., 1904.

(11) Meyer, Adolf.— Brain, 1901.

(12) Buchan, A. Hill.— Review of Neur. and Psy., 1905.

(13) YVilliamson, R. T.— Lancet, 1907.

(14) Fiirbringer.— Dent. med. JVoch., 1904.

(15) Hoffmann and Marx.— Berlin klin. JVoch., 1905.

(16) Herz.— Munch, med. JVoch., 1905.

(17) Lawson, G. B.— New York Med. Journ., 1909.

(18) YVehrung.— Arch. f. Psych., 1905.

(19) McDougall, YV.— Brain, 1903.

(20) Serbsky, YV.— Arb. a. d. Neurol. Insiitut. a. d. JVien. Univ., 1907.

(21) Bevan Lewis.— Text-book of Mental Disease.

(22) Miller, H. YYL— Amet. Journ. of Insanity, 1904.

(23) Turner, J .—Journ. of Mental Science, 1903, 1907, and 1908;
Brit. Med. Journ., 1900.

(24) Goldscheider and Flatau.— Anatomie der Nervenzellen, 1898.

(25) Marchiafava, E., and Bignann, A.— Riv. di pa to!og. nev e merit.,
1903.

(26) Montesano, J.— Centralbl. f. Nervenheil. u. Psych., 1907.

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(27) Reichlin, C.— Riv. Speriment di Fren., 1908.

(28) Bunge.— Phy. and Path. Ghent ., translated by Wooldridge, 1890.

(29) Koster.— Neurol. Centralb ., December, 1903.

(30) Bonhoffer.— Allg. Ztschr.f. Psych ., 1904.

(31) Tansi.— Text-book of Mental Disorders , translated by Ford
Robertson and Mackenzie, London, 1909.

EXPLANATION OF PHOTO-MICROGRAPHS.

Fig. 1.—Nerve-cells in the upper part of the third (pyramidal) layer from frontal
convolution, in a state of fatty degeneration, x 600. Notice also the breaking
up of the myeline fibres into a beaded condition. The section from which this
photo-micrograph was taken was from a case of acute delirium not of alcoholic
origin, but precisely similar appearances are met with in alcoholic cases.

Fig. 2. —Large pyramidal cells from the ascending frontal convolution in a case
of alcoholic insanity. To show the marked increase of satellite cells around the
nerve-cells ( x 400). Many, if not all, these bodies represent mesoglia cells, and
by special methods their cell-body and branches can be shown, the latter to a large
extent embracing the body of the nerve-cells.

Fig. 3.—Longitudinal section of the right posterior tibial nerve in a case of
alcoholic insanity, showing recent degeneration of the myeline, which is darkly
stained and broken up into beads ( x 100).

Fig. 4—Transverse section of posterior tibial nerve in a case of advanced
general paralysis, showing a fairly healthy condition ( x 100) in contrast with—

Fig. 5. —Transverse section of posterior tibial nerve from a case of alcoholic
insanity, showing marked neuritic change characterised by disappearance of
myeline fibres ( x 100).

The Systematic Estimation of the Leucocytosis in Certain
Cases of Insanity: ivith Special Reference to the
Toxamic Theory.Q) By S. Carlisle Howard, M.D.,
Assistant Medical Officer, London County Asylum,
Horton, Epsom ; formerly Assistant Medical Officer,
District Asylum, Murthly, Perth.

SURVEYING insanity as a whole, one recognises as a funda¬
mental fact that insane persons belong to a class who start life
with a “ deficient grade of organisation ” of the nervous system
called “ hereditary predisposition.” Some authorities hold that
this is the sine quA non of insanity, but such a view, I consider,
is not strictly accurate. It is certainly not borne out by
statistics. All observers, using even indifferent discrimination,
must have noticed cases in which no hereditary factor could be
traced, but in which much self-abuse had occurred—either in
the form of alcoholic, sexual, and -other excesses—or where

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syphilis or other powerful toxaemic conditions had been con¬
tracted. Such conditions, I argue, may themselves break
down the most hardy constitution and leave it a prey to
secondary infections or intoxications, which may manifest them¬
selves as insanity. Assuming that the insane, prior to their
attack of mental disease, suffer from either some hereditary
weakness, or some acquired constitutional degeneration, it is
most probable that such defects act a dual part, weakening not
only the nervous system, so that it is more susceptible to the
actions of toxins and environments, but also weakening the
natural defences of the body. The nervous system of these
people is thus laid open to more severe and frequent attacks
from poisonous substances, whether of bacterial, metabolic, or
other sources, than is the nervous system of a more normally
organised individual. In support of this statement I would
mention that Dr. L. C. Bruce (i) has pointed out that over
60 per cent, of maniacal patients were deficient in the normal
protective agglutinin to certain strains of Staphylococcus
aureus. This agglutinin is always present in healthy sera.
Further, Dr. C. J. Shaw (2) has ably demonstrated that the
reason tubercular diseases account for so large a proportion of
the deaths in asylums lies, not in any faulty hygienic pre¬
cautions, but in the fact that the resistive power of the insane
to tubercular infection is below par. Assuming that this
hypothesis is true, we can more readily understand why the
various insanities so frequently resist our efforts to cure them.

Besides this hereditary or acquired weakness of the nervous
system and general defences, some secondary or combination
of secondary influences is usually necessary to tilt the mental
balance of these people towards insanity.

These secondary influences have been very broadly divided
by Dr. L. C. Bruce (3) into two main divisions, namely, the
“toxic” and “non-toxic” causes of insanity. It is with the
toxic division—or, more strictly speaking, with that sub¬
division which Dr. Bruce has called “ the toxins of bacterial
origin ”—that I shall deal. Reviewing the toxaemic theory of
insanity, one finds that Macpherson (4 and 5), more than ten
years ago, compared the pathology of the histological changes
occurring in puerperal and certain of the confusional insanities.
He believed that puerperal insanity was frequently of toxic
origin, and, reasoning by analogy, he classified confusional

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BY S. CARLISLE HOWARD, M.D.

insanities as also toxic. It is now universally admitted that the
majority of puerperal cases are of undoubted bacterial origin.
Further, he states, “the basis of all forms of insanity is a pre¬
sumption for which there is a fairly good foundation, but no direct
proof. . . . There is, however, every reason to believe that

the field of toxic nerve-disease is one of the most extensive in
morbid psychology, and that it is because we are still on the
threshold of inquiry that its recognition is not more general.”

Following closely in the path suggested by Macpherson, we
have Dr. Ford Robertson (6), who, with microscope and highly
trained histological technique, corroborates and augments
Macpherson’s observations. Later, we find Dr. Thomas Claye
Shaw (7) saying, “ It would indeed have been strange if the
advent of bacteriology, and the study of toxins and vaccines,
had not influenced our opinions and treatment of mental
disease. There has indeed been a revolution in our estimation
of causes and pathological processes since the study of micro¬
organisms was seriously undertaken, and it is clear now that
many of our old postulates will have to be re-written.”

Further, we have on the Continent Bianchi and Piccinino (8)
examining the blood and meninges of the insane bacterio-
logically, and discovering, in certain delirious cases, a bacillus,
for which reason they have termed the condition “ acute
bacillary delirium.” A little later we find D’Abundo and
Agostini (9) formulating hypotheses as to the part taken by
intoxications and infections in the causations of nervous and
mental diseases. They regard these agents as the most
frequent, conspicuous, and active elements in the pathogenesis
of nervous diseases in general. They further consider that
infective toxic agents can manifest their action in any part of
the nervous system “ leading to peripheral or central, systemic
or disseminate localisation, and resulting in acute or chronic
neuropsychosis.” At the present day Dr. L. C. Bruce is
prominent and active among the pioneers of the toxic theory.
He champions this theory with much vigour from a general
and exhaustive clinical point of view, paying particular atten¬
tion to hsematological and bacteriological observations. Armed
with a thorough appreciation of the advances made in general
medicine by the improved methods in clinical technique, he
has gleaned much of that positive knowledge the absence of
which Macpherson so much deplored.

LVI. 5

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A resurni of Dr. Bruce’s findings and methods of investiga¬
tion will not be out of place here. His field of research lay
in three principal divisions, viz. :

(1) The estimation of the leucocytosis.

(2) The bacteriology of the urine, faeces, and blood.

(3) The estimation of the excretion of urea and chlorides.

I shall review the first two divisions, and omit the last one
as it does not come within the scope of this article.

Dr. Bruce’s leucocyte count consisted of an estimation of
the total leucocytosis by means of the Thoma-Zeiss apparatus
and a differential count from blood-films stained with Jenner’s
eosin methylene blue. In this way Dr. Bruce examined a
large number of cases of confusional mania, folie circulaire ,
katatonia, hebephrenia, and excited melancholia, in all of
which he found a fluctuating hyper-leucocytosis which bore
a definite relationship to the course of the disease. Such
observations include thirty-six cases of mania of the folie
circulaire type, and thirty-one cases of the confusional type—
in every case a varying degree of hyper-leucocytosis was
observed.

Bacteriologically, Dr. Bruce’s initial case was one of mania
with confusion in the typhoid state. From the blood of this
case he isolated a short streptococcus. The serum of the
patient agglutinated this coccus in a dilution of 1 in 30 within
half an hour. Two control sera failed to give a reaction after
twelve hours. After this case Dr. Bruce and his assistants
made numerous bacteriological examinations of the insane, not
only of the blood but also of the urine and faeces. The last
source ultimately proved the most fruitful. The agglutination
was the test by which the invading organism was identified.
Briefly, if an organism isolated from any of the above men¬
tioned sources was agglutinated by the serum of the patient,
and not by the serum of the controls, that organism was
considered as a causal toxic agent.

I have followed on the lines indicated by Dr. Bruce, and I
hope to demonstrate the high importance of systematic blood
examination.

(1) As a possible means of diagnosis.

(2) As an indication to treatment.

(3) As an aid to the forming of a prognosis.

In the first instance I intend to review briefly the condition

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BY S. CARLISLE HOWARD, M.D.

of the leucocytosis in well known and well understood in¬
fective and infectious cases. By so doing the strong light of
analogy will assist us in reading a possible solution where
certain links in the chain of positive information are at present
wanting. In certain well-recognised infective conditions such as
appendicular abscess, furuncle, carbuncle, empyema, superficial
abscess, etc., the symptom of hyper-leucocytosis is practically
never absent, and may rise higher than 20,000 per c.mm. (10)
of blood. In the same way, in general infections such as
diphtheria, pneumonia, rheumatic fever, etc., a more or less
decided leucocytosis is regularly seen. This rise of the
leucocytes in strength of numbers is regarded as an effort
of the human organism to rid itself of the inimical and
irritating invading factor. In short, it is a protective reaction,
a mobilising of the body’s first line of defence for its self-
preservation.

The knowledge of this functional characteristic or defensive
action of the leucocytes is rapidly becoming universally dis¬
seminated, and in consequence we hear more and more
frequently of the artificial stimulation of a leucocytosis for
prophylactic purposes, particularly before surgical operations.
It is also often used in the initial stages of various diseases.

From this short survey it will be observed that in a large
number of diseases, admittedly of a bacterial origin, a hyper-
leucocytosis is a common and regular feature. Further, it
should be noted that this leucocytosis is regarded as Nature’s
method of removing, or attempting to remove, the causal
disease from the body. From this I think I may with good
reason argue conversely that where there is a hyper-leuco¬
cytosis one may expect to disclose some focus of irritation,
most probably of a bacterial nature. Unfortunately, such foci
are often obscurely placed, and only discovered after very
careful search, and frequently escape one even in spite of every
effort to locate them.

Again, if such a hyper-leucocytosis occurs, as a common
feature, in a series of cases all presenting the same train of
symptoms, and therefore deserving to be classed under a
common diagnostic term, such as cases of confusional mania, it
may be reasonably deduced that such a hyper-leucocytosis very
strongly suggests that that class of disease is of bacterial origin,
or that a bacterial invasion is intimately connected with it.

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There are considerable differences of opinion as to the exact
meaning to be read from leucocytic reactions. Ehrlich, Cabot,
and other authorities on the subject, hold that in conditions of
an inflammatory nature the number of leucocytes per c.mm. of
blood varies directly with the intensity and extent of the
infection. Dr. McCuen Smith, of Philadelphia, at the meeting
of the British Medical Association at Toronto in 1906, stated
that the number of leucocytes per c.mm. of blood is an indica¬
tion of the amount of the body resistance, while the percentage
number of polymorphonuclear leucocytes indicates the intensity
and extent of the infection. Still another method of inter¬
preting the leucocytosis is to estimate the polymorphonuclear
leucocytosis per c.mm. This is done as follows :

Total number of leucocytes ^ Percentage of polymorphs to
per c.mm. other forms of leucocytes

= Total number of polymorphs per c.mm.

For example, in a given case we may have a leucocytosis of
15,000 per c.mm., and a polymorphonuclear count of 70 per
cent., the actual number of polymorphs per c.mm. is therefore
10,500. By this means we know how many of the fighting
variety of leucocytes are in each c.mm. This is the method I
have adopted. The accompanying charts indicate the poly¬
morphonuclear leucocytosis per c.mm. of blood.

In making these systematic observations of the changes
occurring in the relative and absolute number of the white
blood-corpuscles, I estimated the leucocytosis by means of the
Thoma-Zeiss apparatus, after the method advocated by
Coles (11). In the differential count the film was stained by
Jenner’s eosin methylene blue, and an oil-immersion lens was
used. I never counted less than 200 cells, and in doubtful
cases I counted 400. Moreover, care was taken to obtain the
blood at a regular hour on each occasion. The hour selected
was just before the mid-day meal ; by this precaution the error
of the presence of a lymphocytosis excited by food was
avoided.

These observations include cases of mania and melancholia
of the folie circulaire type, i.e., the manic-depressive variety of
Kraepelin, mania with confusion, and so-called alcoholic insanity.
The observations were made either every day or every second
day, and were continued for at least one month, and, in some
cases, for as long as from three to six months. It will be

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BY S. CARLISLE HOWARD, M.D.

noticed that the leucocyte reactions stand in bold relation to
the remissions of such conditions, and in certain cases to their
subsequent relapse.

Case of D. McA —.—Male, xt. 21, admitted September,
1906, suffering from excitement without confusion of fourteen
days’ duration.

History .—His uncle on his mother’s side had suffered from
insanity. The patient was a youth of steady habits, he was
a total abstainer, and smoked in moderation. He had been
losing weight for some two months previous to admission.
Otherwise he had always been healthy.

Physical condition .—He was tall and well developed, but
anjemic, ill-nourished, and run down. His tongue was coated,
his breath was foul, and his bowels constipated. He had very
little desire for food. Previous to admission he had slept badly
and dreamt a great deal. His temperature was 99 0 F., pulse
72—84, and leucocytosis 6000 per c.mm.

Nervous system .—He had no tremors, either of hands, tongue,
or facial muscles. His pupils acted equally to light and accom¬
modation. His superficial reflexes were exaggerated, his deep
reflexes were nearly absent. No ankle clonus was present.
Mentally, though restraining himself with an effort, he was
facetious and childish in his behaviour. His special senses
were hyperacute, and in consequence his attention was un¬
steady. Any little sound or movement in the wards imme¬
diately attracted him. He was not confused, and had neither
hallucinations nor delusions. During the first fortnight of his
stay in the hospital he restrained himself fairly well. Occa¬
sionally he became restless and impulsive, and in explanation
of such conduct he said, “ I could not help it; I just lost control
of myself.” At first he slept very badly, and later he became
restless, excited, talkative, and at times maniacal. During the
more acute period his face was flushed, his tongue and lips were
dry and covered with sordes, and his breath was foul. His
leucocytosis was very irregular, but had never risen above
18,000 per c.mm. At this period I injected him in the flank
with I c.c. of terebine ; three days later his polymorphonuclear
leucocytosis rose to 21,000, his temperature to ioo° F., and his
pulse-rate to 100 per minute. Mentally he became much
quieter and more obedient. Ten days later he had another
attack, when his leucocytosis fell to 5,000 per c.mm. At the

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70 LEUCOCYTOSIS IN CERTAIN CASES OF INSANITY, [Jan.,

end of the twelfth day, however, they rose again to 22,000 and
he again became quieter. This second rise of his leucocytosis
I regarded as being due to the irritation to which he had sub¬
jected the abscess in his flank during his restless period. A
week later he had another slight maniacal attack, during which
his leucocytosis rose to 23,000 per c.mm. On this occasion,
instead of falling and remaining low for several days, it con¬
tinued to swing for nearly a month between normal and 1 3,000

per c.mm. Thereafter it gradually fell to normal. After this
last leucocytic rise his mental symptoms improved and he put
on weight rapidly ; he increased from 9 st. 2 lb. to lost. 12 lb.
in two and a half months. I isolated from the feces and
urine of this case a short streptococcus, which his serum agglu¬
tinated in a dilution of 1—40 in twenty minutes. Control sera
did not affect it in twenty-four hours.

For the leucocytosis of this case see Chart 1.

He was discharged recovered in June, 1907, and has con¬
tinued well ever since.

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Polymorphonuclear leucocytes per c.mm.

1910.]

BY S. CARLISLE HOWARD, M.D.

CiTse 0/ IV. B —.—Male, aet. 16, admitted September, 1907,
suffering from acute excitement and impulsiveness of about one
week’s duration.

History .—No hereditary insanity or neurosis could be traced.
His father and mother were both dead ; I was unable to dis¬
cover the cause. One month prior to admission he had been
incarcerated in the Perth Penitentiary for theft, and had since
been somewhat depressed and moody. He neither smoked nor
drank and he seemed a very respectable lad.

Physical condition .—He was fairly well developed, indifferently
nourished, and very ansemic. Plis tongue was coated, his
breath was foul, and in spite of large doses of saline aperients
and extract of cascara sagrada his bowels had not moved for a
week. His temperature was 97‘8° F., pulse 85—93 per minute,
full, regular, and of high tension. His lungs and heart were
normal. His leucocytosis was not taken until he had been
injected with 1 c.c. of terebine—a week after admission. His
leucocytosis then registered 30,000 polymorphonuclear leuco¬
cytes per c.mm. of blood (vide Chart 2).

Nervous system .—His tongue was very tremulous. His

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superficial reflexes were exaggerated and his deep reflexes
were deficient. There was no ankle clonus. His pupils
reacted to light and accommodation.

Mentally .—On the day of admission he was very excited,
noisy, and somewhat confused. The following day he had
hallucinations of hearing, delusions of identity, and was
dejected. He thought I was God, and sought forgiveness of
his sins. He was constantly moaning or shouting, and refused
to take food. He remained more or less in this state for four
days, taking very little more than a glass of milk a day, and
that only when poured into his mouth. At night he frequently
required one to two drachms of paraldehyde before he could
sleep. On the fifth day after admission I injected him in the
flank with i c.c. of terebene. The following day he was
mentally much clearer; he sat up, took his food voluntarily,
and at night slept eight hours. This improvement synchronised
with a high polymorphonuclear leucocytosis of 30,000 per
c.mm. He continued well for three weeks and then had a
return of his hallucinations. Under the treatment of a large
saline enema and a dose of calomel this attack passed off in
a couple of days. From that date he progressed steadily, and
was discharged recovered two months after admission.

Case of Mrs. McN —.—/Ft. 36, admitted November, 1906.

On admission she was restless, excited, and at times
maniacal. She talked incessantly and incoherently, but was
not in any way confused.

History .—Five years before admission to this asylum she
suffered from puerperal mania, for which she was under treat¬
ment in one of the Glasgow asylums for about six months. In
October, 1905, she became slightly elevated, but was then
successfully treated at home.

Physical condition .—She was well developed and well
nourished, although somewhat anaemic and run down. She
had been in bad health for about one month prior to admission.
Her stomach was out of order, her bowels were constipated,
and she had no desire for food. She had been menstruating
irregularly. She had an aortic systolic murmur. Her tem¬
perature was gS' 6 ° F., her pulse was 77 per minute, full, of
fairly high tension, and somewhat irregular. Occasionally it
quickened in the morning to 80 and 86 beats per minute.

Nervous system .—She had tremors of hands, tongue, and

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Polymorphonuclear leucocytes per c.mm.

1910.]

BY S. CARLISLE HOWARD, M.D.

facial muscles. Her pupils reacted equally, though sluggishly,
to light and accommodation. Both her superficial and deep
reflexes were deficient. Mentally her special senses were hyper¬
acute, and she remained for about ten weeks in a restless, noisy,
and talkative condition. She had no delusions, but she
occasionally showed evidence of hallucinations of hearing. At
the end of these ten weeks she became quieter and commenced
to put on weight. Three weeks later she showed well-marked
signs of depression, which lasted for nearly three months,

during which period I kept a record of her leucocytosis, and
her body reaction was fairly good (vide Chart 3).

After eight months’ treatment she was discharged recovered
but she was readmitted about three months later suffering
again from melancholia. On this last occasion she remained
under treatment for about seven months, and was subsequently
discharged recovered.

The following three cases are particularly interesting, throw¬
ing as they do a side-light upon the question of alcoholism as
a cause of insanity :

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Case of J. Cyn —.—Male, set. 34, was admitted suffering
from maniacal excitement with considerable confusion.

History .—He had a long history of excessive alcoholic and
nicotine indulgence ; he usually smoked from four to six
ounces of strong black tobacco per W'eek. He was a “ chronic
soaker ” rather than of the dipsomaniac type. A few weeks
prior to admission he had taken rather more alcohol than
usual, and, owing to irregular employment, had been under¬
feeding himself.

Physical condition .—On admission he presented all the
symptoms of a chronic toxaemia. He was ill-nourished, ill-
developed, and anaemic ; his tongue was coated with a thick
fur, his breath was very offensive, and his bowels stubbornly
constipated. His skin was dry and sallow. His temperature
was 58 - 6° F., with a tendency to be irregularly subnormal ;
pulse was 98 and feeble.

Nervous system .—His reflexes, both superficial and deep,
were deficient. It was impossible, owing to his confusion, to

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ro illustrate Dr. S. Carlisle Howard's paper.

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1910.] BY S. CARLISLE HOWARD, M.D. 75

test his recognition of pain, temperature, or sensation. He
had fine tremors of the muscles of the hands and tongue.

Mentally, he was incoherent, restless, and impulsive. He
had hallucinations of sight, and delusions that he was going
to die “ to save the world.”

I examined his leucocytosis three days after admission, and
found his polymorphonuclear leucocyte count per c.mm. of
blood to be 14,946. I observed it regularly every second
day from that date until he was discharged recovered four
months later. It was found to fluctuate from 5,000 to
32,600, the majority of the counts being well above the
normal line (vide Chart 4).

Shortly after his admission I isolated from his urine a short
streptococcus, which his serum agglutinated in twenty minutes
in a dilution of 1 to 40. Two control sera did not affect it
in twenty-four hours. A short time later I examined his
faeces bacteriologically. The technique employed was as
follows: A sample of his feces was placed in a sterile
Petrie’s dish, and from it a sterile platinum needle was charged ;
three strokes were then made on each of seven sloped agar
tubes, the same surface of the needle, as near as possible, being
used to make each stroke. The tubes were then incubated
for forty-eight hours, when cultures were found of almost
pure streptococci colonies. There were only six colonies of
Bacillus coli , the remaining growth being streptococci {vide
Chart 4 a). Testing these cocci to the various sugars, as re¬
commended by Houston, I found that they were the same as
those isolated from his urine.

Case of J. C — d. —Male, zet. 27, admitted suffering from
confusion and excitement.

History .—There was again a history of alcoholism and
loose living. He had recently been in prison. He was
confused, restless, and impulsive. During his confinement in
this asylum he made one or two indifferent attempts at suicide.
On one occasion he swallowed an open safety-pin, and on
another occasion he tied a sheet round his neck. He had
neither hallucinations nor delusions, but was a physical and
mental degenerate. He presented an irregular polymorpho¬
nuclear leucocytosis, varying from 2,000 to 13,400 [vide
Chart 5).

It is interesting to note that in this case the leucocyte

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76 LEUCOCYTOSIS IN CERTAIN CASES OF INSANITY, [Jan.,

reaction was very indifferent, and that, although under treat¬
ment for nine months, he did not recover. He was discharged
to the care of his friends “ relieved.”

Case of Alex. C —.—Male, aet. 25, admitted suffering from
acute excitement.

History .—He was an Army pensioner, and while in the
service he lived for several years abroad. During his sojourns
he suffered from dysentery, malaria, and finally heart disease,
for which he was invalided home. For a few weeks prior to
admission he indulged in alcohol to great excess, and in
consequence he became delirious and delusional. He was
treated at home for a week and then sent to this asylum.

On admission he was sleepless, restless, and disinclined to take
food. He had delusions that his stomach had been removed,
and that he was to be cut to pieces and thrown into the river
Tay. His leucocyte reaction was subnormal, being 3,240
per c.mm., and during the six weeks he was in the asylum it
never rose above 8,768 per c.mm. (vide Chart 6). Under
the treatment of bromides, milk diet, and rest in bed, he
made a rapid recovery.

On reviewing these three cases there can be no doubt that
the last-mentioned was one of uncomplicated alcoholism. The
poison having been withdrawn, and the general system placed
in the most favourable circumstances for its rapid restoration
to health, the patient naturally made a speedy recovery.

In the first two cases, however, there is an additional con¬
dition to contend with as evidenced by the polymorphonuclear

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Polymorphonuclear leucocytes per e.inm.

1910.]

BY S. CARLISLE HOWARD, M.D.

hyperleucocytosis. The nature of the complication, arguing on
the lines previously mentioned, I judged to be a bacterial one.
This conclusion was later strongly supported by the isolation
of a streptococcus from both the urine and fa:ces of the first
case, which organism was agglutinated by the patient’s serum,
and was not in the least affected by the sera of two control
cases. It naturally follows that although the alcohol, which
may be considered as the “ last straw,” is withdrawn, yet the
body must overcome or suppress the complicating source of
toxaemia before recovery can take place. In the first case we
saw that recovery took place within four months. In the

second case the body was incapable of overcoming the toxaemia
even within nine months. The possible explanation of this I
shall discuss later when drawing a comparison between the
acute and chronic cases.

Case of Mrs. R —.— /. Et. 40 ; admitted January, 1907,
suffering from hallucinations of sight and hearing, with acute
excitement.

Physical condition .—She was very anaemic and ill-nourished.
Her tongue was covered with a white fur ; her breath was foul
and bowels constipated. Her temperature was 98’9° F., pulse
85, full, irregular in rhythm and of high tension. She had
little desire for food, and occasionally had to be hand-fed.
She slept irregularly, and frequently required paraldehyde.

Nervous system .—Her pupils reacted equally to light and

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c.mm.

78 LEUCOCVTOSIS IN CERTAIN CASES OF INSANITY, [Jan.,

accommodation. She had fine tremors of the fingers and
tongue. Her sense of touch was deficient, but that of pain was
normal. Her plantar reflexes were deficient, and there was a
tendency to dorsiflexion of the foot. Her knee reflexes were
markedly deficient. She had no ankle clonus. Her organic
reflexes were under control.

Mentally , she was elevated, noisy, and restless. Her special
senses were hyperacute. She was constantly chattering inco¬
herently, but she always remained conscious of her surroundings.
She had vivid hallucinations of sight and hearing. Occasion¬
ally she barricaded her bed with pillows, bed-clothes, or any¬
thing movable she could get hold of, in order “ to keep away
evil spirits.” Her attention was readily attracted, but she

lacked the power of concentration. During her quiescent
periods she always remembered and could relate what had
occurred during the time of her excitement.

The initial attack of mania for which she was admitted into
this asylum lasted for five months. Since that time she has
had recurrent attacks, each one lasting about fourteen days,
and I was thus enabled to obtain records of her leucocytic
reactions which corresponded with the alternating phases of
her mental condition (vide Chart 7).

Case of Mrs. M —.— Ait. 66 ; admitted in May, 1907,
suffering from acute excitement with confusion.

History .—Up to about three months prior to admission she
was healthy and active. She then began to grow thin, look
pale, and lose interest in her work. She had severe headaches
during the day, and at night she suffered from insomnia.

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Polymorphonuclear leucocyte* per o.min.

1910.]

BY S. CARLISLE HOWARD, M.D.

Physical condition .—She was anaemic and ill-nourished. Her
complexion was sallow and unhealthy ; her skin was greasy.
Her tongue was coated with a white fur, breath was foul, and
she was very constipated. Her pulse-beat was from 82 to 94
per minute, hard and incompressible; temperature normal.
She had reduplication of the second sound, heard at the apex
and the aortic area. She had varicose veins of the legs.

Nervous system .—Her pupils reacted equally but sluggishly
to light and accommodation. Her hearing was very good.
Her motor functions were deficient and senile. Her plantar
reflex was delayed and abnormal ; there was slight dorsiflexion,
with considerable abduction of the foot. Her knee reflexes

were practically absent. She had fine tremors of the muscles
of the hands and tongue. Her organic reflexes were under
control, although during severe attacks of confusion with torpor
she passed her motions in bed.

Mentally she was confused, restless, noisy, and at times
impulsive and dangerous. She had the delusion that she was
blind and said she was haunted by dreams.

The leucocytosis shows that the power of her body to react
to the toxaemia is very poor and unsatisfactory. She has now
been under treatment in this asylum for about a year, and she
shows no tendency towards mental improvement {vide Chart 8).

In considering the foregoing charts and cases, a most striking
difference will be noticed between those which recover and

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those which do not. In the curable cases the body reaction, as
registered by the polymorphonuclear leucocytosis, is high and
powerful. Such cases usually run a fairly definite and favourable
course. In the unrecovered cases, judging by the leucocytosis,
the course and the relapsing character of the case, the body is
apparently incapable of reacting to the bacterial invasion. In
consequence the toxaemia continues to assert its destructive
action, and attack follows attack in quick succession till, finally,
organic brain changes occur, and with them come fixed delusions
and dementia.

The reason why one person is capable of reacting to and of
resisting such a bacterial invasion while another person is
incapable of offering anything but a weak resistance (and, in
consequence, mentally and intellectually succumbs) is probably
but part of the, at present, impenetrable mystery of hereditary
predisposition. This theory is supported by the observations
of Drs. Bruce and Shaw. The former discovered in the insane
as a class an absence of normal agglutinins to certain strains
of Staphylococcus aureus, while the latter observed a deficiency
in the resistive power of the insane to the tubercle bacillus.
This deficiency, he holds, accounts for the high mortality among
that section of the community from tubercular diseases.

From such a comparison of the curable and incurable cases
it will be seen that an estimation of the polymorphonuclear
leucocytosis may be a valuable means of forming a prognosis.
This is particularly so in cases of mania, which class of disease
forms at least 50 per cent, of the admissions into most
asylums.

In those cases in which the leucocytosis fails to react in
anything but a small degree, and in which the mental symptoms
are prolonged over many months—as exemplified in Charts
5, 7, and 8—a bad prognosis may with confidence be given.
Such leucocyte reactions can but mean one of two things ;
either a very severe toxaemia, causing a leucopaenia, or a defi¬
ciency in the activity of the leucocyte-producing tissues. In
either case the ultimate result will be the same. Since the
body is not in a condition to offer satisfactory resistance to the
causal toxic agent, the nervous system will continue to be
poisoned till its higher centres are eventually destroyed by the
ever-present toxin.

Again, if the leucocyte reaction is such as is demonstrated

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igio.]

BY S. CARLISLE HOWARD, M.D.

8 I

in Charts I, 2, 3 and 4, and the patient’s environment and
age are favourable, a good prognosis maybe readily given. In
such cases the leucocytosis would register the resistance offered
by the body, and by a judicious stimulation, either by a terebine
abscess or otherwise, the body may be made to react more
powerfully and over a longer period than it would do were the
disease merely allowed to run its course. In the wise and
special use of such means there is an encouraging possibility of
suppressing and even eradicating the seat of infection before
permanent brain damage has occurred.

In the three so-called alcoholic cases previously discussed, I
stated on the evidence of a polymorphonuclear leucocytosis
that I considered two of these cases to be suffering from a
toxaemia (of a streptococcal character) complicated with
alcoholism. The third case I considered was one of uncom¬
plicated alcoholism. The course and termination of these cases
justified and corroborated the diagnosis made. In the uncom¬
plicated case, once the patient was placed in a more healthy
environment, his supply of alcohol stopped, and his daily
habits regulated, the recovery was rapid. In the other two
cases, however, this treatment was not sufficient to obtain a
quick return of the mental balance. The cause of this retarda¬
tion was without doubt the action of that more subtle toxaemia,
the presence of which was indicated by the hyperleucocytosis
and bacterial agglutinins in the blood. From these obser¬
vations it will be apparent that the systematic estimation of the
leucocytosis may be of much diagnostic value. By its means
a case of simple alcoholism may be readily differentiated from
more serious conditions. It is stated by Cabot that alco¬
holism is occasionally associated with a hyperleucocytosis.
The fact that a hyperleucocytosis is only sometimes found
would seem to indicate that some complicating source of
toxaemia is occasionally associated with this condition. This
can be readily understood when the state of the alimentary
canal is kept in mind.

These observations are the result of repeated and continuous
estimation of the leucocytosis. An examination of the accom¬
panying charts very clearly shows that a single estimation, or
even half-a-dozen counts, may coincide with a temporary
leucopaenia, and the result of such observations would be
entirely misleading and deceptive.

LVI. 6

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In regard to treatment, I mentioned that, in the cases of
Me A— and W m. B—, terebene abscesses were made in the
flank, and that in consequence the polymorphonuclear leucocy-
tosis rose as high as 21,000 per c.mm. of blood in the former
case, and 30,000 per c.mm. in the latter. As a result—or at
least synchronously with this rise in the polymorphs—there
was an abatement of the acute symptoms and a rapid improve¬
ment in the general tone and character of the physical condition.
The question arises—were these changes in the patient’s condi¬
tion and demeanour a mere coincidence, or were they vitally
connected with the leucocytosis which had been artificially
induced by the injection of terebine ? The literature of
psychiatry contains many instances in which, after an inter¬
current attack of one of the exanthemata, of carbuncles,
erysipelas, or some other severe inflammatory state, unexpected
recoveries have been recorded. Unfortunately such inter¬
current conditions which are followed by a favourable turn in
the mental symptoms are of exceptional rather than common
occurrence. A striking example came under my notice about
twelve months ago. A female patient was admitted into this
asylum suffering from melancholia of the manic-depressive
type. She had previously been under treatment here. Two
days prior to admission she set fire to her nightdress, sustain¬
ing a severe and extensive burn over the left thigh and lower
part of the abdomen ; she also received a number of smaller
burns on the fingers of both hands and upon the right thigh.
I only estimated her leucocytosis on two occasions, when it
registered 31,040 polymorphonuclear leucocytes per c.mm. on
the first day, and 30,600 per c.mm. on the second day. She
remained under treatment in the asylum for about three months,
and during that time she showed no mental symptoms beyond
slight irritability and a tendency to be emotional, yet she had
been depressed for five weeks prior to admission, and her
previous attack treated in this asylum lasted for six months.
Dr. Clouston, in his Clinical Lectures on Mental Diseases, says,
“ I think we shall some day be able to inoculate a septic
poison and get a manageable counter-irritant and fever, and so
get the alterative effect of such things, and the reaction and
stimulus to nutrition that follows febrile attacks.”

The “alterative” effect referred to by Dr. Clouston is
what we need to study with the greatest care in order that we

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1910.] BY S. CARLISLE HOWARD, M.D. 83

may understand what produces the effect and the manner in
which it obtains its result.

In examining the leucocytosis of the intercurrent diseases
which are reported in literature as being followed by a remission
of the mental symptoms, it will be found that they are diseases
which are very frequently associated with the phenomenon of
hyperleucocytosis. I have already mentioned that this in¬
crease in the number of the leucocytes is Nature’s method of
repelling, or attempting to repel, the invading and irritating
factors productive of the disease. This rise of the leucocytosis
in these secondary conditions is, I consider, the cause of the
“alterative” effect commented upon by Dr. Clouston. If in
a condition such as mania, which is accompanied by a hypcr-
leucocytosis, an intercurrent disease of an inflammatory nature
occurs, e.g., erysipelas, the leucocytosis, providing the leucocyte-
producing powers of the individual are fairly normal, will, owing
to the extra stimulus, be greatly increased. This addition to
the defensive forces is obviously bound to have a very definite
action upon the course of the primary disease, i.e., the mania,
as well as upon the intcrcurrent condition. By a study of
such accidental cures we see dimly into Nature’s methods
and get a hint of a means we might profitably adopt. To
test the efficacy of this method it remains but to imitate Nature.
This I have done by injecting 1 c.c. of terebene in two of the
cases here quoted, and in doing so I have been able to
corroborate similar results obtained by Dr. Bruce. In some of
Dr. Bruce’s cases the best results followed upon the accidental
contamination of the abscess cavity by Staphylococcus aureus
and other organisms. Such a contamination led to a well-
sustained leucocytosis, and none of the patients presented
disagreeable physical symptoms. In fact they steadily gained
weight and made excellent recoveries.

In all the foregoing cases it will have been noticed that the
general physical symptoms were very much alike. I will
now review these symptoms and also supplement them from
other cases which have come under my observation.

In such toxic cases the patient is usually anaemic and ill-
nourished. These symptoms almost invariably come on a
month or two before any mental symptoms are noticed. The
temperature is irregular and usually subnormal. It frequently
rises a point or two above normal at the beginning or during

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an acute attack. The pulse is irregular in rhythm and tension,
and it increases in both characters at the beginning and during
an acute attack. This observation is valuable in the case of
impulsive patients. It is usually the first sign noticeable, and
when present is distinctly indicative of an impending attack.
The tongue is frequently covered with a dirty white fur, the
breath is foul, and bowels severely constipated. In the course
of an acute attack of mania the teeth and tongue may be
covered with sordes. The appetite is usually poor and variable,
the desire for food is often absent or perverted. The skin
may be dry, or unnaturally moist and greasy. Under these
latter conditions the odour is always offensive, and, in spite
of frequent bathing, usually remains so until convalescence.
Headaches and neuralgic pains are frequently present, and in
women menstruation is often suppressed. The reflexes, both
superficial and deep, are irregularly abnormal.

Such symptoms occur very frequently in the initial stages
of various conditions of disease, and are to be met with in
every-day practice. In them there is nothing very striking.
They are the signs of malaise which may precede many acute
conditions or accompany many chronic ones. In states of
insanity, however, they are alike interesting and suggestive,
especially when observed with a hyperleucocytosis and the
presence of specific agglutinins in the blood. Symptoms
such as these suggest that insanity is not merely a mental
aberration, arising de novo in some part of the central nervous
system, but also a very serious disturbance of the normal
physiological balance. Some authorities hold that such an
upsetting of the physical health is entirely secondary to the
mental disease. Such a statement is incompatible with the
mental improvement which accompanies the return to physical
health in those cases which recover. Further, it cannot be
said that the physical improvement is due to the mental
regeneration, for we very frequently find patients who grow
stronger and healthier in body while not in mind ; in fact the
prognosis in such cases in usually very bad. Again, the
condition of the intestinal flora of these forms of insanity is
considerably changed. Normally, in agar stroke cultures of
the feeces of the human subject, the growth of the Bacillus coli
communis is so abundant that all other organisms are obliterated.
In the insane the growth is stunted and abnormal, and colonies

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i 9 io.]

BY S. CARLISLE HOWARD, M.D.

of cocci are frequently seen between the colonies of coli. In
some cases the coli are very scanty and occasionally almost
absent. A sketch of the growth taken from the feces of a
case of alcoholic mania is given opposite page 74. In it the
Bacillus coli is almost absent and colonics of cocci are very
numerous.

Resumd.

The points deserving notice are :

(1) That the insane as a class possess an inferior grade of
organisation of the nervous system, which may be due to
hereditary factors or may be the result of devitalisation by
toxins—such as accompany syphilis, influenza, and other
allied diseases.

(2) That the balance of this inferiorly organised system may
be readily overthrown by numerous secondary conditions, one
set of which is broadly termed a “ toxtemia.”

(3) That in this country and abroad toxins of some des¬
cription or other, whether of intra- or extra-corporeal origin,
are widely credited as the active cause of the majority of
psychopathic conditions.

(4) That that class of the insane falling under the category
of mania presents a very definite and persistent clinical picture,
a most noteworthy and important feature of which is the hyper-
leucocytosis. Moreover, that the general physical symptoms
are similar to those found in the more common toxic condi¬
tions. This fact, taken in conjunction with the hyperleucocy-
tosis, the abnormal condition of the bacterial flora of the
intestine, and the presence of specific agglutinins in the blood-
serum, strongly support the theory of the toxic origin of these
conditions of insanity.

(5) That maniacal patients as a class form at least 50 per
cent, of the admissions in most asylums, and that therefore
anything which aids in their diagnosis, prognosis, or treatment
is a step of great value.

(6) That for purposes of diagnosis the estimation of the
polymorphonuclear leucocytosis may be of use to differentiate
simple alcoholism from more serious conditions in which alco¬
holic excess has merely precipitated an attack although it
receives the credit of being the exciting cause.

(7) That the systematic observation of the leucocytosis is of

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value in prognosis. It has been shown that in those cases in
which the leucocytic reaction is not marked there is a strong
tendency to chronicity, terminating in fixed delusions and
dementia ; and conversely, that those in whom the leucocyte
reaction is high most frequently recover.

(8) That with regard to treatment by the artificial stimula¬
tion of the leucocytosis, the mental illness is often considerably
shortened, and that an impending attack may be aborted.

References.

(1) L. C. Bruce. — “Symptoms and /Etiology of Mania,” Editi. Med.
Tourn., February, 1908, p. 119.

(2) C. J. Shaw.—“Opsonic Index to Various Organisms,” Journ.
Ment. Sri.. January, 1908.

(3) L. C. Bruce.— Studies in Clinical Psychiatry , 1906.

(4) J. Macpherson.— Mental Affections , 1899, pp. 52, 53.

(5) J. Macpherson.—“Mania and Melancholia,” Journ. Ment. Sri.,
1891, p. 212.

(6) Ford Robertson.— Pathology of Metital Diseases, 1900.

(7) T. Claye Shaw.—“ Introductory Address to the Section of
Psychological Medicine.” Brit. Med. Journ., September 28th, 1907.

(8) Bianchi and Piccinino.— Vide Ford Robertson, loc. cit., p. 240.

(9) D’Abundo and Agostini.— Ibid., p. 341.

(10) Da Costa.— Clinical Hcematology, 1906.

(11) Alf. C. Coles.— Diseases of the Blood, 1908.

(') The essay for which was awarded the bronze medal of the Medico-Psycho¬
logical Association, 1908.

The Histological Evidence that Toxins reach the Spinal
Cord via the Spinal Roots ; with Special Reference
to Plasma-Cells. By David Orr, M.D., and R. G.
Rows, M.D.

In May, 1907, we published the results of our first series
of experiments dealing with the question of toxic absorption
along the lymphatic paths of nerves and the effects upon the
spinal cord, medulla, and pons.

The experiment consisted in placing a celloidin capsule
containing a broth culture of an organism underneath the
sciatic nerve or under the skin of the cheek of rabbits and
dogs, and we held from the microscopical examination of the

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1910.] BV DAVID ORR, M.D., AND R. G. ROWS, M.D. 87

tissues that toxins travelled upwards in the perineural sheath.
On reaching the cord they induce degeneration of the myelin,
commencing at the point where the fibres lose their neurilemma
sheath and become incorporated in the central nervous system.

We have continued our investigations into the above
question, and naturally many side-issues have arisen, but what
has engaged our attention most has been the observation of
the histological changes in the nerve between the toxic focus
and the spinal cord. We thought that, once the histological
reaction had been observed and its character noted, our
original thesis would rest on the more secure basis of con¬
firmatory evidence, and so we would be free to enlarge the
scope of our investigations.

Our experimental work is by no means complete. There
are several points which require careful control, and so we can
only show one part of the investigation on hand. Our method
is precisely the same as formerly, with this exception, that in
this section of our experiments we endeavour to obtain a
toxic effect of a subacute or chronic nature. In this demon¬
stration, then, we hope to show the histological evidence for
believing that the toxins gain the perineural lymphatic system,
spread between the fasciculi of the nerve along the septa, and
into the nerve-bundles to some extent, and, it will be seen,
pass upwards over the spinal root ganglia to reach the cord
by both anterior and posterior nerve-roots. The toxins while
travelling towards the cord affect the non-nervous elements,
especially the vessels, to a much greater degree than the
fibres of the nerve or the cells of the root ganglia ; and the
reaction is of an irritative or subacute nature. The changes
in the perineurium are most intense at the site of the capsule.
One important fact to be noted is the early reaction around
the capillaries and the veins, a fact which seems to point to
these structures being the channel by which the lymph makes
its way back into the general circulation rather than to any
selective action on the part of the toxin.

The capsule with the inflammatory reaction around it was
cut in transverse section. The organisms inside stained well.
Outside, in the immediate neighbourhood of the capsule, there
were some small groups of organisms. The exudate sur¬
rounding the capsule was composed of three layers: (1) a
layer of degenerated polymorphonuclear leucocytes, and cells

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with a large nucleus and a considerable quantity of protoplasm
which stained imperfectly and showed marked regressive
changes; (2) a fibrous layer in whose meshes were many
fairly well stained round mononucleated cells ; (3) a layer
composed of mononucleated cells and typical plasma-cells.

On examining the nerve the most striking feature was the
large collection of plasma-cells lying in the meshes of the
perineural sheath. Many of these lay loose in the spaces,
but they were for the most part collected in groups round the
veins, which were dilated, and infiltrated their adventitial wall.

In the sciatic nerve, root ganglia and spinal roots, there were
proliferative changes in the smallest vessels, the earliest of
which consisted in the presence of small round cells in the
adventitial sheath. The more advanced irritative phenomena
consisted in the development of a periarteritis bearing a striking
resemblance to that found in a chronic encephalitis such as is
seen in general paralysis of the insane. At this stage the
proliferation in the adventitial sheath is composed of adventitial
cells, some mononucleated cells, and typical plasma-cells.
Many of the finest capillaries show only plasma-cell formation
in the adventitial sheath.

In the posterior root ganglion the nerve-cells showed a mild
degree of degenerative change, but the capsular cells around
each nerve-cell were greatly increased in number, and in many
instances had invaded the nervous elements. Plasma-cells in
large numbers were still met with in the lymph-spaces of the
sheath of the ganglion, and at the proximal pole of the latter
there was often a large collection of typical plasma-cells
situated in the interval between the anterior and posterior
spinal roots.

In the anterior and posterior spinal roots the reaction around
the small vessels was, as indicated above, very marked, and
plasma-cell formation was a prominent feature. Some veins
in this situation showed at times large collections of small
round cells in the adventitial lymph-spaces. Occasionally one
observed small circumscribed areas in which the myelin was
atrophied, leaving the axis-cylinder bare. In the space so
formed there were, not infrequently, typical reticulate cells, the
“ Gitterzellen ” of Nissl. Finally, it is worthy of note that no
proliferation or cell grouping has been seen around the arterioles.

In the histological changes which we have shown you one

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has no difficulty in recognising the results of irritation, and
owing to the nature of the experiment and the distribution of
the lesions the reaction cannot be otherwise than due to
lymphogenous toxicity. The lesions must map out the course
of the toxic lymph, and therefore pathology teaches us, in this
instance, the path of lymph-flow in nerves.

But we are inclined to go one step further, and apply our
results to the pathology of general paralysis of the insane, in
which the irritative vascular phenomena and those of the sup¬
porting tissues of the brain are a constant, marked, and pro¬
gressive feature. Just as in this series of experiments, so in
general paralysis of the insane the adventitial lymph-space
infiltration, composed of proliferated adventitial cells and plasma-
cells, is one of the most striking histological findings. Clinical
and pathological investigations point clearly to the fact that
general paralysis of the insane is a toxi-infective encephalitis
of a subacute or chronic nature, and the changes found are
not comparable to those seen in blood infection or intoxication.
We suggest, therefore, that whatever may be the exciting agent
in the causation of this disease, its primary and even its later
effects are exerted via the lymph-channels connected with those
of the central nervous system, and that absorption of toxins
along nerves is worthy of attention.

Ependymal Alterations in General Paralysis. By
Harvey Baird, M.D.Edin., Senior Assistant Medical
Officer, Cardiff City Mental Hospital.

A GRANULAR condition of the ventricular ependyma,
especially that of the fourth ventricle, has long been recognised
as one of the most important of the post-mortem lesions of
general paralysis. In the opinion of the writer it is present in
at least 90 per cent, of the cases, and the more carefully the
examination of the ependyma is made, the greater will be the
percentage of cases showing granulation in asylum post-mortem
books. In the Journal of Mental Science , July, 1905, the
writer (1) recorded the frequency of this condition in an analysis
of 1 3 1 consecutive post-mortems on male paralytics at Wakefield

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90 EPENDYMAL ALTERATIONS IN GENERAL PARALYSIS, [Jan.,

Asylum, and on 112 male and 19 female cases at Horton
Asylum. The percentages were 87 8, 90, and IOO respec¬
tively. Blatchford (2) ( Journal of Mental Science , 1903,
p. 483) states 70 per cent, of paralytics were recorded as
exhibiting granular ependyma, and of the non-paralytic deaths
i6'6 per cent, of men and 5 3 per cent, of women. There were
83 paralytic deaths and 369 non-paralytic. The writer is
convinced that granularity of the ependyma, especially that of
the fourth ventricle, is the most valuable naked-eye diagnostic
sign of general paralysis. This statement is supported by that
of Bolton (3), who considers the most characteristic naked-eye
sign of dementia paralytica to be granularity of the ventricular
ependyma, referring specially to the lower half of the fourth
ventricle.

Apart from general paralysis, granulations are stated to be
met with occasionally in hydrocephalus, in dementia associated
with senility or cardio-vascular degeneration, and in some coarse
organic lesions. In the writer’s opinion one is most likely to
meet the condition in cases of progressive senile dementia. In
the dementia cases the lateral ventricle more frequently and
more prominently exhibits the condition. The writer has,
however, observed in the case of a woman, set. 73, well-marked
granulations down to the calamus scriptorius.

Admitting, then, the frequency and importance of the lesion,
its nature of formation may be discussed. It is somewhat
strange that, considering the vast amount of work in connec¬
tion with general paralysis, comparatively little attention has
been paid to this condition. Thus no mention is made of it in
Bevan Lewis’s (4) text-book, which devotes much space to
the pathology of general paralysis, and only a few lines in the
portion of the recent atlas of Nissl and Alzheimer (5) dealing
with the histo-pathology of the disease. Ernest Jones (6), in a
recent address on the pathology of general paralysis, makes no
mention of the ependyma. It is also curious that, notwith¬
standing the enormous amount of attention given to the
examination of the cerebro-spinal fluid, little should be said of
the cells lining the cavities in which much of that fluid lies.

Various opinions have been given as to the nature of
granular ependyma. Beadles (7) ( Journal of Mental Science,
vol. xli, p. 32), assumes as irritant causes degeneration and pro¬
liferation of epithelium, probably causing downgrowths. Then

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BY HARVEY BAIRD, M.D.

connective tissue from the neuroglia and the outermost coats of
the vessels undergoes active increase, causing wart-like growths
on the surface. Pelizzi (8) (Rivis/n Sperimentale di Freniatria,
1896, p. 496) says the granulations are essentially composed of
proliferated neuroglia, and surface epithelium plays no part in
their formation. Weigert says the granulations are due to the
loss of the resistance of the normal epithelium checking the
growth of the neuroglia. Bolton thinks that the cholin and
nucleoproteid in cerebro-spinal fluid cause an irritative over¬
growth, and also that syphilis may play a part. Dagonet (9)
(“ La Neuroglie dans la Generate,” Soc. Clin. Med. Metit., June,
1908) states that the granulations are thickened tufts of
neuroglial fibres, which project into the spaces of the cavities,
but states that some of the ependymal fibres may play a part
in their formation.

Ford-Robertson (10) states that the ependymal granulations
are neuroglial, though submitting elsewhere (1 1) that the
granulations in the pia-arachnoid are epithelial.

Before committing one’s self to an opinion as to the forma¬
tion of granulations, a description may be given of the appear¬
ance of sections of cases in all stages, from that of normal to
that of marked “ frosted-glass ” granulations. Twenty cases
were taken. The stains principally used were Nissl’s blue,
haematoxylin, and Weigert’s neuroglia stain.

Normally, the ventricular aspect of the medulla is covered
by a layer of epithelium, cubical or cylindrical in shape, the
nucleus staining deeply with Nissl’s blue, the body of the cell
fairly deeply. Underneath the epithelium is a layer containing
few nuclei, and consisting mainly of fibres running parallel to
the surface. The thickness of this layer varies ; it is usually
more evident towards the middle line. Thirdly, one comes
upon many more nuclei, deeply stained, and the cell-body
sometimes showing. This is continuous with the general
structure of the medulla, but the cells proliferate to such an
extent in some cases that it may be called a layer. In the
lateral ventricle it is a distinct thin layer over the grey matter.
The principal feature to bear in mind is that there is first
epithelium, next a layer with very few cells, then a considerable
number of cells.

When the ependyma appears granular to the naked eye
many differencies appear on section, and in the slighter cases

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especially similar naked-eye appearances may be the result of
dissimilar microscopic alterations.

(1) Firstly, there may be simple proliferation of the surface-

cells, with no downgrowths. There may be seven or eight
layers of epithelial cells, those on the surface being dead. This
condition alone is rare in the medulla in general paralysis ; it
is usually accompanied by downgrowths or by budding-out
granulations, but in senile dementia there may be simple
proliferation only, and in the lateral ventricle in general para¬
lysis. The writer has also noted this epithelial proliferation in
a case of melancholia dying of phthisis, but in which there had
been syphilis. ,

(2) There may be invaginations or foldings, giving a wavy
or convoluted aspect to the surface, accompanied by very
slight or almost no epithelial proliferation. Deep invagination,
with very slight epithelial proliferation, the writer has only
seen in the lateral ventricle.

(3) Ingrowths, associated with localised proliferation of
epithelial cells, are probably the commonest alterations seen in
the slighter cases of granularity. A row of cells may grow
directly downwards or in a slanting direction. Often at the
end of the row is a distinct clump or cluster. On the other
hand, a localised aggregation may be just beneath the surface.
This later condition may also be observed in senile cases, and
there may be no naked-eye evidence of granularity in such.

(4) Sometimes the surface-cells proliferate densely at places,
and become more or less arranged in rows. The inner cells
tend to have their long axes transverse before any fibres are
laid down. At other places, instead of a dense row of cells
only, it appears as if the original layer split into two rows, and
enclosed between are cells with their long axes parallel to the
surface, and with some fibre formation. Elsewhere this fibre
formation is still more distinct, and the inner layer of cells,
like those on the surface, may or may not persist. The result
of this process is to produce a thick fibrous membrane, con¬
sisting of rows of cells and fibres parallel to the surface. The
external layer of cubical cells may disappear.

(5) Distinct budding-out granulations may be the most
evident alteration. The granulation is a projecting tuft which
may be entirely covered with the usual surface epithelium, or
only partially so, or not at all. Some show surface cells half

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BY HARVEY BAIRD, M.D.

way up their sides. Probably trauma is responsible for the
loss of the upper part. Occasionally the granulation has a
pediculated aspect, and it may even at times resemble some¬
what a figure of eight. The interior of the granulation consists
of cells parallel to the surface and a few fibres. The cells are
usually smaller than those just described in the fibrous mem¬
brane formation, and the fibres fewer. Sometimes the granula¬
tion appears to consist almost entirely of epithelial cells,
arranged in whorls, and with scarcely any fibre formation.
Just below the granulation is very frequently a cluster of
epithelial cells of the same nature as the surface cells. Often
the cluster is obviously the termination of a direct down-
growth from the epithelium on the surface, there being a con¬
tinuous row of cells. Again, one often sees a big cluster at
each side of the base of the granulation, and a row or two con¬
necting the clusters. Frequently isolated clumps of epithelial
cells which have grown inwards are arranged circularly,
appearing like a transverse section of a gland, or like the
central canal of the spinal cord. These clusters are also seen
not connected with granulations. Often the in-grown cells
form a distinct layer, which may extend the whole distance of
the surface of the ventricle.

(6) Lastly, an advanced case, with great thickening, may
be described. Here we find no cubical cells on the surface,
but at once come upon an enormous number of flattened cells
and fibres, all parallel to the surface, and arranged very
uniformly. The thickness of the layer as a whole varies,
being usually very marked centrally, and completely obliterat¬
ing the V of the lower part of the medulla. The layer may
consist of as many as forty rows of these cells. Next we
come upon clusters and rows of cells like the original epithe¬
lium, and similar to the clusters the result of downgrowth,
described previously. The clusters here are so numerous that
they practically form a layer, though an irregular one both as
regards depth from surface and arrangement. A cluster may
be in the midst of the flat cells, but most of them are below.
Next is the layer with few cells, which varies much in
thickness. At places it may be as thick as the outside layer
of flat cells, at others it is very thin. It is to be noted in all
these sections that in whatever way the epithelium has altered,
whether by forming budding-out granulations or a more

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uniform thickened membrane, this layer with few cells is
always underneath. The layer is itself certainly increased in
thickness frequently.

From these remarks it is evident that one must conclude
that in granular ependyma by far the main element is epithelial
change. There is proliferation, downgrowth, cluster formation,
the laying down by the outer cells of fibres and the cells
becoming arranged in layers parallel to the surface. The
presence of budding-out granulations or of a membrane
thickened generally, depends probably on whether the epithelial
change is localised or general. If localised the proliferating
cells below shoot the granulation out. The view that the
condition is due to ordinary neuroglial overgrowth seems to me
untenable. Why should the neuroglia specially bud out beneath
the ependyma, and not, say, on the surface of the cortex ? In
sections stained by Weigert’s method one does not see the
surface belt of neuroglia turning up into the granulation. Often
one can demonstrate the two to be apart, e.g., a row of epithelial
cells may separate them. The fibres, however, if present in
a granulation, can take on Weigert’s stain. Hence the view
may be held that these granulations consist of a kind of
neuroglia, not formed by outgrowth from the ordinary neuroglia
beneath, but, both neuroglia and ependyma being epiblastic, by
the ependymal cells practically becoming neuroglia cells as
they lay down fibres.

Another point to consider is the primary or secondary
nature of the epithelial change. Probably the majority of
observers have concluded that the epithelial proliferation is
the result of irritative products in the cerebro-spinal fluid.
The writer is inclined to believe the condition a primary one.
If the lesion were confined to the surface, irritation from the
fluid might cause overgrowth, but even that is doubtful.
Warts on the hands, for instance, are not caused by external
agencies. Further, the granular ependyma is evident, no
matter how early the case. It appears more likely that the
condition is one of those general proliferative changes which
characterise general paralysis, e.g., subdural false membrane
formation. Again, these proliferated epithelial cells, many of
them arranged like cells of glands, must have a secretion.
This secretion probably alters the cerebro-spinal fluid. The
secretion may be toxic. The neuroglial overgrowth may be

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JOURNAL OF MENTAL SCIENCE, JANUARY, 1910.

Fig. 4.

To illustrate Dr. Harvey Baird’s paper.

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JOURNAL OF MENTAL SCIENCE, JANUARY, 1910.

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Fig. 6.

Fig. 7.

To illustrate Dr. Harvey Baird's paper.

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13V IIARVEY BAIRD, M.D.

the result of this toxic secretion. There appears to the writer
thus to be an analogy between cancer and general paralysis.
The epithelial proliferation, ingrowth, and formation of clusters
are suggestive, coupled with the progressively fatal course of
both affections.

References.

(1) “Statistical Observations on General Paralysis,” Journal of
Mental Science, vol. li, p. 581.

(2) “ Granular Ependyma in General Paralysis,” ibid., vol. xlix, p. 483.

(3) Ibid., vol. liv, p. 40.

(4) Text-Book of Mental Diseases, pp. 54S—5 75.

(5) Histologische Studien zur Differenzial-diagnose der progressiven
Paralyse von Alois Alzheimer, 1904, p. 139.

(6) Lancet, No. 4 of vol. ii, 1909, p. 209.

(7) Journal of Afental Science, vol. xli, p. 42.

(8) Rivista Sperirnenia/e di Freniatria, 1896, p. 496.

(9) “La Neuroglie dans la Generate,” Soc. Clin. Med. Ment., June,
1908.

(10) Pathology of Mental Diseases, p. 182.

(11) Ibid., p. 125.

DESCRIPTION OF PLATES.

[For these micro-photographs I am indebted to my colleague, Mr. E. Barton
White, who devoted much care to their preparation.]

Fig. 1.—An early stage. Note localised proliferation and downgrowth of
epithelium.

Fig. 2. —An unusual deep downgrowth in lateral ventricle. Same section
exhibits epithelial proliferation elsewhere.

Fig. 3.— Epithelium has grown in, forming a layer, below which the layer with
few cells is well seen. Above, the appearance is as if a granulation had sunk in.

Fig. 4.—A granulation under high power. Note the epithelial cells beneath
arranged in circular fashion, also clumps of cells showing line of ingrowth.

Fig. 5.— An advanced case, showing enormous epithelial overgrowth, with fibre
formation, beneath which is layer of actively proliferating epithelial cells.

Fig. 6.—Another advanced case exhibiting three distinct layers: (1) Epithelial
overgrowth with cells arranged parallel to surface ; (2) cells actively proliferating;
(3) pale layer well seen.

Fig. 7.— The same under high power. Note the acinous arrangement of
epithelial cells.

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96 THE BLOOD-PRESSURE IN MENTAL DISORDERS, [Jan.,

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The Blood-pressure in Mental Disorders. By Sidney
CLARKE, M.A., M.D.Camb., Senior Assistant Medical
Officer, Leicestershire and Rutland Asylum.

Tiie interesting paper by Dr. Turner published in this
Journal (!) upon the blood-pressure in the insane has led
me to make these few remarks, which I have based upon a
large number of observations ( 2 ) obtained by Martin’s modified
Riva-Rocci sphygmomanometer. I attempted besides taking
the systolic pressure to estimate the diastolic also, but my results
in the latter case were not satisfactory, for so many likely errors
were always present.

It has been stated by certain authorities that the blood-
pressure varies in certain forms of insanity, being raised in
melancholia and lowered in mania, etc. To this Dr. Turner
does not agree.

In the first place it must be remembered that the range of
blood-pressure in health is very wide. It lies between ioo—
150 mm. Hg., generally in the neighbourhood of 120 mm. Hg.,
hence care must be taken before attributing a small rise or fall
in the pressure to any particular cause; a change of 10—15
mm. Hg. from the average should at least be present.

I agree with Dr. Turner that in idiots and imbeciles (without
epilepsy) the systolic pressure is low, generally lying around
the lower limit of the normal range, and it seems natural that
this should be so, for these patients often exhibit other signs of
defects in the circulation, such as lividity of the extremities or
an increased frequency of the pulse-rate, etc. My sphygmo-
manometric records were quite in keeping with the general
bodily condition of the patients.

In dementia of the aged the average systolic pressure lay at
the higher limit of the range, and was quite comparable to
that seen in healthy old people. Mental dissolution does not
seem to directly influence the blood-pressure. In those cases
where there was evidence of cardiac failure the blood-pressure
was much lower, and in those with arterio-sclerosis I have
obtained both high and low systolic pressures, which confirms
the opinion that this pathological state of the arteries is not
always associated with a hyperpiesis.

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BY SIDNEY CLARKE, M.A.

Neither in mania nor melancholia did I find any characteristic
change in the average blood-pressure, nor was there any
constant alteration with recovery unless it was accompanied
with a marked improvement in the general bodily health. In
patients after an acute phase of excitement, during which
active and vigorous muscular movements had taken place, a
rise of the systolic pressure was nearly always to be noticed,
and this appeared to me to be comparable to that seen in
healthy persons after exertion. But sometimes a fall could be
registered which could be attributed to fatigue. This was well
marked in one of the patients, whose systolic pressure was
generally about iio mm. Hg. This man one very hot day
walked at a great rate round the garden until he was tired, and
shortly afterwards his blood-pressure had fallen to 76 mm. Hg.
Next day the pressure had returned to the average height.

The finer and purposeless movements of the chronic maniac
or agitated melancholic do not influence the sphygmomano-
metric readings to any marked extent. This form of muscular
activity seems to be of an almost automatic nature, producing
but little energy, and it is conceivable that the muscles do not
require any marked alteration in their blood supply.

Changes in the mental or emotional state alone, unaccom¬
panied by marked restlessness or energetic motor activity, as a
rule did not influence the average blood-pressure, but occa¬
sionally a small rise was observed. I have not noticed any
high pressures in cases of confusional insanity.

My observations (extending over a period of one and a half
years) confirm in the main those of Dr. Turner, and I do not
think that there exists any definite relationship between the
various forms of mental disorders and the general blood-
pressure excepting in cases of congenital deficiency, when the
pressure is as a rule subnormal. The variations which I was
able to record in the blood-pressure were for the most part more
satisfactorily accounted for by the changes in the muscular
activity rather than alterations in the mental states of the
patients under observation.

(') Journal of Mental Science, July, 1909 .—(") " Observations upon the Blood-
Pressure in Mental Disorders,” Thesis, Camb.

LVI.

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98 THE OCCURRENCE OF ORGANISMS IN THE BLOOD, [Jan.

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The Occurrence of Organisms in the Blood and Cerebro¬
spinal Fluid in Mental Diseases. (*) By Winifred
Muirhead, L.R.C.P. & S.Ed., Pathologist Royal Asylum,
Morningside.

In the mass of conflicting evidence which has accumulated
in recent years as to whether organisms are the exciting factor
in the production of certain insanities, I have found it difficult
to discriminate between cause and effect. Is the organism or
group of organisms the specific pathogenesis of certain insanities
or merely a bacteraemia secondary to the psychosis ?

My own observations, which have extended over nearly three
years, have, if anything, increased this difficulty, and yet have
convinced me that there is a great field for further investigation.

Drs. Ford Robertson, McRae, and Jeffrey were the first in
this country to state that a diphtheroid bacillus was the cause
of general paralysis of the insane, and this bacillus was named
Bacillus paralyticans brevis and longus, being of two types. In
later publications Ford Robertson and McRae (i) demonstrated
that the probable site of the infective focus was the genito¬
urinary and lower alimentary canal in tabes, and chiefly in the
mucous membrane of the mouth and naso-pharynx in general
paralysis. They state that they have also been successful in
the treatment of these cases with a polyvalent serum.

Eyre and Flashman (2) have shown that diphtheroid
organisms have been isolated in the mucous membrane of the
throat of the sane as well as the insane, also in other insanities
besides general paralysis.

Lewis Bruce (3), investigating other types of insanity, has
shown that in acute insanities with excitement there is a hyper-
leucocytosis with an increased polynuclear percentage, and that
specific agglutinins are present in the blood-serum of cases of
mania to certain types of streptococci rarely present in the healthy
sane; at the same time there is an absence in 60 per cent, of
maniacal patients of a normal protective agglutinin to certain
streptococci. Bruce found that the Bacillus coli in the intestinal
tract was largely replaced by streptococci, these also being
excreted in the urine, and he suggests that the toxins formed in
the bowel by this overgrowth, and possibly the organisms them¬
selves, as he has succeeded in isolating streptococci from the

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1910 .] BY WINIFRED MUIRHEAD, L.R.C.P.ED. 99

blood of some of these insanities, are absorbed into the general
circulation and act as a cerebral poison.

Bianchi (4) has isolated a bacillus, and members of his clinic
cocci in the blood and meninges of acute delirious insanity, and
yet maintains “ that it remains to be shown whether such
organisms are really pathogenic or aggravating concomitants.”

It seemed to me, if an organism existed in connection with
general paralysis, and was circulating or invaded the general
circulation during a seizure, that although apparently more
difficult, the isolation from the blood or cerebro-spinal fluid was
of the greatest importance to obtain reliable evidence as to,
firstly, whether there was an organism constantly associated
with general paralysis, secondly, whether the organism was
morphologically identical in each case.

I have not succeeded in achieving my object. I have isolated
a bacillus in general paralysis, but also an identical bacillus in
other acute insanities. To prevent confusion I shall call this
bacillus “ Organism A.”

During life, from twenty-five cases of general paralysis I
isolated an identical diphtheroid bacillus in pure culture in
eight from the blood, and in three of these eight from the
cerebro-spinal fluid. In four cases I reduplicated my results
twice and in one case three times from the blood. Briefly, in
32 per cent, of general paralysis I isolated organism A from the
blood, and in 7*5 per cent, from the cerebro-spinal fluid, as many
lumbar punctures were performed.

Table I .—Analysis of Positive Cases of General Paralysis of

Insane

during Life.

No.

Stage of
disease.

Blood.

Blood-

film.

C.S.F.

3 rd

R 1

P s

• >>

• )»

•

• ff

* >» '

. -

• 99

2 nd

—

. —

R, recovery of organism A ; P, bacillus present in blood-film;
-, negative ; \ recovery of organism from spleen of mouse by
inoculation ; 2 , see Fig. 1.

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IOO THE OCCURRENCE OF ORGANISMS IN THE BLOOD, [Jan.,

The blood was withdrawn as early as possible after the com¬
mencement of a seizure, and it was especially in the early
specimens that I succeeded in isolating A from the cerebro¬
spinal fluid. It is interesting to note that in only two of those
three cases did I succeed in isolating A from the cerebro-spinal
fluid post mortem. In the negative as well as positive cases I
repeated the examination two or three times.

From twenty-seven post-mortems of general paralysis I suc¬
ceeded in eight cases, or 29*6 percent., in isolating a pure culture
of organism A. Fifteen of these were examined during life,
five being positive, and in one of these cases (see Table II)
Bacillus paralyticans brevis only was recovered from the cerebro¬
spinal fluid associated with another bacillus. In only one case
did I isolate A from the heart blood.

The Bacillus paralyticans brevis was recovered three times or
11* 1 per cent, from the cerebro-spinal fluid, and twice or 7^4 per
cent, from the bronchi. On these two occasions organism A
was recovered in pure culture from the cerebro-spinal fluid. I
have not succeeded in isolating either the Bacillus paralyticans
brevis or longus from the blood or cerebro-spinal fluid during
life, and have been equally unsuccessful in isolating diphtheroid
bacilli from the urine ante-mortem, and urine, intestinal mucous
membrane and bronchial glands post mortem.

Table II. —Analysis of Post-Mortem in General Paralysis.

Posi¬

tive.

? e g a - C.S.F.
tive.

Bron-

H.B. Lungs. Bronchus, chial
gland.

Intes¬

tines.

Examina-
Urine. tion during
life.

- -

B.P.B. 0

- 0

- -

- 0

B.P.B. -

+ r

- -

0 -

- -

+ r

- -

+ r

1 B.P.B.

- -

- 0

+ r

1 -

- -

- 0

1 -

- -

- 0

1 -

- -

- 0

4- r

- -

' "

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1910.] BY WINIFRED MUIRHEAD, L.R.C.P.ED.

IOI

Table II— continued.

Posi- Nega¬
tive. tive.

C.S.F.

Bron-

H.B. Lungs. Bronchus, chial
gland.

Intes¬

tines.

Examina-
Urine. tion during
life.

- - - O

-----

- - - -

0 - - 0

0 - - -

- - - 0

- 0

- - - 0

B.P.B.

- - - 0

B.P.B.

- - - 0

8 19

A, organism A ;

B.P.B., Bacillus paralyticans brevis ;

- nega-

tive; o, no examination; -f, examination; r, recovery of
organism A.

In conclusion, from an examination of fifty-two cases of general
paralysis ante-mortem and post mortem I isolated an identical
organism in sixteen of them, or 307 per cent., and in five cases,
or 97 per cent., post mortem the Bacillus paralyticans brevis of
Ford Robertson was recovered. Five of these general para¬
lytics were females, and in only one post mortem I isolated A
from the cerebro-spinal fluid. This woman was pregnant; the
child was born alive at about eight months, with no signs of
congenital syphilis, and lived a few hours. No diphtheroid
organisms were isolated from the child, and the microscopical
appearances of the brain were those of a normal foetus. The
only other living child presented some stigmata of congenital
syphilis. Sections of the brain of all post-mortems were typical
of general paralysis.

From twenty-nine cases of other insanities, I isolated
organism A from the blood in seven out of twenty cases of
delirious insanity, or 35 per cent. The twenty-first case of
delirious insanity was suffering from enteric fever and the
specific bacillus was isolated from the blood twice. All these

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102 THE OCCURRENCE OF ORGANISMS IN THE BLOOD, [Jan.,

patients were acutely ill with rapid pulse, subnormal or raised
temperature, and often a hyperleucocytosis. The temperature
on admission usually was above normal; the extreme “ ill look ”
of the patient was very obvious.

In many of the cases the cerebro-spinal fluid was examined
bacteriologically with negative results, both for organisms and
increase of lymphocytes.

I had no opportunity of making post-mortems in any of these
seven cases.

The blood from four normal male controls proved sterile.

Table III. —Analysis of Bacteriological Examination of Blood

in other Insanities.

Type.

No.

Posi¬

tive.

Organism.

Nega¬

tive.

P.M.

Senile insanity with seizures

___

Negative.

Delirious insanity 1

Organism A

„ „ typhoid* .

B. typhosus
abdominalis

Excited dementia 3

Streptothrix*

C.S.F. strepto¬
thrix.

Dementia praecox

—

Delusional insanity

—

Acute cerebral softening

—

Negative.

Normal controls .

O, No examination. *. See Fig. 2. Associated with a delicate diplococcus.
See Fig. 4. >, Four of these delirious insanities were young women with symptoms
of chorea. In one case in particular, a girl, set. 16, the cause of her insanity being
acute rheumatic fever, her condition was such as to give very little hope of her
recovery. The blood was withdrawn a few hours after admission, and in the broth
culture there were two organisms, A and a delicately growing diplococcus which
might have been the Micrococcus rheumaticus ; unfortunately I lost it at the
second subculture. 3 , The patient, a male, although over the usual age for
general paralysis, clinically resembled a rapidly progressing one closely. He was
so restless that an anaesthetic was necessary both for lumbar puncture and with¬
drawal of blood. The cerebro-spinal fluid was greatly increased in amount and
pressure, the latter possibly due to the high blood-pressure, but no increase of
lymphocytes was present and it proved sterile. In the broth culture from the
blood there were two organisms, a very delicately growing streptothrix and a
coccus. Both of these strains I was unable to cultivate artificially after the first
subculture. Three months later I again isolated a delicately growing streptothrix
from the fluid of a hasmatoma auris, this time associated with a diphtheroid bacillus
of the Hoffmann variety. The former again lost at the second subculture. Post¬
mortem six months later; a streptothrix was isolated in pure culture from the
cerebro-spinal fluid, this time a much coarser variety which grew vigorously for a
few months and then quite suddenly died. This sequence points to more than a
coincidence, and, if only such, is a very interesting one.

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1910.] BY WINIFRED MUIRHEAD, L.R.C.P.ED. 103

Technique .—The arm at the elbow is sterilised as for opera¬
tion ; a compress of corrosive sublimate in spirit 1 in 1000 is
applied, if in case of general paralysis, immediately on com¬
mencement of seizure, and, in case of acute insanities, soon
after admission. This soak remains on half-an-hour to several
hours according to the time at the disposal. A tourniquet is
applied, the soak is removed, a little ether is rubbed over the
exposed median basilic vein, and the needle of the syringe is
immediately inserted into it; 10 c.c. of blood is withdrawn and
at once emptied as equally as possible into three flasks contain¬
ing 100 c.c. of Bouillon. Care must be taken to have no
draught and the operation performed quickly.

For lumbar puncture the back is sterilised in the same way
and all other precautions observed. With restless patients it
seems to be easier to control them in bed, and if the patient is
extremely restless it certainly is safer to give an ansesthetic, as
even with a platinum needle there is danger of it being
broken.

The syringe used for the blood is graduated to hold 10 c.c.;
there are no joints, the point is ground to fit the needle
accurately, and the other end drawn out and narrowed is
plugged, not too tightly, with cotton-wool, and over this rubber
tubing is slipped for suction if necessary. The whole syringe
is enclosed in a glass tube plugged at the ends with wool. It
is sterilised by hot air raising the temperature to 175 C°.

For lumbar puncture, platinum needles four inches long are
conveniently sterilised by hot air in test-tubes, and again, if
suction is necessary, Burroughs Wellcome & Co.’s all-glass
hypodermic syringe, which has been sterilised in test-tubes by
hot air, can be inserted into the needle and suction applied by
the withdrawal of the piston. The fluid is collected into
sterile centrifuge tubes.

Blood-films are made as soon as possible, the lobe of the ear
is gently cleaned with water and ether, and films are made on
clean slides or long cover-glasses by \ in. with cigarette-
paper, then stained with either Jenner or Leishman’s stain.
The broth flasks are incubated at 37 0 C. for forty-eight
hours, hanging-drop preparations are then made, and also
plate-cultures of agar or bynohsemoglobin agar 5 per cent. If
there is a growth in the broth it is always very slight, and in the
H. D. will perhaps show a very few small clumps of bacilli.

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It is extremely difficult to subculture from the broth, and I
have often made two or three plates from one flask, never
using less than i c.c. of the broth for plating, which I collect
in a sterile pipette, and possibly only one of these plates will
have a single colony. Subcultured on agar the growth will be
feeble for one or two subcultures at short intervals.

At post-mortems the brain is removed from the skull, the
surface over the third ventricle is seared with a red-hot iron, a
sterile pipette is inserted into the ventricle, and 5 c.c. of
cerebro-spinal fluid is withdrawn; a certain portion is emptied
into broth, while the remainder is emptied into a sterile centri¬
fuge tube. If more fluid is withdrawn the surface is again
seared and a fresh pipette is used. Cultures are made on agar
and broth from the centrifuge deposit in each tube, and
microscopic examination is also made.

Heart blood. —The heart is exposed, the surface seared, a
sterile knife is plunged into this area, and the blood is with¬
drawn with a sterile pipette and emptied into an agar and broth.

Bladder. —The surface is seared, an opening is made with a
sterile knife, the urine is withdrawn by means of a pipette and
is emptied into broth. Microscopic examination is also made.

Lung. —Pneumonic or other patch is seared, a sterile knife is
used to open inner surface, a platinum loop is drawn over the
part, and the material is planted on agar and broth.

Bronchus. —The upper part of the tube is seared as far as
possible with the pointed end of the iron, then a platinum loop
is inserted into the tube and the material planted on agar and
broth.

Intestinal mucous membrane. —The surface is seared, the peri¬
toneal and outer coats are cut, the inner coat is gently scraped
with a blunt director, and the material planted in broth.

Morphology. —Organism A is a bacillus which belongs to the
group of Coryne-bacterium of the diphtheria type. Most
commonly a short bacillus with a central segment and some¬
what pointed ends, fairly pleomorphic, varying to a long
cylindrical bacillus showing two or three segments, clubbed
forms and “ peg-top ” forms, which have a tendency to being
curved. Length varies from 1-6 n, and in thickness from
0*4-1 /u at clubbed ends. On liquid media and stained smears
the bacilli group in “ Chinese letters,” clumps, rosettes, or they
may lie parallel; occasionally long unbranched threads. In

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1910.] BY WINIFRED MUIRHEAD, L.R.C.P.ED.

105

blood-films I have found them as single bacilli, usually showing
central segment, or small groups, and often with the bacilli
parallel to each other. Metachromatic granules are also invari¬
ably present in twenty-four hours in agar and bynohcemoglobin
agar cultures, bipolar, or irregularly distributed, and vary in
size. Compared with two strains of typical diphtheria bacilli
the granules persisted longer in old cultures and were more
irregular in size and distribution. It stains well with all aniline
dyes, Neisser positive, Gram positive, but very easily decolour¬
ised.

Pathogenicity .—Very slightly pathogenic to mice, possibly
because of the large dose given relative to the weight of the
animal. The first occasion in which I isolated the organism
from the blood was by inoculating a broth culture from the
blood into a mouse subcutaneously; this animal was killed in
six days, and organism A recovered in pure culture from the
spleen. A second control mouse was left, and in two weeks it
was dying with symptoms of paresis of the left side of the body.
No organisms isolated, and owing to an unfortunate accident
brain and spinal cord were lost. Testing pathogenicity of
thirteen strains of organism A, five of them were pathogenic to
mice from one to three days with a dose of 2 c.c. twenty-four
hours’ broth culture subcutaneously. The mice used were all
about the same age, and excepting for two strains those used
were over two years old. It did not prove pathogenic to rabbits
and guinea-pigs, although with intra-peritoneal inoculation a
definite malaise was present lasting from twenty-four to forty-
eight hours. The virulence for these animals was not raised by
passage through a mouse.

Cultural reactions.

Agar.

Bynohaemoglobin agar 5 per cent.

Glycerine agar 6 per cent. .

Agar stab.

„ plate .

] Very delicate, flat greyish growth
confined to streak; discrete and
confluent colonies, “ frosted glass ”
appearance.

Semi-translucent, old cultures dryish.

Growth in course of stab small dis¬
crete colonies, somewhat beaded
appearance, not spreading.

Very small pin-point colonies, not
spreading, flat, dryish, not sym¬
metrically round, x 50 ; granular
appearance ; periphery wavy, yel¬
lowish colour and more dense in
centre.

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Cultural reactions.
Blood serum (Loeffler)

Potato alkaline .

Gelatine streak and stab 22 0 C. .
Broth .

Nitrate broth o - 5 per cent. .

Lead broth o‘i per cent.

Litmus milk ....

Glucose peptone litmus water 1
per cent.

Dextrose peptone litmus water 1
per cent.

Saccharose peptone litmus water '
1 per cent.

Lactose peptone litmus water 1
per cent.

Maltose peptone litmus water 1
per cent.

Inuline peptone litmus water 1
per cent.

Formate peptone litmus water 0^4
per cent.

Anaerobic broth.

„ glucose formate broth .

Grows much more feebly than on
agar and not a typical growth as
with B. diphtherice.

No apparent growth; fair number of
involution forms, short and swol¬
len, not nearly so pleomorphic as
with B. diphtherice.

Grows very feebly.

Clear, fine powdery or slightly floc-
culent deposit, sticking to tube,
acid, later slightly alkaline or
neutral. Trace of indol.

As in broth, most strains gave a
trace of nitrites.

No apparent growth; very few
strains gave trace of H 9 S.

No coagulation, no change, or
either slightly acid or alkaline.

Clear, powdery deposit, acid no
pellicle.

Clear, powdery deposit, acid with
majority of strains.

Clear, powdery deposit, acid or
alkaline equally.

Clear, powdery deposit, acid.

[ Grows very feebly.

Temperature .—Grows best at 35-37 0 C., feebly at room tem¬
perature, and easily dies at temperature above 40° C. Sub¬
cultures made after ten days at 37 0 C., and six weeks at 22 0 C.
grow very feebly. Subcultures after fourteen days at 22 0 C.
grow well.

Hiss serum water media I have not found satisfactory.
Variations were continually present in the cultural reactions
with the same batch of media.

As regards vaccines in treatment, these failed to make any
difference, and in only one case did I obtain any reaction, viz.,
a general paralytic, third stage, who had been having small
doses of his own vaccine without any result. The dose then

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1910.] BY WINIFRED MUIRHEAD, L.R.C.P.ED.

107

was enormously increased, jumping from 8,000,000 bacilli to
110,000,000; the temperature rose (no local reason), a leuco-
cytosis was present, and mentally he became confused, excited,
and dirty in his habits. He slowly returned to his normal
condition. No control inoculation of a totally different vaccine,
such as staphylococci, was performed.

The opsonic index I found too variable to be able to draw
any reliable conclusions.

Conclusions .—What is the pathological significance of this
organism in these two mental diseases ? Is it a causal factor,
or is it merely a concomitant ? Can we attach any patho¬
logical importance to it ? Where is the source of the infective
focus ?

In answer to the first of these questions, if this bacillus is a
cause of general paralysis and delirious insanity it is absolutely
impossible to ignore the incidence of syphilis in the former,
which we therefore must reckon as a predisposing agent, and
this predisposing agent must of necessity have the power to
give general paralysis the characteristic symptoms which are
present in no other type of insanity. Syphilis as a predisposing
cause in delirious insanity is a negligible quantity. Now of
those two different insanities where I have isolated this bacillus,
in one, viz., general paralysis, we assign to the almost invariable
predisposing cause of syphilis a most important place, while in
the other, viz., delirious insanity, the predisposing causes are
acknowledged to be many and varied, and “ inherited insta¬
bility ” will possibly be the only condition almost invariably
present.

Presuming that organism A is the cause of general paralysis
and delirious insanity, it would appear that the predisposing
factor of syphilis is a more important factor than the causal
agent in the production of the former.

Again, the percentage of cases in which I have obtained
this organism in both insanities is comparatively small.

The result of the few animal experiments has not as yet
been confirmatory; there is a slight pathogenicity, but the
toxicity of the organism appears to be low. Vaccine treatment
also did not prove satisfactory.

Therefore I do not consider that I have brought forward
sufficient evidence to justify a statement that organism A is
the cause of general paralysis and delirious insanity.

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In answer to the second and third points raised, it is quite
possible that this organism is a concomitant and probably to a
certain extent an aggravating one. I obtained it only once in
a second stage general paralytic, and this man ultimately
progressed rapidly, otherwise it was obtained in cases well
advanced where the resistive powers were extremely low, and
consequently the invasion of organisms would have been easy.
Exactly the same condition holds in the seven cases of
delirious insanity who were acutely ill, and I have only
obtained this bacillus in such cases.

In the patient suffering from post-rheumatic delirious
insanity there were two organisms, and it is quite possible
that the diphtheroid bacillus was secondary to the coccus.
In another rapidly progressing case, that of dementia with
excitement, the organisms were also mixed in the blood and
haematoma auris. That a mixed invasion should occur points
still more to the lowered resistive power of these patients.

In negative cases during life, with one or two exceptions of
contamination, the blood was sterile, and post-mortem the heart-
blood most commonly, and the cerebro-spinal fluid on several
occasions, were also sterile.

How can the incidence of the diphtheroid bacillus be
explained ? I do not know, unless it is possible that this
type of bacillus has a certain selective affinity for the nervous
system, with the production of a neuro-toxin of low toxicity.
The fact that the vaccine treatment was not efficacious rather
strengthens the deduction that whatever significance this
bacillus has, it probably is of no great importance.

In answer to the fourth point, I have not yet obtained
sufficient evidence to determine the source of the infection or
to evolve any theories.

References.

(1) “ Morison Lectures” and others, Review of Neurology and
Psychiatry , 1906.

(2) Archives of Neurology, vol. iii.

(3) “ Morison Lectures,” Journal of Mental Science , April, 1908.

(4) Bianchi, Text-book of Psychiatry.

DESCRIPTION OF PLATES.

Fig. 1.—Blood-film from a case of general paralysis, made shortly after the
commencement of a seizure. Stained with Jenner. x 1000.

Fig. 2. —Blood-film from a case of enteric fever, showing two Bacilli typhosus
abdominalis. Stained with Jenner. x 1000.

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JOURNAL OF MENTAL SCIENCE, JANUARY, 1910.

Fig. 2 .

Fig. 3.

To illustrate Dr. Winifred Muirhead s paper.

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JOURNAL OF MENTAL SCIENCE, JANUARY, 1910.

Fig. 4.

Fig. 5.

To illustrate Dr. Winifred Muirhead’s paper.

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PRINCETON UNIVERSITY

JOURNAL OF MENTAL SCIENCE, JANUARY, 1910.

Flo. 6.

Fig. 7.

Fig. 8.

To illustrate Dr. Winifred Muirhead's paper.

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1910 .] OCCASIONAL NOTES. 109

Fig. 3. —Film of organism A. Byno-haemoglobin agar culture 24 hours. Stain
carbol methylene blue, x 600.

Fig. 4.—Film of streptothrix. Plate culture from fluid of haematoma auris;
byno-haemoglobin agar 48 hours. Stained fuchsin. x 1000.

Fig. 5. —Culture of organism A on byno-haemoglobin agar 48 hours. Photo
from drawing.

Fig. 6. —Colony of organism A. Plate byno-haemoglobin agar 24 hours, x 60.

Fig. 7.—Colony of Bacillus paralyticans brevis. Plate byno-haemoglobin agar
24 hours, x 60.

Fig. 8.—Colony of Bacillus paralyticans longus. Plate byno-haemoglobin agar
24 hours. x 60.

(>) The essay for which was awarded the second prize of the Medico-Psycho¬
logical Association, 1909.

Occasional Notes.

The Superannuation Act.

After many years of effort the Superannuation Bill has
passed into an Act of Parliament, and although not fulfilling
the aspirations of the most sanguine, it is to the majority
of prospective pensioners a most satisfactory solution of a
previously unsatisfactory problem.

The gratitude of the Association is especially due to Sir
William Job Collins, whose reputation and skill alone assured
its passage through the House of Commons. It is perhaps
not too much to say that in the hands of any other member
of Parliament it would probably have failed.

To Lord Monk-Bretton an almost equal amount of thanks
are due for his skilful pilotage in the troubled waters of the
Upper House.

Dr. Shuttleworth’s exertions have been beyond all praise,
nor can there be any doubt that the weight of the Asylum
Workers’ Association greatly strengthened his indefatigable
exertions.

The Association, too, must not forget the less conspicuous
but by no means unimportant labours of the Parliamentary
Committee. The steady work of this body for many years
past contributed most importantly to the collection of facts
and the formation of opinions, constituting the ground work
on which the Bill was built.

Thus ends in a most satisfactory manner one of the most

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IIO OCCASIONAL NOTES. [Jan.,

important objects for which this Association has striven during
the last thirty years. The energies that have been so long
occupied in this matter are now free to be used in other
directions. The existing state of the Lunacy Law offers
many opportunities for their employment, and no doubt some
of these will soon be absorbing the activities of that most
valuable body, our Parliamentary Committee.

A report of the Commemorative Dinner, which took place
on December 20th, 1909, appears in this number of the
Journal.

The Section of Psychological Medicine at the British Medical

Association at Belfast.

This Section, held under the Presidency of Dr. Outterson
Wood, appears to have been one of the most successful meetings
in recent years.

The President, in opening the Section, took for his text the
desirability of promoting a much closer connection between
psychiatry and neurology, and the Section, after discussion,
passed a resolution recommending to the Council the desira¬
bility of having a combined Section at future meetings, to be
called “ The Section of Psychological Medicine and Neurology.”

This resolution, we believe, has been adopted by the Council,
and it will be interesting to observe the results of this new
departure. The President’s view that it will be of advantage
to both these departments of medicine will probably be amply
verified.

Dr. Mercier contributed a valuable and interesting paper on
somatic delusions and local lesions. Dr. Shuttleworth’s paper
on Mongolian imbecility was also of great interest both for its
subject-matter and its illustrations. Dr. MacCormac contributed
a paper on the superficial and deep reflexes in relation to
various forms of mental disease, which possessed the merit of
much originality of observation. Dr. Crothers’ paper on here¬
dity in the causation of inebriety was a useful addition to this
aspect of the subject. The report of the Royal Commission
on the Care and Control of the Feeble-minded was very ably
brought under consideration by Dr. Dawson.

Abstracts of these papers were published in the British

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IQIO.]

OCCASIONAL NOTES.

I I I

Medical Journal of September 11 th, and are evidence of the
valuable work of the Section.

The Section also passed a resolution commending the Super¬
annuation Bill, and another drawing the attention of the
National University and of the Queen’s University to the
desirability of establishing lectureships in mental diseases.

Sir James M. Moody.

The honour of knighthood conferred on Sir James M. Moody
will be appreciated by every member of the specialty as a
recognition of its claims to a share in the distinctions so liber¬
ally awarded in several of the public services and so parsi¬
moniously allotted to others.

Every member of the Association will concur on personal
grounds in congratulating Sir James on his hardly earned and
well-deserved distinction, and join in wishing him a long
enjoyment of his honour.

The marvel, however, is not that one member of the specialty
has received such distinction, but that it has not been extended
to many more. The management of great institutions of two
thousand patients and upwards certainly demands a degree of
ability and capacity for protracted service such as is required
of few officials of Government departments in which honours
are obtained almost as a matter of course.

In each of the three kingdoms are to be found men who, in
the midst of their arduous and successful administrative work,
have found energy for literary and scientific activity, not in¬
frequently associated with teaching in universities and medical
schools. It is to be wished that some of the honours, often
won by mere routine departmental drudgery, might find their
way to the encouragement of these splendid workers.

The honour conferred on Sir James Moody may be con¬
sidered as an omen of a wider recognition of public merit,
which has been hitherto too largely limited to those servants
of the Crown more directly in touch with the national
exchequer.

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I 12

OCCASIONAL NOTES.

[Jan.,

The Library.

The Library of the Association, to which especial attention
is again drawn by a notice in “ Notes and News,” is worthy of
more support than has been hitherto accorded to it.

The members of the Association are scattered in isolated
groups of two and three throughout the country, a large
majority of them being remote from access to any consider¬
able scientific library. Under such circumstances, if the
scientific spirit is to be encouraged and developed, it is
absolutely essential that opportunities of seeing and consult¬
ing the best and most recent scientific works and periodical
publications is absolutely essential.

The individual members of the asylum staff cannot do this
without an outlay, which would be a very serious sacrifice of
income ; neither can the governing body of the individual
asylums be expected to make such an expenditure.

A subscription to such a library as Lewis’s will no doubt give
a supply of current works, but cannot supply the more serious
works and periodical literature which are of greater impor¬
tance.

The problem for the circulating library of the Association
is principally this of providing the periodical literature. The
Journal receives a considerable number for review, but hitherto
these have been used up in the reviewing. It is hoped that
many of these will be available in future for the Library, but
they will probably not be usable during the current year of
issue.

An ample supply of periodicals might be obtained if asylum
committees would make a small grant for the purchase of such
periodicals, and if the asylums would form themselves into
groups (divisional or otherwise) so as to prevent too much re¬
duplication. These might then be available for circulation
amongst the asylums of the group or division at an early date.
At the end of the year they might either be added to the
asylum library or be sent as a contribution to the central
library. The cost of such an arrangement to each asylum
would be so small that even if a grant in aid could not be
obtained from the committee, it might be collected by subscrip¬
tion from the committee members or even by the joint subscrip-

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I 14 REVIEWS AND NOTICES. [Jatl.,

The feeding of a starving person, whether insane or suffering
from temporary aberration, due to emotional debauchery in
political excitement, is certainly legitimate medical treatment;
the method is warranted by scientific knowledge, and the
intention of its use has the sanction of the highest benevolence,
which cannot be affected by any circumstances of a political
character.

Part II.—Reviews and Notices.

The Sixty-Third Report of the Commissioners in Lunacy , 1909.

The Report opens with a succinct summary of the recommendations
made by the Royal Commission on the Care and Control of the Feeble¬
minded (1908), on which numerous remarks and suggestions are made.

The suggestion is made that provisions similar to those contained in
Sections 14, 16, and 18 of the Lunacy Act of 1890 will need to be
retained to prevent “ an unnecessary increase in the number of cases
requiring the order of a judicial authority to be made on petition sup¬
ported by two medical certificates.”

The Commissioners express their concurrence in regard to the exami¬
nation into the mental condition of persons in whom, whether convicted
or acquitted, any question of mental defect may be raised.

If the Chancery Division of the High Court of Justice becomes the
authority relating to the management and administration of mental
defectives, the Commissioners express the hope that some attempt
should be made to cheapen the procedure.

The amalgamation of the Chancery Masters with the Lunacy Com¬
missioners is also supported, and it is urged that the recommendation for
the immediate appointment of two additional medical commissioners
should be carried out. The necessity that the Commission should be
predominantly medical is insisted on.

The suggestions for increased facilities for the treatment of incipient
and unconfirmed insanity and for the advance of scientific investigation
are also warmly supported.

The Commissioners state that the recommendation that an architect
should be appointed in connection with the Lunacy Board has been
already carried out. This would seem to indicate that the treatment by
bricks and mortar still takes precedence to that by medical science in
the opinion of the Treasury. The delay in appointing the additional
medical commissioners is a scandal, which should overwhelm with con¬
fusion and shame any representative body that possessed the faintest
perception of responsibility or the least glimmering of a moral
conscience.

The Commissioners also recommend that the “present disqualifi-

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cations should be relaxed to enable leading members of the medical
profession to become honorary commissioners.” The fact that such
persons are specially disqualified reads like an extract from Alice in
Wonderland. What mental perversion or obsession could have induced
the original framers of these regulations to arrive at such an absurd and
irrational decision ?

The Commissioners strongly support the extension of the boarding-
out system, and the placing it under proper supervision. They warmly
endorse the proposal for the establishment of observation wards,
reception houses and mental hospitals for incipient mental disorder.
They recommend the extension of ihe clauses in the Lord Chancellor s
Bill of 1900, relating to the notification and registration of cases of
unconfirmed insanity, to cases received in such observation wards, etc.
This would be a large question, requiring very careful consideration
and adjustment.

Finally, the Commissioners very properly protest against their body,
however modified, being made a sub-department either of the Home
Office or of the Local Government Board. This is a position that
should be strongly defended by all who care for the welfare of the
defective minded.

The statistics of the Commissioners show a total of 128,787 persons
certified as insane in England and Wales, this being an increase of
2,703 during the year 1908. The increase is 333 in excess of the
average of the decennium, and 386 in excess of the quinquennial period.
The result is that at the close of 1908 there was one insane person to
every 278 of the population—the highest ratio that has ever been
recorded.

This depressing fact is to some extent ameliorated by the statistics of
first admissions; these were 5'io per 10,000 in 1908, which is con¬
siderably lower than the 5'5 2 of 1902, although contrasting unfavourably
with 5 02 in 1907, and is only a traction lower than the 5• 11 of 1906.

The admissions were 384 in excess of 1907, the ratio per 10,000
being 6^29 as compared with 6 26, and being lower than the same ratio
in any year since 1901.

The recovery-rate on the total of admissions was 35'3S, being i'3i
lower than 1907, and r84 below the average for the ten years 1899 to
1908 inclusive. The death-rate was 9'53 on the daily average number
resident, being "46 below the average for the decennium. These two
factors are important elements in the increase of the insane population
during the year.

The mortality, for males 107’5 and for females 88'2 per 1,000, when
contrasted with that of the general population (16 and i4’i respec¬
tively), show that there is still a large possible accumulation from further
diminution of the death-rate.

The Report draws attention to the new tables in connection with
causation, and, while insisting on its value, wisely abstains from drawing
conclusions on so complex a subject from the results of a single year.

A diagram of the relationship of the forms of insanity to each age-
period is of distinct interest, and will form a valuable means of com¬
parison with the occurrence of insanity in future years.

An analysis, with chart, of the causes of death shows that malignant

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Il6 REVIEWS AND NOTICES. [Jan.,

diseases and bronchitis are nearly three times, and apoplexy half,
as frequent in the insane as in the general population, while fatty and
valvular disease of the heart, epilepsy, pneumonia and phthisis are
largely in excess.

Allusion is made to Dr. Maudsley’s munificent offer of .£30,000
to be applied to the establishment of a hospital for incipient and un¬
confirmed insanity. The suggestion is made that the clauses in the
Lord Chancellor’s Bill, previously referred to, should apply to the
inmates of such a hospital. It must be regretted that this piece of
legislation has not been effected, in anticipation of the establishment of
such institutions.

Model rules (pp. 36 and 37) are given for the taking of stock and the
auditing of accounts in asylums. These should materially aid in the
prevention of the “scandals ” that have from time to time vexed com¬
mittees of management.

Dysentery and diarrhoea receive very considerable attention, as in
previous years, but the statistics for the year do not show any marked
general amelioration.

Dr. Mott’s summary of the conclusions of his study of the incidence
of tuberculosis in the London County Asylums is quoted in full. The
general adoption of his recommendations should lead to considerable
reduction in this source of mortality.

The Commissioners again report that several of the registered
hospitals fail to adequately discharge “ their primary function of receiv¬
ing and maintaining at low rates of payment patients of education and
refinement, but of limited means, who would feel acutely the surround¬
ings and association of a county asylum.”

Does the hope expressed, that these institutions would “ voluntarily ”
bring themselves up to the “high standard of liberality” attained by
some of them, imply a possibility of other means being employed to
attain this very desirable end?

The supplement on scientific research work in asylums gives a record
of very satisfactory progress in this respect. The good results of this
supplement will, however, become more obvious in the next year or
two.

The new statistical tables must have added largely to the work of the
already over-burthened Commission, and this will not be lessened as
time goes on. It is sincerely to be hoped that before the next report is
printed the Commission may have been strengthened by additions to
its personnel , which will enable it to grapple with some of the many forms
of work that are needing attention. The recent Royal Commissions
ought to have impressed even a British House of Commons with the
desirability of giving much greater attention to the national health.

The Fifty-first Annual Report of the General Board of Commissioners
in Lutiacy for Scotland , 1909.

On January 1st, 1909, there were in Scotland 18,197 registered
insane persons of whom the Board had official cognizance. Of these,
2,682 were maintained from private sources, 15,464 by parochial rates,

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and 51 at the expense of the State. The total increase during the past
year was 289, as at January 1st, 1909.

The general results during 1908, as compared with 1907, are, in
regard to registered lunatics, as follows: (1) There was a total increase
of 267, due to an increase of private patients by 44 and of pauper
patients by 223. (2) The total increase of 267 arose from an increase
of the number in establishments by 229, and by an increase of the
number in private dwellings by 38. (3) The increased number of 229

in establishments arose from an increase of 52 private patients and of
177 pauper patients. Of pauper patients in establishments, the
average increase during the preceding five years was 175, so that the
increase of 177 during the year 1908 has been nearly the same as the
average increase of that quinquenniad. (4) All pauper lunatics in
establishments continue to be provided for in institutions of a public
character.

In the number of non-registered lunatics the following changes
occurred during 1908 :

In the Criminal Lunatic Department of Perth Prison the number is
two more than last year.

In training schools for imbecile children the number is twenty more
than last year.

The total increase in this Report is now shown to be 12,373 persons
as compared with 5,824 persons, on January 1st, 1858.

The following tabular statement shows the proportions of the insane
in Scotland per 100,000 of the estimated population as at January 1st
in the past twenty-four years :

Year*.

Private

patients.

Pauper

patients.

Total.

Average f 1886-90 ....

247

290

of i 1891-95 ....

267

313

5 years. [1S96-1900.

288

337

January 1st, 1901 ....

5 °

299

349

„ 1902 ....

303

353

„ 1903 ....

308

358

„ 1904 ....

307

359

„ 1905 ....

3 "

363

„ 1906 ....

5 *

3 12

363

„ 1907 ....

312

362

„ 19 08 ....

5 i

3*4

365

„ 1909 ....

5 i

3*5

366

The above statement shows that the number of private patients in
proportion to the population slightly fluctuated of recent years, but the
pauper patients still tend to increase. It is to be noted, however, that
the increase in the past year, from 365 to 366 per 100,000, was due to
accumulation as the number placed on the register for the first time
fell below that of the preceding year by 105. But for a decreased rate
of removal by discharge and death there would have been a decrease of
the total number on the Register. The Commissioners state that the

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Register does not, of course, include a large number of persons of
unsound mind in Scotland who might be brought under official cognizance
consequent on administrative changes, thus increasing the amount of
registered lunacy without any change in the actual proportion of mental
unsoundness in the community.

The Commissioners conclude that the rise in the proportion to the
total population from 1893 onwards may be held to coincide generally
with the extensive development of the hospital side of asylums, and
either as cause or effect with their more perfect equipment for the
reception, classification, and treatment of persons of unsound mind
who would not formerly have been placed in asylums. This influence
has, however, apparently reached its greatest strength, and has fallen,
consequently representing a positive decrease of occurring insanity in
forms calling for certification.

Having regard to the numbers registered for the first time, the pro¬
portion to population has fluctuated within somewhat narrow limits for
the thirty-five years now' concluded, and is now lower than it was in
1875 as regards private patients ; but the pauper patients rose in pro¬
portion up to 1902, when it attained the maximum of 52 - 6. It has
since fallen throughout the last five years to 5o'5, 47^9, 45'i, 48-3, and
466. The Commissioners regard these figures as trustworthy regarding
the registered insane, especially regarding the pauper class.

There would seem to be an increase in the number of voluntary
patients who are admitted to asylums without disagreeable or trouble¬
some formalities. The Commissioners favour a change in the law
which would permit of a person being received into and kept in an
asylum for three days on his own written application to the Super¬
intendent, provided the sanction of the Board be at once applied for in
the usual way on admission, and that no voluntary boarder be retained
for any longer period than three days without such sanction.

The recovery-rates, excluding transfers, were much the same as in
the former year—38'4 for private patients and 40^5 for pauper. While
the proportion of recoveries among private patients has varied from one
year to another it has shown no certain indications of falling off,
unless the lowest point reached during the last two years be regarded
as such. Among pauper patients a continuous decrease is recorded
between 1880-84 and 1900-04, and in the past four years a tendency
towards a still further decrease appears to be in force. The recovery-
rates have, no doubt, in recent years been unfavourably affected by the
increased use of observation w'ards connected with the parochial
hospitals of several large parishes, which receive persons suffering from
passing attacks of mental disorder, of whom some, in the absence of
such wards, would have been removed to asylums, and would have
been discharged recovered shortly after admission. But the lowering
of the rate is probably to be mainly ascribed to the accumulation of
chronic patients, and to the fact that the development of nursing and
the improved means of hospital care in asylums have led to their being
more freely used for the reception of patients whose age and whose
mental and physical condition are such as to preclude hope of recovery.
Persons in moribund states, or suffering from incurable physical
diseases, complicated w’ith mental unsoundness or decay, are now sent

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to asylum hospitals instead of being sent to ordinary infirmaries, or of
being kept at home until death takes place, and returns obtained last
year prove conclusively that of late years the number of persons
admitted at ages so advanced as to render recovery almost impossible
has largely increased.

The new arrangements for the treatment of incipient insanity in the
Royal Infirmaries of Edinburgh and Dundee will, no doubt, in time
also have an effect upon the recovery-rate.

The death-rate for the year was rather lower, as is shown by this
table :

Proportion of deaths per cent, of number resident in
all establishments.

Classes of patients.

l® 9 °- 94 -

1895-99.

I9OO-O4.

1905-

1906.

1907.

I908.

Private patients

7'6

T 9

9 -i

7‘3

Pauper patients

. 87

8-5

9'2

9'5

Both classes

•i 8,5

9'4

As regards pauper patients, the lower admission-rate must have
contributed in some degree to this result, the mortality during the first
year of admission being always very high.

We are glad to observe that the number of attendants and servants
who left for one reason or another was 164 less than the number for
the previous year. Those who resigned voluntarily numbered T23
fewer. No doubt the assurance of pensions now granted by the
legislature will have a favourable effect on the service and render these
changes fewer. There is, however, so much unrest in the domestic
class that it would be well to discriminate between the attendants and
servants in these returns. Asylum artisans are largely a class enjoying
fixity of tenure and slow to move, whereas kitchen and laundry servants
are just as difficult to retain. The Commissioners again recur to a
recommendation, which is having careful consideration already, and
will no doubt result in an improved state of matters. They recommend
that the administrators of institutions in which changes among attendants
occur frequently should inquire carefully into the causes. Experience
tends to show that in the case of men a high class of attendant and
security for permanent service are best obtained by increasing the
number of married attendants, and where comfortable cottages for
married attendants are provided for such of the staff as do not necessarily
require to sleep in the asylum. The great bulk of the changes occurs
in the case of attendants and servants who have only been a short time
in asylum service. As the number of attendants and servants who
resigned voluntarily constitutes 75 per cent, of the whole number of
changes during the last year, it may be inferred that, although the
inducements to enter asylum service are not pecuniarily unattractive to
those who seek employment, a large number find the service on trial

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not to be congenial. This may be due in part to the trying nature of
the service, and possibly still more to the general want of freedom
inseparable from the discipline of a large institution, which causes a
preference to be given to employments, perhaps less well paid, in which
the workers’ time, after certain hours, is wholly at their own disposal.

The year is marked by the resignation of Dr. Rutherford at Dumfries,
and Dr. Clouston at Edinburgh. Both were granted handsome super¬
annuation allowances. Their successors are Dr. Easterbrook and Dr.
G. M. Robertson. Dr. McNaughtan has also resigned on pension, and
has been succeeded by Dr. Sturrock in the Criminal Lunatic Department
of H.M. Prison at Perth.

The private and pauper patients provided for in private dwellings
during the year show some increase, the latter class on January ist
having numbered 2,826 as compared with 2,780 on the corresponding
date of the previous year. The record of the year is as favourable as
usual.

The Commissioners again urge that the poorer class of the private
insane should be accommodated in the district asylums, and not be
subject to removal whenever their beds are required for the rate-sup¬
ported class.

The following extract from the Report has a special interest at the
present time when the Poor Law has been cast into the melting-pot,
and our legislators are face to face with new recommendations regarding
the feeble-minded and the inebriate. No doubt the Association will
consider these weighty reports in due course, and it is well that we
should reproduce these suggested amendments as specially affecting
Scotland.

The main respects in which the Board think that the existing
(Scotland) Acts stand more immediately in need of amendment are
briefly indicated in the following suggestions :

“To amend the term ‘lunatic,’ which is at present defined to be a
person ‘certified by two medical persons to be a lunatic,’ etc., whereas
the term is often employed in the Acts to persons who from the circum¬
stances of the case cannot have undergone certification as lunatics ; also
extension of the definition so as to embrace imbeciles who are wholly or
partly unable to earn their own living on account of mental defect, thus
bringing within the scope of the definition a large number of persons of
unsound mind already on the register of the Board, and otherwise
extending the scope of the definition in a desirable direction.

“ To amend the term ‘ house,’ which is defined at present as ‘ any
house in which a single lunatic is kept under an order of the Sheriff,’
thus rendering the term inapplicable to houses in which patients are
kept under sanction of the Board, which is now, in point of fact, the
only authority used in such cases, and also rendering it inapplicable to
a house in which an insane person may be kept, contrary to law,
without either a Sheriffs Order or the sanction of the Board.

“To amend the provisions relating to the acquisition of land by district
lunacy boards, these provisions being at present expressed in such a
way as to leave the powers of district boards on the subject a matter
of some uncertainty.

“To enlarge existing provisions with regard to the powers of the Board

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to make regulations so as to enable the Board, with the approval of the
Secretary for Scotland, to make regulations for the good order and
management of all establishments for the insane in Scotland ; and also
to provide that plans for all such establishments shall be submitted to
the Board and receive their sanction before being put into execution.

“To enable the Board in all cases to determine the number of patients
which may be received into any establishment for the insane, and to
provide that no larger number shall be received without the Board’s
sanction.

‘ To give directors of Royal asylums and district boards of lunacy
permissive power to grant superannuation allowances to officers, atten¬
dants, and servants in their employment to the same extent and on like
terms as are given by the laws of England in the case of county and
borough asylums, and of Ireland in the case of district asylums.

“To provide for the audit of the accounts of district boards of lunacy
by placing such boards in that respect upon the same footing as county
councils.

“To amend the provisions for the election of district lunacy boards
(at present contained in the Prisons [Scotland] Act, 1877), and to
provide for the representation of parish councils on such boards.

“To extend the provisions with regard to the reception of private
patients into district asylums, so as to enable district boards, if they
see fit, to make separate provision for the accommodation of private
patients at low rates of board, and to give such of these patients as
belong to the district security against removal to make room for pauper
patients.

“To give the Commissioners extended powers in the matter of visiting
any establishment or house into which they have reason to believe that
persons, not being persons under the care of their natural guardians, are
resident on account of mental disorder or defect, and without legal
authority.

“To do away with the certificate granted after the first three years of
residence have passed and annually thereafter, which is at present
necessary in order to keep in force the sherifFs order in the case of
patients in asylums ; and to put upon a more clear and satisfactory
footing the provisions in regard to the discharge of patients.

“To extend the existing provisions for the protection of insane persons
not kept for gain, who are harshly or cruelly treated, or are subjected to
restraint or coercion, so as to cover also the case of those who are
seriously neglected, or are inadequately protected from sexual danger.

“To provide against the removal from the poor-roll of pauper patients
for whose removal to an asylum, or to another house or guardian, the
Board have issued an order.

“To provide that when a patient in an asylum has been removed with
the sanction of the Board to the lunatic wards of a poorhouse, or to a
private house, and still remains on the Board’s register, he may be
transferred back to the asylum, with the sanction of the Board, and
be received therein in virtue of the original sheriff’s order for recep¬
tion.

“To amend the provisions for the protection of female patients in
asylums, and in private houses under sanction of the Board, their pro-

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[Jan.,

tection not being adequately provided for either by the existing Lunacy
Acts or by the Criminal Law Amendment Act of 1885.

“ To enable district lunacy boards to erect, or to combine for the
erection, of institutions for the care of idiot or imbecile children sup¬
ported by parishes.

“To secure that applications to inspectors of poor on behalf of idiot
or imbecile children shall be carefully considered, and shall not be
rejected without adequate reasons, and that when such young persons
are provided for in institutions for idiot or imbecile children they shall
not be removed from supervision on being discharged after attaining
eighteen years of age, but shall remain under charge of the parish
council until such time as the Board have assurance that they will be
satisfactorily provided for otherwise.

“To empower parish councils to combine in making arrangements
for the boarding out from asylums of pauper patients, and for their
subsequent supervision and visitation, thus enabling the smaller
parishes in combination to attain success in this direction such as is
attained by the large urban parishes.

“To provide that in the case of uncertified insane persons who are to
be placed under private care, or in the lunatic wards of poorhouses, it
shall be lawful for the Board to grant their sanction, and to register the
patient on one certificate of insanity, and without any further certifica¬
tion of lunacy.

“To provide that a person desiring to enter an asylum as a voluntary
boarder may be received on his own written application, but may not be
kept for more than three days without the written authority of a Com¬
missioner in Lunacy.

“To provide that, as regards the receipt and transmission of letters to
and from patients, the sheriff of the county in which an asylum is
situated shall be put in the same position as the Board ; and that the
provisions of the Act in regard to visitors to patients shall be placed
upon a somewhat wider basis than is the case at present.

“To provide that the powers of the Board to initiate steps for the
appointment of judicial factors shall not, as at present, be confined to
persons who are being ‘ detained and taken charge of as lunatics,’
since that description is as likely as not to be inapplicable to persons
unable to manage their affairs on account of mental defect.

“To provide for the more certain determination of parishes to be held
chargeable with the maintenance of insane prisoners sent to asylums ;
to provide for their reception by asylums serving as district asylums ;
and to provide that in the case of such prisoners undergoing sentences,
the order for their reception into an asylum shall not lapse on expiry
of the term of sentence, as is the case at present.

“To provide that pauper patients for whose removal from Scotland an
order is sought need not personally appear in court, as is necessary at
present, in obedience to certain provisions of the Poor Law dealing
with paupers whose removal is sought, which make no exception in the
case of lunatics.

“To provide that in the case of lunacy districts consisting of a single
parish or combination, the parish council shall be empowered to levy
and collect lunacy assessments for providing and altering asylums,

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along with the assessments for relief of the poor. At present these
lunacy assessments are levied and collected by the burgh or county
authorities within such parish, and the change here referred to is sought
by the corporations of the larger burghs, and is concurred in by parish
councils in such burghs almost without exception.

“To provide that letters of agreement as to the rate of board to be
paid for non-pauper patients received into asylums shall be sufficiently
stamped with a sixpenny stamp. Hitherto a sixpenny stamp has been
regarded as sufficiently stamping such an agreement, but founding on a
recent decision, the Inland Revenue authorities have held that these
agreements are liable to a bond duty at the rate of 2s. 6 d. per each ^5
of the annual rate agreed upon, which lays a heavy additional burden
upon a family in which the misfortune of insanity occurs.

“To provide that district boards of lunacy shall have power, for the
purpose of obtaining instruction and assistance in pathological investiga¬
tion for medical officers of asylums under their charge, to make annual
contributions towards any pathological laboratory having for its object
investigation into the pathology of mental diseases.

“To enact for Scotland a provision in terms of Section 330, Sub-sections
(1) and (2) of the English Lunacy Acts 1890-91, for the protection
of medical persons against proceedings in respect to certificates of
lunacy granted in good faith and with reasonable care.

“ These suggestions, being of the nature of amendments of existing
laws, do not deal with what may be termed the main recommendations
of the Report of the Royal Commission on the Care and Control of
the Feeble-minded, but, as has been said, they include many important
recommendations of that Commission. Many of the proposals made
above are such as did not fall within the scope of that Commission’s
report, but all of them are, we believe, in harmony with the spirit of
that report, and their passing into law would in no way interfere with or
render more difficult the adoption of other measures recommended by
the Commission that may in future be the subject of legislative con¬
sideration.

“These proposals involve provisions which are, in our opinion, urgently
needed to place the lunacy law of Scotland on an efficient and satis¬
factory footing, and we venture to express the hope that a bill giving
effect to them will be introduced into Parliament at an early date.”

Fifty eighth Report of the Inspectors of Lunatics in Ireland for the year
ending December 31 ^/, 1908.

In this, their latest report, the Irish Inspectors have not quite as
satisfactory a tale to tell as in either of their two previous reports, the
increase of the total amount of insane in establishments having been
greater in 1908 than in 1906 or 1907, the increase for the three years
being respectively 189, 164, and 213. The last figure, however, is less
by 200 than the average increase for the preceding ten years, so that
there is not really much to arouse apprehension as regards the increase
of insanity. The total number of insane in establishments on December
31st, 1908, was 23,931,

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If we divide the twenty years ending 1908 in four five-year periods,
and calculate the average number of insane under care for each period,
we find the increments for the past three quinquennia have been
respectively 138, X4'46 and 8'26 per cent.-, and if we take district
asylums alone the percentage increases for similar periods have been
1876, 2118 and 1373 respectively. So that while there was a rise in
the rate of increase during the period 1894-1903, there has been a very
large reduction in the last quinquennium ending 1908. According to
the Inspector’s reports for the past five years, the average increase
for the ten years immediately preceding each year reported on shows,
as might be expected, a corresponding reduction, the increments being
534, 500, 500, 459 and 413, so that although the increase in 1908 was
somewhat higher than that of the two years preceding, when the
average is taken for a series of years the rate of increase continues
steadily reducing. This is a significant fact, and one which certainly
gives ground for hoping that the rate will continue to decrease in future
years until the volume of insanity eventually becomes stationary, or,
possibly, may even begin to show signs of decreasing.

It is rather disappointing to find that admissions to district asylums,
both total and first admissions, show a decided increase, since for the
preceding five years from 1902 to 1907 they showed a progressive
decrease. (The total admissions showed a slight increase in 1907.)
The inspectors are inclined to attribute the increase last year to the
large number of patients admitted from workhouses—over 100 more
than in either of the two previous years—and probably their surmise is
correct. It must not be forgotten, however, that a considerable
proportion of patients sent to asylums from workhouses are not, properly
speaking, “workhouse patients,” i.e., uncertified pauper insane who
have lived most of their lives in workhouses, but are many of them
acute cases sent into the workhouse by their friends as a convenient
half-way house, from which they can be transferred to the asylum
without any further trouble or expense to their relatives.

The rate of increase of the ratio of admissions to population is
decreasing, the proportion per 100,000 population of total admissions
for each of the last four quinquennia being 66 o, 7 2'6, 83-2 and 84^6
respectively, and of first admissions 51 - 2, 55'6, 662 and 67-0, these
figures showing that in the case of total admissions there has been an
increase of 14, and in first admissions of but o - 8 per 100,000 in the
last of these periods as compared with the previous one, the increase in
the preceding quinquennia having been over 10 in each case. This is
quite a remarkable drop in the rate of increase. In the years 1902,
1903 and 1904 the ratio reached its high-water mark. It is to be noted
that the increase in admissions in 1908 was confined to ten asylums,
there having been a decrease in ten, while in three the number
remained stationary.

The recovery-rate was 36^9 percent, on admissions, or 17 below that of
the previous year. The rate shows a tendency to decline during the
past ten years, as is shown in Table VIII, which is probably due to a
larger number of incurable and senile cases having been admitted during
later years, especially from workhouses.

The death-rate, 7*1, is practically stationary, but was lower last year

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than for any year since 1896. The highest mortality, 11*2, was in
Killamey, and the lowest in Waterford, 4/1, where it was also lowest in
the preceding year; 26'$ of the total deaths were due to phthisis. A
new and useful column, for which our acknowledgments are due to the
Inspectors, has been added to the supplementary table on page 17,
giving the mortality from the disease in each of the District Asylums,
which is full of significance. It varies from 3*1 per cent, in Carlow to
50 per cent, in Clonmel. This fact is difficult of explanation on the
usual theory. The Inspectors allude to the “ close connection between
tubercle and insanity”; and eminent authorities have frequently laid
stress on this connection. But is it proved ? Has insanity per sc any
intimate or necessary relation to consumption ? It is extremely doubt¬
ful if this is the case. No doubt the number of asylum insane who die
of consumption in proportion to asylum population is very largely in
excess of the ratio in the case of the general population. But the
general death-rate, including deaths from all causes, is very much higher
in asylums than in the sane population. Not phthisis alone, but pneu¬
monia, heart disease, epilepsy, apoplexy and paralysis, dysentery and
diarrhoea, all these diseases occur in a much higher proportion (from
four to eight times as much) in asylum patients than in the outside
population. Moreover, as the number of patients under fifteen years of
age in asylums is a negligable quantity, while the age-period 15 to 35 is
what may be termed par excellence the phthisical period of life, in order
to make a just comparison as regards the incidence of consumption
amongst the sane and insane respectively it is this period which should
be specially, if not exclusively, considered. According to the Registrar-
General’s figures the relative mortality from phthisis among the popula¬
tion at large during the period 15 to 35 is over 50 per cent. —in other
words, during that period of life more than half the deaths in Ireland
are due to phthisis. But that is the maximum rate amongst the asylum
population, and has only occurred in one asylum, the average rate in all
asylums being, as stated, 26 3 per cent. So that as far as relative mor¬
tality is concerned the insane have a more favourable record than the
sane. That is one notable circumstance.

Another fact difficult of explanation on the usually accepted theory
is the almost astounding difference in the phthisical mortality in the
various asylums. Why are only 3 per cent, of the deaths in Carlow
asylum due to consumption and 50 per cent, in Clonmel, 9 per cent, in
Armagh, and 41 per cent, in Killamey? Surely only one inference can
be drawn from these figures, viz., that insanity, quoad insanity, has but
little to say to the prevalence of phthisis amongst the insane, but that
this is probably due mainly to two causes : First, the relative liability to
the disease amongst the general population, for this varies a good deal
in different districts; and secondly, the conditions which prevail in
any individual asylum as regards site, soil, ventilation, heating, sanitary
arrangements, overcrowding, etc. This conclusion is borne out by
writers who have given special attention to this question. It is only
necessary to quote here Dr. Chapman’s conclusions in his supplementary
report on the statistics presented by the Committee of the Medico-
Psychological Association on Tuberculosis in 1902. He classifies
asylums into two divisions, a “ better ” and a “ worse,” according as the

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tubercular death-rate does or does not exceed 2 per cent, of the popula¬
tion, and expresses the opinion that “ the tubercle can hardly be due to
any essential difference in the two groups of asylums, and cannot have
any special connection with insanity, but is causally associated with the
individual asylums.” And what he regards as tiie most important de¬
ductions from the statistics are thus stated :

“(1) That infection is one of the strongest causative elements in the
prevalence of tuberculosis in asylums.

“(2) That a healthy (dry and well-drained) site is of extreme
importance.

“(3) The causes of tuberculosis in asylums inhere in the asylums
themselves, and not in the character of the patients sent to them.”

Notwithstanding the fact that so distinguished an authority as Dr.
Mott has (at all events as regards the London County Asylum) arrived
at conclusions diametrically opposed to those of Dr. Chapman, as far as
Ireland is concerned the facts certainly go far to support Dr. Chapman’s
views, and we are at least justified in the opinion that any causal con¬
nection between tuberculosis and insanity is as yet non proven. The
solution of this problem is of vital importance; the one theory tends to
provoke a more or less laissez faire, or even a fatalistic attitude, the
other furnishes a powerful incentive to set our houses in order, to
remove every possible source of tubercular disease, every condition
likely to favour its spread, and to see that our insane patients have the
benefit equally with the sane of such remedial measures as modern
medical science has proved to be the most effective in combating the
great “ white plague.”

There has been no reduction in the phthisis mortality during the past
twenty years, the average percentage mortality for the three last quin¬
quennia and the four-year period preceding, as calculated from the
table on p. 18 of the Inspectors’ Report, being 26'88, 292S, 26’69 and
2 7‘09 respectively. Additional columns in this table giving the percent¬
age mortality of phthisis and general paralysis would be useful and
informing. The percentage death-rates from general paralysis during
the same respective periods were 2^46, 3's6, 365 and 3^92, so that there
has been some increase in the relative mortality from this disease.
The ratio in English asylums for the year 1908 was i6'8 per cent, of
the total mortality, or more than four times as great as in the Irish
asylums.

The Inspectors urge the desirability of a much larger extension of
asylum farms as one of the most important elements in the treatment of
the insane. This is especially obvious in the case of Ireland, where
the large majority of asylum patients belong to the agricultural class.
The inspectors say: “Not only do large farms attached to asylums
afford means of healthy labour in the open air and an outlet for that
restlessness and desire of motion so common amongst the insane, thus
producing quietude and peace where formerly there was noise and
excitement, but the interest aroused in agricultural work also brings
back the wandering mind to sane views, and so helps to promote
recovery.” With these views, it is needless to say, we are in hearty
accord. It is mentioned that the Scottish Lunacy Commissioners have
suggested, as a reasonable allowance of land, an acre of arable land for

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each male patient. In Ireland there are close on 11,000 male patients
in asylums with an acreage attached of 3,776 acres, so that we are still
far from having reached the Scottish ideal.

Might we suggest that a table giving the occupation of patients in
asylums would be a useful addition to those already furnished. In the
statistical tables of individual asylums such a return has always been
given, and a summary of these, giving the aggregate numbers for the
entire country, as in the English Blue Book, would be of distinct
advantage.

The disposition inherent in many Irish public bodies to set them¬
selves “agin’ the Government” has been exemplified in the case
of Carlow asylum, when, on the promotion of the former super¬
intendent, Dr. Jas. Fitzgerald, to Cork Asylum, the Committee pro¬
ceeded to elect the assistant medical officer to succeed him, who,
however well qualified he may have otherwise been, had not completed
the five years’ asylum service required by law in any candidate for that
position. This action on their part being declared illegal they en¬
deavoured to postpone the election until such time as the necessary
condition should be fulfilled, and succeeded in effecting a very protracted
delay in making the appointment. Eventually proceedings were insti¬
tuted to compel the Committee to carry out the duty of appointing
such an officer, and the Court of King’s Bench issued a mandamus to
that effect, a proceeding which was confirmed on appeal, with the result
that Dr. Thomas Greene was appointed, who had served with credit as
Assistant Medical Officer of Ennis Asylum.

In the Inspectors’ remarks on asylum attendants we heartily concur.
Last year we had occasion to comment on the very stationary recovery-
rate in asylums. Next in importance to assiduous medical care and
supervision in the treatment of the insane comes the character of the
nursing staff. Without the co-operation of intelligent, humane and
fairly well-educated attendants little or no advance in the curative treat¬
ment of insanity can be effected. There is no doubt whatever that the
nursing staffs of asylums at the present day are far superior to what they
were twenty-five or thirty years ago, an improvement due in no small
measure to the persistent efforts of our own Association to raise their
status and qualifications. But we must not be content to stand still,
and continuous and strenuous endeavour will still be required to raise
the standard of nursing in asylums. And this can be achieved mainly in
two ways, by inducing, where possible, asylum committees to act
liberally as regards pay and privileges so as to attract a higher class of
candidates to the service, and secondly, by the special teaching by
the medical staff of everything that an attendant should know, which
will have the effect not only of providing them with a certain amount
of useful expert knowledge, but which is also calculated to vastly
enhance their interest in their work and their conception of their
calling, and so raise it from what it is to be feared it loo frequently has
been, a condition of wearisome monotonous drudgery, to that of an
interesting and honourable vocation.

The other matters touched on in the Inspectors’ Report are
more or less of a routine nature, and do not call for any special
comment.

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REVIEWS AND NOTICES.

[Jan.,

Drugs atid the Drug Habit. By Harrington Sainsbury, M.D.,
F.R.C.P. London : Methuen and Co. 8vo., pp. 307. Price
7 s. 6 d.

This book is a welcome addition to medical literature, for it is
written in a style that is attained by few of the recent works on medical
matters. It is not a mere compilation of facts and ideas relating to the
subject, but a careful, thoughtful, and philosophically reasoned exposition,
of large information, well digested. It is written in excellent English,
with admirable clearness of expression and logical sequence of state¬
ment. The literary embellishment gives evidence of wide reading
illuminated by a broad grasp of cognate scientific subjects.

The book commences with an admirable historical sketch, followed
by chapters on definitions, the objective of drugs, the rational and
psychic basis of drug treatment, etc., ending with chapters on habit
control, uncontrolled habit, preventive and curative treatment. The
historical sketch is particularly excellent, and many of the chapters are
admirable both for the matter and the clearness of exposition.

The author has, moreover, kept rigidly—in some respects too rigidly—
to his thesis, and this might induce some critics to consider him too
much wedded to his subject in the practical treatment of disease.

Dr. Sainsbury’s concept of disease, however, sometimes appears to
be too much that of an entity; it is certain that he does not really
regard it as such, but in his illustrations he nearly approaches this
attitude, and fails to emphasise the fact that the manifestations of
disease are merely physiological processes in excess or defect.

The equation of disease as = A + B + C+ D + x does not take
into consideration the altered values of A, B, etc., with which x, although
the cause, has nothing to do; similarly the drug y is credited with
merely countervailing x , without relation to its effects in restoring or (as
is too often the case) still further disturbing the relations of the physio¬
logical processes A, B, etc.

This leads naturally to a far too great trust in the treatment of
symptoms.

Dr. Sainsbury, indeed, sees so much of the good and alludes so little
to the disadvantage of drugs that it suggests the old quotation, “ de
mortuis .”

One excursion is made beyond the drug area in the chapter on
“ ideation ” which is very able, and, on the whole, satisfactory.

Knowing how difficult it is to get patients to relinquish the bad
habits which have produced their disorder or to adopt hygienic pro¬
cedures, and how they will swallow a remedy and persist in their evil
habits, is it not much more important and right to attach the mental assur¬
ance, which a physician should always give, to the former rather than to
the latter, and to explain the real value of prescription futilities ? If the
patient is so ignorant that a drug fetish is really needed, is it not better
to apply it, “ more Africano,” to the outside of the abdominal wall, rather
than in our “civilised ” fashion to inflict it on the long-suffering mucous
membrane of the intestinal tract ? Should we not always insist, even
when the drug is not a mere futility, on the necessity for abandonment

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of bad habits, rather than encourage trust in the drug, which only
temporarily countervails their evil effects ?

The author, in his closing paragraph, insists that drugs are natural
forces, and implies that therefore they must be good. Everything in
Nature maybe so regarded, but it becomes a “drug” only when it
affects the physiological processes in a manner that is not merely
nutritional, and the question is, not whether they come direct from
Nature or are prepared by art, but whether their physiological effect is
for good or ill ?

The concluding chapters on habit show that, in spite of long suffer¬
ance, probably every drug has an ill effect. Drug-treatment resolves
itself, therefore, into the question of how much evil may be done that
good may ensue.

We commend the book to our readers as both interesting and
valuable, and as a brilliant addition to medical literature.

The Relation of Medicine to Philosophy. By R. O. Moon, M.A.,
M.D.Oxon. 8vo., pp. 221. London: Longmans & Co., 1909.
Price 4J. 6 d

Three chapters of this book have already appeared in the British
Medical fournal , and the author, although he does not profess to have
produced a history of medicine such as that of Haesen, Withrington
or Kurl Springel, may be congratulated on having produced a very
finished sketch from his chosen point of view.

The first three chapters are devoted to the relation to Greek
philosophy. Then follow chapters on the influence of early Christianity,
of Arab philosophy, on the various influences of the middle ages,
of the renaissance, and of Paracelsus, concluding with studies of the
effect of philosophy on medicine in the seventeenth and eighteenth
centuries, and of the thought of the present time.

Without any attempt at criticism in detail, the opinion may be
expressed that the task of Dr. Moon has been most ably executed, as
well in its literary finish as in the comprehensive grasp of the subjects
treated. In his final paragraph he says that “ now it will be rather the
custom for philosophy to come to medicine, and taking from her all
the truths which through the ages she has been slowly recovering from
ignorance and chaos, gather them up into one vast generalised truth
which will enable men to lead the lives of intellectual and moral beings.”
This is the keynote of the spirit in which the book is written.

Die Gehirncbetfliiche von Paralytischen \The Brain Surface in General
Paralysis]. By Professor Nacke. Leipzig : Vogel, 1909.
Pp. 58, large 4to.

Professor Nacke here brings, with his usual laborious care, a contri¬
bution to his study of the morphology of general paralytics from a new
side. The work is mainly an atlas of forty engraved plates (after
drawings) of the brain surfaces of forty-nine general paralytics, mostly
represented in natural size. The author furnishes an introduction and
LVI. 9

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130 REVIEWS AND NOTICES. [Jan.,

explanations, but he puts forward his work not so much as an argument
as a collection of documents which will be of value to all workers,
whatever their own personal views may be.

This value of the atlas is well set forth by Professor Flechsig in the
preface he has written to it. He points out the importance of the
problem as to what determines the incidence of general paralysis in only
striking a minute proportion of the syphilitic, and he regards Nacke’s
work as of permanent interest to all who are engaged in this field,
whatever their own standpoint may be in regard to the question of the
significance of the external form of the cerebral hemispheres. The
limits within which the brain may vary without ceasing to be normal
are still uncertain, and Flechsig believes that Nacke’s atlas will furnish
the stimulus to a new scientific movement. Havelock Ellis.

Traite Internationale de Psychologic Pathologique. Tome Prem.: Psycho-
pathologie Gejierale. Felix Alcan, Paris, 1910. Large 8vo.
Pp. 1028. Gravures 353. Pr. 25 fcs.

This work is the first of three volumes to be published under the
direction of Dr. A. Marie, aided by Bechterew, Clouston, Grasset,
Lugaro, Magnan, Pilcz, Raymond, and Ziehen, whose names alone are
a sufficient guarantee that the divisions of the work will be adequately
dealt with by the long list of almost equally distinguished contributors.

The second volume will be devoted to “ Mentalite morbide (clinique
et psychologique),” and the third, final, volume will be devoted to
“ Principes Generaux a’Assistance et Therapeutique.”

The volume under consideration, of the contents of which this
notice is intended only to give a sketch, without any attempt at detailed
criticism, commences with a chapter by Dr. F. Grassel on the relations
of psychiatry and neurology, in which the unity of human neurobiology
is insisted on. This is followed by a chapter on the history of mental
medicine by Dr. F. Del Grico. To this succeeds a very valuable
contribution by Dr. A. Marie on psychiatric anthropology, which is
copiously and interestingly illustrated. The fissures and convolutions
of the brains of the insane are dealt with by Dr. Mingazzini, and the
chemistry of the cerebral substance is treated by Dr. A. Marie. Next
follows a very copious and systematic chapter by MM. A. Marie and
Dide treating of the “Examen physiopathologique par functions.” To
this succeed contributions by Klippel, Lugaro, Marinesco, Dide, Medea,
and L. Levastine on general pathologic anatomy in mental medicine.

Human psychologic evolution at puberty is dealt with by Professor
Marro, and the volume concludes with essays on methods of examina¬
tion, Dr. Clouston dealing with the clinical, Professor Bechterew with
the “ psychologique objectif,” Ferrari with the “ medico-pedagogique,”
and Professor Ferrari with the medico-legal.

This enumeration of the contents will be sufficient to indicate the
great value of the work as a contribution to medico-psychologic litera¬
ture. The writers have in all cases maintained the reputation that
most of them have already gained in relation to their special subjects.

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The work is open to the general criticism, which appertains to all
such undertakings, that some subjects are treated in too little detail,
whilst others—but this is much less frequently the case—are given a
relatively larger consideration.

The literary side of the work is of high character, and the numerous
illustrations are for the most part admirably produced. The typesetter
has made a curious mistake in an English quotation on the female
voice, p. 840, but this exception only emphasises the general correctness
of the letterpress.

The work is of such importance that every alienist physician should
study it and every psychologic library possess it for reference.

Part III.—Epitome of Current Literature.

1. Neurology.

A Proof of the Existence of Neuro-fibrils in the Living [ Una prov dell'
csistenza della neuro-fibrille nel vivente]. (Piv. di Pat. Nerv. e
Merit., fasc. iv, April , 1909.) Lugaro, E.

Neuro-fibrils have often been suspected of being artificial productions
due to the action of precipitation, by histological reagents, of cellular
colloids. This suspicion has been strengthened by the fact that, outside
of the body, appearances similar to the neuro-fibrils may be obtained by
precipitation of organic and inorganic colloids. Lugaro is of opinion
that, in view of these suspicions, it ought primarily to be demonstrated
that neuro-fibrils exist in the living, and proof afforded that they are
not artificial products of our manipulation or of post-mortem coagulation.

Pighini, in a recent work, pointed out that he has subjected extracts
of nervous substance to the several treatments wnich pieces of nervous
tissue receive in the fibrillary methods of Cajal and Donaggio. He
holds that he has attained from these methods networks which were a
specific product of the technical process adopted, inasmuch as they
were not obtained by other methods, eg., by the action of alcohol,
formol, or perchloride of mercury. Lugaro draws different conclusions
from the data of Pighini, and holds that experiments of the kind are
not able to solve the question. It would be too much to say that in
living organism structures do not exist solely because it is possible to
manufacture them artificially by precipitation.

With the object of proving that neuro-fibrils exist in the living and in
order to eliminate every doubt, Lugaro has made the following experi¬
ments in three young rabbits and two young cats, and without using
narcosis. The lumbo-sacral medulla was exposed and deprived of its
dura mater. On the medulla in situ and still living was poured slowly
a litre of boiling physiological solution (chloride of sodium) at a
temperature that varied in the different experiments between 8o° and
ioo u C. The coagulation of the spinal cord in this way was extremely
rapid, the surrounding tissues being also coagulated to a depth of 7-8 mm.

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132 EPITOME. [Jan.,

In all the animals, including one in which the spinal cord was boiled
for five minutes, the preparation after the use of fluoride of silver
showed very fine reticulated neuro-fibrils in the elements of the cord,
as it did also in the pieces taken from animals which had been killed.

The positive finding thus obtained appears to Lugaro to demonstrate
in an indisputable manner that neuro-fibrils exist in the living, that
they are a true organic part of the cell, and that, therefore, it is
permissible to formulate hypotheses about their function.

Lugaro purposes describing more particularly and later the results of
a methodical and complete study of the researches which he has under¬
taken to prove his thesis. Hamilton C. Marr.

Complete Survey of the Cell Lamination of the Cerebral Cortex of the
Lemur. [Croc. Royal Soc., B, vol. lx.xx, 1908.) Mott , F. JV. t and
Kelley , A. M.

In this communication, the authors give notes on the material and
method used in their investigations, and then a short account of the
lemur and the correlation of its mode of life and habits with the cortical
development of the brain. This is followed by a general description of
the brain and a histological description of the cortex.

The brains of four lemurs were used, lemur bruntieus, lemur rnongoz,
and two specimens of lemur eatla. They limited themselves to mapping
out the main types of the neopallium, namely, the motor, frontal,
temporal, post-central and visual types, to pointing out variations in
these types, and to giving some description in the text of the inter¬
mediate areas. Essentially there is little difference between their results
and those of Professor Brodmann (who made his researches with the
brain of lemur macaco ), except that he has defined more subdivisions of
the cortical types, and in their diagram they have given a broader band
for the motor area, carrying it further back, especially in the lower
part; and they have not carried the visual area so far forward on the
dorsal surface. A. W. Wilcox.

2. Physiological Psychology.

The Psychology of Puberty \La Psychologie de la Puberie]. Marro , A.

This paper of Dr. Marro was a communication to the International
Congress of Psychology held at Amsterdam in 1907. The first part
deals with the normal psychology of puberty, and the second part with
the morbid psychology. The evolution of puberty is accompanied by
remarkable physical and biological modifications, which act on the
sentiments, thoughts, and actions of young people of both sexes. First,
there is an increase of sensations, which increase the excitability of the
individual and make him sensitive to the attractions of sensuality and con¬
sequently inclined to amorous emotion. Secondly, there is a greater
energy of reaction, which affects the excito-motor centres as well as the
representative centres multiplying associations, which unite and give to
the individual means to assure the function of reproduction. The
hyper-excitability manifests itself with analogous effects, though not
with equal intensity, in both sexes.

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In young men, the onset of puberty is marked by a stubbornness
which makes them find insupportable all obstacles put to their liberty.
Courage, boldness in their desires and thoughts, and, consequently, in
their actions, are essentially marked. The feeling of personality makes
itself felt clearly and with force; they love to affirm it, even in opposi¬
tion. The spirit of rebellion in the family and towards teaching authori¬
ties is born, and reproofs are badly taken. The mirage of military life
attracts by reason of the vanity of the uniform, the novelty of the
occupation, and the tendency to fighting.

They begin to have a liking for wine, they give themselves airs, they
learn to smoke, overcoming the distaste which tobacco at first excites.
The community of tendencies unites the individual to his companions,
and the bonds of friendship strengthen with those whose sentiments
harmonise with his own.

The young man submits very easily to the suggestion of example and
to words which strike his imagination and urge his action. Although
he may be truly egoistic, the conscience of a new force and the flattery
of self-respect makes him inclined to generosity, and the want of reflec¬
tion associated with this makes him often a spendthrift. He has
aspirations towards a new life, and his love for consideration makes him
attempt a thousand projects; meantime he flees from the difficulties of
real life and passes easily from a too great confidence to a discourage¬
ment which is not justified. From this source come very frequently
many hypochondriacal occupations and the mysticism in which the
young man buries himself. The “ unforeseen ” characterises the mental
state at this epoch. The individual is conscious of impulses that he has
not yet acquired the capacity to rule or regulate by reflection and judg¬
ment. As a result numerous unconsidered actions contrast w.th the
habits and former character, and from which it would be imprudent to
deduce his real nature and destined future. At first there is an abyss
between the aspirations of a boy and reality, between such forces as he
imagines and those which are real, between that which he proposes to
do and that which he accomplishes. Many disillusions attend his
desires, but, step by step, under the sting of desire, under the stimulus
of self-respect, with the lessons which experience every day teaches him,
he develops more and more and approaches nearer to the end which he
desires.

In the girl, the evolution of puberty presents notable differences.
Thus, while the young man reveals his tendencies to action with a view
to showing what he can do, the young woman, by the exhibition of her
qualities, seeks to be seen as she is. The increase of activity which cor¬
responds in the boy to the arrival of puberty is expressed in the girl by
a suppression of bodily activity, although the condition is revealed by
mental manifestations.

The difference in the nature of girls compared with that of boys is
noticed when the punishments of boys and girls are compared. With
boys punishments are for active faults, altercations, assaults, thefts, or
attempts at theft, etc. ; in girls punishments are for idleness, negligence,
or slovenliness. They excel boys only in one category of the active faults
—sins of the tongue.

This passive condition of girls is only apparent, and resembles the

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134 El-ITOME. [Jan.,

immobility of the magnet which attracts the iron approaching it. That
is to say, puberty transfers the girl into a power which excites the
attention of the male, and causes him to use the excess of physical
power which the development of puberty has given him in order to
overcome the obstacles which stand between him and the object he
wishes to attain.

Two mental conditions are noticeable in the girl: first, amiability;
when this is exaggerated it is called “ coquetry,” and by it the girl
attempts to make herself more pleasant in the eyes of men and her
companions. The second condition arising in the girl is modesty or
reserve, which is represented morally as bashfulness, physically as
virginity. Although apparently contrary to the first quality, the second
is only the complement of it, because the price of the conquest increases
in proportion to the obstacles opposing it. These two propensities
which the evolution of puberty develops in the girl explain to us all the
peculiarities of her mental state, of her effective life, and her conduct
compared with that of boys. All that demands continuous effort is less
developed in the girl. Thus the attention is less durable, the judgment is
less fully developed, the faculty of synthesis is less fully complete. On
the other hand, curiosity is more lively, the power to analyse is greater,
states of mind depending on the emotion are very frequent, and in her
voluntary determinations the elaboration of reasoning is more easily
troubled by impulses of feeling.

Religiosity, confidence in the Divinity, and fervent invocations are
naturally developed in the girl because of the lack of trust she has in
her own forces, and the need she feels of being under a protective
power. Love of order, love of preservation, of the cares of the house
and of children are some of the details in which the progress of youth
distinguish the girl from the boy, who is more affected by outside
occupations.

As the young girl arrives at the period of maturity, she acquires little
by little a higher conception of her personality, and learns to value
herself more and more. Her conduct tends always to become more
regular. Feeling henceforth that in order to reach the place in society
occupied by other women nothing remains for her but marriage, she
co-ordinates all her desires to this end and prepares herself by putting
in play all her alluring attractions.

In discussing the second part of his subject, viz ., the morbid
psychology of puberty, Dr. Marro states there are conditions in which the
development of puberty is arrested in all its manifestations in those
which directly concern the sexual instinct as well as in the mental
manifestations associated with it. In addition to vice, which may be
the result of arrested development, other disturbances may appear
starting true maladies, which proves the weakness of the organism when
it is put to the proof.

Manifestations of abnormality originate generally very early in
puberty. Sometimes the individuals remain idle, dull, taciturn,
solitary, indifferent to amorous feeling, or subject to a frenzied violence
quite disproportionate to any provocation which they may receive. At
other times they are very restless and turbulent, always in movement
without fixed aim, incapable of attention or reflection, dominated by

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sudden impulses which they do not know how to resist, by caprices
which succeed each other without rule or limit, precocious in wicked¬
ness, gourmands, vain, inconstant and suspicious. The infractions of
family discipline open the way to outrages against social law, and
this epoch may be considered as the beginning of the criminality of
man, at first with outrages against property and then against personality.
Love of wandering, alcoholic drinks, games of hazard, and distaste for
regular occupations are seen much more than formerly. This explains
the number of trades attempted by these individuals, who hate regular
work and change their occupations in the vain hope that the new
occupation will be less tiring and less fatiguing than the old.

The mental troubles of this age are distinguished by their super¬
ficiality and quick cure. They are generally troubles due to moral
shocks which affect young people early in the crises of puberty. The
second order of mental alterations, which are the true psychoses of
puberty, may also appear. They may be regarded as a kind of failure
in the development of the organism. Sometimes sexual abuse gives it
an impulse. Alterations of vegetative function precede and then follow
mental alterations, which form the true psychosis of puberty.

Hamilton C. Marr.

Suggestibility in the Normal State [Contribution a P Etude de la Sug¬
gestibility a PEtat de Veille']. {Arch, de Psychol., April, 1909.)
Jung, E.

Professor Jung, the Geneva zoologist, has for many years past
occupied himself with experiments on the suggestibility of the normal
healthy human subject under the ordinary conditions of life. His
attention was first directed to the subject by finding that a student in
his laboratory, who had been accidentally furnished with a microscopic
slide which the cover-glass had come away from and left quite clear,
produced in good faith a peculiar drawing of a diatom which ought to
have been but was not there. Since then Jung has kept a certain
number of clear slides wherewith to test students from time to time.
During fifteen years eighty students have been subjected to this experi¬
ment. Of these, sixty-three (863 per cent.) obstinately resisted all
suggestions and saw nothing; six saw nothing at first, but afterwards
saw something vaguely; eleven furnished drawings of organisms which
had been described to them but which they had never seen. They
were aged from eighteen to twenty, seven of them men and four women.
This shows in relation to the number of each sex submitted to the
experiment a relatively greater suggestibility of men. Jung does not
believe, however, that men generally are more suggestible than women,
but rather the reverse, and supports this belief by the results of some¬
what similar experiments he has made in schools. Jung has never
been able to obtain any but negative results from more advanced
students, over the age of twenty-one.

In another series of experiments adults proved much less resistant—
the experiment of the “magnetised card.” This experiment Jung
learnt from Professor Frdddricq, of Liege, and admits that he had
himself been a dupe to it. The experiment is based on a trick of a
familiar character. Eight cards are arranged on a table in a diagra-

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136 EPITOME. [Jan.,

matic form corresponding to the features of the face ; the operator then
states that, though personally sceptical in occult matters, there are
mysterious forces in Nature, and that if a bystander will touch one of
the cards he (the operator) will be able to detect that card by the sen¬
sation it imparts to him. He leaves the room, a card is touched, and
on returning, after carefully and tentatively feeling all the cards he
fixes on the right one, which has of course been indicated to him as he
entered the room by an accomplice touching the corresponding part of
his own face. Then an innocent by-stander is invited to test his own
sensitiveness. In this way Jung has tested 420 persons, of whom only
68, or 16 2 per cent., entirely resisted the suggestion, while 352, or 83'8
per cent, experienced sensations in the absence of any objective stimula¬
tion. Among these are not included any who, at first thinking they felt
something, realised that they were mistaken. It was found that men
resisted the suggestion much better than women (42 per cent, as against
8 per cent.), that suggestibility diminishes with age, all subjects below
twenty proving suggestible, and that men acquire resistance with
advance of age to a greater extent than women ; the exceptional case is,
however, mentioned of a distinguished professor of physics who experi¬
enced a sensation up his arm like a shock from a Leydeu jar. The
results obiained frequently far exceeded the sensations suggested : one
lady, a skilful pianist, was unable to play for a day or two, her fingers
having become stiffened ; another suffered for days from muscular
tremors. Jung is convinced that by this method alone, without any
hypnosis, it is possible to obtain lasting paralyses, anaesthesias and
hyperesthesias in healthy persons. By variations of the “magnetised ”
card method Jung produced thermal, olfactory, visual, and auditory
hallucinations; all these, however, were less easy to obtain than the
muscular sensations. Such experiments have obviously a high value in
enabling us to estimate the weight to be attached to evidence, apart
from the illustrations they furnish of the normal basis of many morbid
phenomena. Havelock Ellis.

Pseudo-infantile Characters [/ Caratteri Pseudo-infantili\ (Soc. Ital.
per il Progresso delle Scienze, Oct., 1908.) Giujfrida-Ruggeri.

The author, who has long been interested in the morphological
significance of infantile characteristics, in relation more especially to
the masculine and feminine types, here returns to the question. He is
chiefly moved to do so by the views of Hagen, who maintains that the
infantile type is the primitive human type, and that the lowest races are
those that are nearest to the infantile type. Prof. Giuffrida-Ruggeri does
not completely dissociate himself from this point of view, and with
Hagen he assumes that the infantile type is morphologically inferior,
but he considers that this view can only be accepted with considerable
reservation. We must recognise, he holds, the existence of pseudo-
infantile characters, which it would be “a pure illusion without any
scientific basis ” to regard as really indicative of infantile affinities. He
makes this distinction very largely in the interests of women, whose
morphological resemblances to children might otherwise seem to involve
inferiority. “ Each sex is perfectly adult in all its characters.”

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It may be observed that while this conclusion is entirely sound, the
conception of pseudo-infantile characters would scarcely have been
necessary for its purpose if the author had not started with the assump¬
tion that infantile characters imply inferiority. This assumption is so
rooted in his mind that he attributes to the present reviewer, without
any warrant, the statement that women are “ immature ” because they
present certain infantile characters. As a matter of fact, morphologically,
infantile characters are more often superior than inferior. The European
adult is nearer to the child than the Australian or even the negro adult,
and it may be plausibly maintained that in the course of civilisation we
are moving towards, rather than away from, the type of the child.

Havelock Ellis.

The Psychology of Adolescence [Psychologic de l’Adolescent]. (Arch, de

Psych., April, 1909.) Lemaitrc, A.

Professor Lemaitre has long occupied himself, from the pedagogical
side, with the psychology of youth, and he here brings together a number
of cases—which, without being common, he regards as not rare—illus¬
trating certain morbid aspects of adolescence. Eight of these cases,
mostly occurring in boys between twelve and sixteen, illustrate what the
author proposes to term parapsychism. He regards it as the second
phase in a morbid evolution (often really psychasthenia) of which the
first stage is a latent physical condition and the third stage a conscious
physical or psychic malady. This second stage is a more or less con¬
scious psychic crisis, and even so far as it is conscious the subject
usually seeks to conceal it from everyone. These boys are for the most
part dreamy, imaginative, a little eccentric, and are candidates for tuber¬
culosis or neurasthenia. In one case, the parapsychic stage appeared
at the age of fourteen with nyctophobia and agoraphobia, and eventu¬
ally resulted in a sudden breakdown which involved complete cessation
of studies; in another case, the parapsychic stage appeared, in an
amiable and intelligent boy, in an irresistible but innocent hemosexual
attraction to young men ; in the third stage tuberculosis appeared and
death at nineteen. In an exceptional case—a boy whose health had
never been completely re-established after pneumonia—the parapsychic
stage was brief and sudden, consisting of a very vivid dream of the
subject’s own tombstone; in the afternoon he was unable to go to
college, and was shortly after ordered complete cessation from work and
rest by the sea. In the case of a boy of fourteen, of high intelligence,
various minor disturbances began to appear, accompanied by increasing
defects in handwriting ; they culminated in severe anaemia involving
temporary cessation of study. In yet another case, with alcoholic
heredity, there were hallucations, with religious and erotic hyperaesthesia,
followed by remorse; in this case treatment by suggestion proved
beneficial. A case is also presented of rudimentary doubling of con¬
sciousness associated with auditory hallucinations, and the author
points out (what is undoubtedly true) that doubling of consciousness
in highly sensitive, nervously exhausted, or hysterical individuals is
often an effort of Nature to attain self-protection and self-reparation by
discharging and isolating injurious groups of images capable of forming

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an independent whole. Finally the case is given in full detail of a young
dtglnlri superieur , of English origin, who possessed considerable intel¬
lectual aptitude associated with a variety of morbid tendencies.

Havelock Ellis.

3. /Etiology.

The Role of Syphilis in Ihe s.Etiology of Dementia Prcecox [Role de la
Syphilis dans I'Ptiologie de la Dane tice Prccoce\ ( Gaz. des Hep.,
June, 1909.) Roubinovitch, J., and Levaditi.

The examination of the cerebro-spinal. fluid by the Wassermann
method has enabled the role of syphilis in the aetiology of certain
mental disorders to be more precisely defined. By these means the
theory of the syphilitic origin of tabes and general paralysis has been
confirmed. The researches of Plaut have also demonstrated that
certain forms of juvenile dementia are due to hereditarily transmitted
syphilis. The present research was undertaken to determine if syphilis
might not be an occasional factor in the genesis of dementia praecox.
Fifteen cases were examined by the Wassermann method. In only
three of them was a positive reaction obtained (fixation of the comple¬
ment). No definite history of syphilis, either hereditary or acquired, was
furnished in these three cases. Nevertheless such infection was possible.

From these results the writers draw the conclusion that the cerebral
changes which characterise dementia praecox are not attributable to
syphilitic infection. In the majority of the cases (twelve) the negative
reaction definitely excluded the possibility of specific infection. It may
rarely happen that infection has occurred. It is then purely accidental
and has no causal significance in the production of the malady.

H. Devine.

The Causes of Transient Cerebral Paralysis. (Bristol Med. Journ.,
March, 1909.) Parker, G.

The histories of five cases of transient cerebral paralysis are given in
this paper, one occurring in uraemia, two probably due to arterio¬
sclerosis, one arising in a healthy man under great mental excitement
with possible sclerosis, and another in gouty glycosuria.

They all, even the uraemic and gouty ones, seemed to be due to
some form or other of local and temporary cerebral anaemia, and the
author is of opinion that a great number of transient paralyses in
various diseases are so caused.

This acute localised brain anaemia is produced either by vascular
degenerations or by compression from active oedema, and accounts for
their transitory character. A. W. Wilcox.

4. Clinical Neurology and Psychiatry.

Contribution to the Literature on Korsakoff's Polyneuritic Psychosis [ 7 m r
Lehre von dcr Korsakoff schcn folyncuritischen Psychose ]. (Aeur.
Cbl., 1909, Hr. 7.) Choroschko, IV.

This article deals with localised symptoms in the cerebrum in a case
of Korsakoff’s disease. Knapp and Kutner have already described dis-

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turbances of a hyperkinetic character—epileptiform and Jacksonian
seizures and choreiform movements—with polyneuritic symptoms.
Similar disturbances in connection with Korsakoff’s disease are
naturally very interesting.

The case cited is that of a woman, set. 40, a Russian landowner.
Nothing is noteworthy in her history except her strong addiction to
alcohol. The mental malady followed a severe attack of gastro¬
enteritis. The primary symptoms were a nodding spasm and an affec¬
tion of the eyes which seemed to be optic neuritis. Later on there was
failure of memory and weakness of the extremities. Korsakoff’s
symptom-complex was established. There were fairly well accentuated
polyneuritic symptoms and a hyperkinetic disturbance which showed
itself in clonic contractions of the muscles of the neck, and latterly a
motor disturbance in the fingers.

The fact that the contractions of the neck-muscles appeared simul¬
taneously with the neuro-psychic symptoms, and ceased with them,
points to the motor affection being a symptom of Korsakoff’s disease.

As regards the involuntary twitchings of the fingers, these have been
noticed in the same way by Korsakoff in connection with polyneuritic
psychoses, and by others in multiple neuritis without mental symptoms.
They are variously described as athetose, athetoid, clonic or chorei¬
form.

The head movements were diagnosed as tic, chiefly because the
same muscles (those on each side of the neck) took part in them con¬
tinuously, and gained strength in so doing. They are thought to be
clinical signs of a local disturbance in the cerebrum. They remind the
author of similar symptoms in general paralysis, and in the following
table the symptoms of the two diseases are compared :

General paralysis. Korsakoff's disease.

Clinical picture:

Typical psychic disturbances; Symptom-complex of Prof,
psychic signs peculiar to Korsakoff; psychic sym-

general paralysis. ptoms of polyneuritis.

Accompanying and local symptoms :

Epileptiform attacks; Jack- Epileptiform attacks; Jack¬
sonian attacks, paralytic sotiian attacks ; apoplecti-

attacks. form and pseudo-apoplecti¬

form attacks. (Knapp.)

Symptoms of continued hyperkinesis :

Cortical spasm (W A. Mura- Choreiform movements,

toff); tic (Seglas). clonic spasms in the

fingers and neck. (Knapp
and author.)

Cause:

Syphilis. Various.

In comparing the two diseases, it is found that the accompanying
symptoms are similar, and it is evident that in both the exciting cause
has affected the whole nervous system. When the causes of the
diseases are looked at, however, there is a difference. General paralysis
is ascribed to syphilis only, while polyneuritis has such a variety of

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causes that enumeration is difficult: Alcohol, carbon bisulphide,
arsenic, lead, quicksilver, tobacco, gastro-enteric and autoin poisonings ;
pneumonia, typhus, pyaemia (resulting from carbuncle), dysentery,
leprosy, post-puerperal states, tuberculosis, influenza, beri-beri, etc.

In view of these facts no fixed conclusion can be reached at present
as regards causation, but Dr. Choroschko makes the following surmises :
(1) That all the enumerated agents in entering into the organism cause
such conditions (toxic ?) by their influence on the metabolism as to
bring about the polyneuritic psychosis. (2) That there is a certain
nervous psychic constitution—a certain type of human being—that
after being poisoned by the above-named virus is so disturbed in
his normal functions that the phenomena of polyneuritic psychosis
results. (3) That all the above-named agents by unrestricted working
on the human organism can produce the peculiar psychosis.

In the two latter conclusions the idea of the polyneuritic psychosis
being a nosological entity is dispelled, and the conception of a poly¬
neuritic constitution or a psycho-polyneuritic symptom-complex arises.

Hamilton C. Marr.

Myxcedematous Condition of the Skin accompanying Manic-depressive
Insanity [ Ueber myxcedematose Hautverdnderung a is Parallelvorgang
bei tnanisch-depressiver Psychose\ ( Neur. Cb /., Nr. 4, 1909.)

Tomaschny.

The case described is that of a female, who from the age of fourteen
had been subject to recurrent attacks of insanity. The myxcedematous
condition occurred in connection with an attack at the age of twenty-
three.

The history of the patient shows that her father and mother were
both insane. A brother and a sister of her father committed suicide,
and a cousin of her mother was insane.

After admission to the asylum at the age of twenty-three, she had
two maniacal and two depressed periods. During both attacks of
depression she showed a peculiar physical condition. Soon after she
began to be depressed, there appeared a cushion-like swelling in the
skin and underlying tissue of the under half of the face, and particularly
in the lips. This swelling increased until in a few weeks the face
became quite disfigured, and assumed an appearance similar to that of
patients suffering from myxoedema. The swelling was fairly firm, quite
painless to the touch and left no mark on depression. The tongue
was not affected. A thorough examination was made for other
symptoms of myxoedema, but no further physical change was discovered.
The temperature did not depart from the normal. She was given thyroid
extract tablets for five days, but these affected her unfavourably.

In addition to the deformity of the face, there was noticed a large
increase of tissue on the body, especially in the regions of the shoulders
and hips. It was difficult to decide whether this was abnormal, or
whether it was only a natural condition resulting from rest after a
lengthened period of excitement. She gained in all about 22 lbs.

The myxcedematous condition continued during both attacks of
depression (eight months and ten months), and when the excited state

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commenced the swelling began to disappear and was not observed for
ten weeks.

That there was a connection between the mental and physical signs
cannot be doubted (in the history of a former attack a swelling of
the lips is noted), but the cause of this connection remains to be
discovered. Hoche found myxcedematous changes in a case of coal-
gas poisoning, and Mcllwaine has described two cases of mycedema
following respectively influenza and loss of blood from anaemia. In the
two latter cases, a toxic condition was ascribed to the blood. In the
case here described, it is also very probable that the physical condition
was due to a toxin similar to that found in certain diseases of the
thyroid gland. As the bodily and mental conditions were in this case
connected, the toxin must play a part, either as cause or effect, in the
mental disturbances.

The case illustrates the attitude that has often been taken up with
regard to manic-depressive insanity, 7 nz., that this insanity is closely
related to disturbances of metabolism. Hamilton C. Marr.

The Diagnostic Value of Forges' Reaction with Glycocholate of Sodium
on the Serum of General Paralytics [AW valore diagnostico della
reazione di Forges col glicocolato sodico sul siero dei malati di
paralisiprogressiva\ ( Riv. di Fat. nerv. e merit., vol. xiv, Fasc. ii.)
Tommasi, C.

Dr. Tommasi has made a series of comparative researches between
the reaction of Porges and that of Wassermann in cases of general
paralysis, and gives'his opinion of Porges’ reaction in this paper.

At a meeting of the Berl. med. Gesellsch. in December, 1907,
Porges affirmed that by mixing equal parts of blood-serum of a tabetic
or a paralytic with lecithin in physiological solution a characteristic
flocculent precipitate is obtained. The mixture, he asserted, remained
clear if normal serum was treated, or the serum of diseases other than
those noted.

Again at another meeting the same author referred to the result
of some comparative researches in which he tried to prove that his
reactions had in syphilis and general paralysis the same specific value
as Wassermann’s reaction. He found a positive reaction in 80 per
cent, of cases of syphilis, 70 per cent, of cases of tabes, and 100 percent.
of cases of general paralysis, and negative in other maladies. At the
same meeting Grosz and Kraus contributed their experience, which
confirmed the finding of Porges.

As a result of these suggestions, analogous methods were proposed
for the substitution of Wassermann’s reaction. Porges proposed to
substitute for lecithin, which he used in his primary researches, glyco¬
cholate of sodium. Lecithin in suspension was very unstable, and his
reaction with lecithin had been demonstrated by Zalla as not specific.

Dr. Tommasi has made experiments in nineteen cases, ten of which
were cases of general paralysis, one a healthy individual, one a case of
idiocy, one of epilepsy, and six cases of senile dementia. He has
reached the following conclusions regarding Porges’ reaction:

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(1) Porges’ reaction with glycocholate of sodium is not constant in
general paralysis.

(2) A positive reaction may be got in subjects free from general
paralysis and syphilis and in a percentage of cases almost equal,
although not greater than that of general paralysis.

(3) The reaction does not always give constant results, positive

or negative, in the same individual, whether he is affected or not by
general paralysis. Hamilton C. Marr.

Fugues in Mental Pathology \Les Fugues en Pathologie Mentale\

( Journ. de Psychol., July and Aug., 1909.) Baton and Froissart.

The first two portions of this paper are devoted to a critical discus¬
sion of the definition of a fugue and an extensive resumi of the literature
of the subject. The authors then describe the various clinical varieties,
viz. :

(1) Fugues in “second” states (ambulatory automatism), occurring
in epilepsy, hysteria, and some alcoholic conditions. The normal
passes into the “ second ” state abruptly, and the subject enters into a
new life, usually without any dangerous reactions or extravagances.
There is, subsequently, amnesia, more or less complete for the period.

(2) Psychasthenic fugues. As in all impulsive obsessions the idea of
flight causes much anguish ; the subject fights against it and eventually
yields, experiencing much relief.

(3) Fugues in acute hallucinatory psychoses, confusional insanity.
The fugue is frequently an instinctive act of defence in such conditions
as flight from terrifying hallucinations.

(4) Fugues in chronic delusional states—flight from persecutors.

(5) Fugues in maniacal states. Such frequently occur in the pro¬
dromal state of hypomania, the motives being generally bizarre.

(6) Fugues in demented states. They are of especial importance in
the earlier phases of dementia praecox, and are apparently motiveless.

(7) Fugues in children. Usually indicative of degeneration or moral
perversion.

(8) Fugues among soldiers are usually examples of one of the above,
but are especially mentioned because of the peculiar conditions of
existence.

The differential diagnosis of fugues from allied conditions is dis¬
cussed as well as the medico-legal aspects of the subject.

H. Devine.

Neurasthenic headaches [La cephalee neurasthenique]. (Le Prog. Med.,

Jan. 2$rd, 1909.) Riche , A.

Headache is nearly always present in neurasthenia; at times it becomes
the most prominent symptom. It is troublesome more from its persist¬
ence than actual intensity. More importunate than painful, its obses¬
sing character augments the mental fatigue from which the patients
suffer. It is either diffuse or localised to the forehead, eyes, root of
nose, temples. Various comparisons are employed by the patients to
describe their sensations, according to the locality affected. If diffuse,
a feeling of emptiness, a foreign body in the head, a sensation as if the

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brain were moving about ; if localised, a tight cord around the temples
or metal band (occipito-frontal). Frequently they complain of a feeling
as if a heavy helmet were being worn. Localised to the nose the sen¬
sation is that of a pince-nez too tight. The discomfort usually com¬
mences on rising in the morning, is temporarily relieved during meals,
but is aggravated during digestion.

The writer discusses the differential diagnosis of this condition and
the cephalgia associated with cerebral syphilis, tumour, auto-intoxica¬
tions, Bright’s disease, neuralgia, and migraine.

H. Devine.

Clinical Contribution to the Study of Alcoholic Epilepsy \Contributo
clinico alio studio della epilessia alcoolica ]. (Arch, di Psichiat .,
vol. xxix,fasc. vi, 1908.) Ramella.

The case recorded in this paper is of interest as illustrating in a very
striking way the role of an epileptic organisation in predisposing to
pathological drunkenness. The patient was a man, set. 40; no details
are given with regard to his family history, and as to his personal
antecedents it is merely stated that he had undergone thirty-five terms
of imprisonment for drunkenness and minor offences. He was admitted
to the asylum of Udine under the author’s care four times, the symptoms
on each occasion being practically identical, viz., psycho-motor agita¬
tion, hallucinatory disorder, suicidal and destructive impulses, all these
symptoms clearing up within some twenty-four hours and leaving only
a vague trace in the patient’s memory. During one of his sojourns in
the asylum he succeeded in getting access to wine, and drank a quantity
equivalent to nearly two ounces of absolute alcohol. For an hour and
a half no symptoms appeared, and then the patient became suddenly
agitated and aggressive ; he showed symptoms of hallucinatory confusion
with suicidal impulses; there was general cutaneous analgesia, the
pupillary reaction to light was almost lost, and the deep and superficial
reflexes were increased. This condition quickly gave place to a stuporose
state lasting about an hour, after which the patient had a series of
typical epileptic seizures with enuresis. After a few days of post¬
epileptic dulness the patient got back to his normal level, but remem¬
bered nothing whatever about the attack. W. C. Sullivan.

The Clinical Examination of Painful Sensibility by Pressure [EExplora¬
tion Clinique de la Sensibiti Douloureuse par la Pression\ (Bull.
Soc. Clin. Med. Ment., March , 1909.) Cleramranet, Af.

Pain upon pressure is only systematically looked for in certain organs,
as the testicle, eye, etc., and in the trunks of nerves in certain diseases.
The author hence advocates a more extensive application. He draws
attention to the one whicli he terms the “ pression ungueale." When the
terminal phalanx is placed upon the table and pressure applied at the
anterior extremity of the nail, an acute pain is produced. If the finger
is in a state of semi-flexure, then pressure should be applied to curve
the finger more, so as to make the end of the nail bend under the nail
itself. The pain produced is piercing, immediate, and causes a complete
muscular relaxation of the whole hand. If the finger is flexed, there is
also produced some articular pain, which is due to the distension of the

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ligaments. Both of these conditions manifest the deep sensibility.
These pains are often abolished in general paralysis of the insane,
rarely so in cases of hemiplegia, and are absent in patients with cerebral
syphilis, or cerebral tumours with dementia. In acute alcoholism a
hyperalgesia exists.

Pressure over the internal tibial crest causes, also, acute pain. This
is absent in cases of tabes, but not so in dementia or cerebral syphilis.
Similar pain can also be produced by pressure under the ear, over the
second and third dorsal interossei, and in other muscles, such as the
pectoralis major, especially at the place where the tendon emerges from
the muscle.

If this pain upon pressure were more investigated, the author con¬
siders that it might often aid a diagnosis in certain diseases.

Sidney Clarke.

Juvenile General Paralysis \Un cas de paralysie glnlrale juvenile ].

{Prog. Med., March 8 th, 1909.) Remond and Chevalier-Lavaure.

These writers describe in the above journal a very good case of
juvenile general paralysis in a girl. Nothing about her parents was
known. The child developed more or less perfectly up to the age of
fourteen, although her intelligence was somewhat limited and her reading
defective, but her manual work was quite satisfactory to her masters.
It was then noticed that her activity became less, she forgot to carry
out orders, and her intellect became more enfeebled. She appeared to
be too well developed for her age, as evidenced by her features,
breasts, and pubic hair. Motor troubles then appeared, leading to
ataxia ; speech became defective, and the tongue was tremulous.

The tendon reflexes were abolished, but Babinski’s sign was
absent.

There was inequality of the pupils, the left being the larger, and the
“ Argyll-Robertson ” syndrome was very clear. The disease pro¬
gressed typically, and she died two years later.

At the autopsy the dura was thickened and fibrous, the arachnoid
opaque, with opalescent tracts along the vessels. There was an abun¬
dance of cerebro-spinal fluid. The pia was very adherent to the brain,
especially on the right side, and along the boundaries of the frontal and
parietal lobes. There was marked atrophy in the frontal lobes, the ven¬
tricles dilated, and the surface over the grey muscle irregular and rough.

Microscopically, sections stained by Nissl’s, Van Gieson and Weigert
Pal’s stains confirmed the diagnosis.

The interest in this case lies in the fact that it occurred in a “ feeble¬
minded,” and its course was that of a purely progressive dementia,
without any delusions of grandeur or of wealth.

Sidney Clarke.

The Slow Recovery in some Acute Mental Disorders [ Guerison tardive
cTctats aigus graves ]. {Bull. Soc. Clin. Med. Ment., May, 1909.)
Legrain, M.

M. Legrain calls attention to the slow recovery of some acute
cases of insanity. It is well known that certain mental diseases are
fatal, whilst in others the prognosis, although not absolutely grave,

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is not at all hopeful, for the cerebral cells become completely dis¬
organised. The duration of the illness, too, is a factor which has to be
considered, and the longer it has lasted the more gloomy is generally
the prognosis. But this is not always so, and he cites several cases
which had been given up as hopeless, since they showed no improve¬
ment in periods of time ranging from two to six years, yet in which
mental recovery took place quite unexpectedly. In consequence of
this, he deems it advisable to discuss the subject in order to make one
remember when giving a prognosis that tardy recoveries do occur.

Sidney Clarke.

Inborn Hotnosexuality and Pseudo-homosexuality \Echte Angeborene
Homosexuality und Pseudo-homosexualitat\ ( Deutsch. tned. Woch. y
No. 34, 1909.) Nacke, P.

Nacke returns once more to the question of sexual inversion because
he finds that many misapprehensions still prevail. This he puts down
to the fact that the typical invert very rarely seeks medical aid, so that
the commonest forms of this anomaly as well as its wide prevalence
remain alike unknown. He mentions an early experience of his own,
when, never having seen an invert, he asked Hirschfeld to send him
two. When they arrived, one, to his astonishment, turned out to be a
man he had known for sixteen years, a near relation of his own wife.

Nacke proceeds to distinguish between the genuine invert and the
pseudo-hemosexual person who is normal and merely adopts
homosexual practices when separated from the opposite sex. Nacke
definitely denies that true inversion can ever be produced by masturba¬
tion, seduction, imitation, etc., and he regards it as more than doubtful
whether inverts can be considered degenerates; he has not found that
they show an unusual number of stigmata of degeneration, and in
general society they cannot be distinguished from other people. Nacke
would punish the pseudo-homosexual person but not the true invert,
who is to be regarded as a natural variation. Treatment he regards as
useless, and he doubts whether either hypnotism, as practised by Moll,
or the psycho-analytic methods of Freud’s school can produce a really
permanent result. Havelock Ellis.

So called Moral Insanity \Ueber die Bewertung der Imbezillitat und
der sogenannten Moral Insanity in prakiischer und forensicher
Beziehung]. (. Psych.-Neurol. IVoch., No. 52, 1909.) Friedldnder.

The author emphasises the difficulty of diagnosis in those cases of
psychic weakness in which the chief defect lies in the moral sphere,
referring to a case in which seven opinions were all different (sexual
neurasthenia, feeble mind, dementia praecox, etc.), while for the magis¬
terial and lay mind the case was simply one of moral depravity. Such
cases are very deceptive even for an experienced observer, and Fried-
lander considers that no report should be made after a mere short
interview, but only after long-continued observation. With Mendel,
Nacke, Hoche, Aschaffenburg and others, Friedlander refuses to accept
moral insanity as an independent disorder, not because he has never
seen a case of the kind, but because he believes that psychology and
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psycho-pathology forbid us to admit such isolated affections ; they fall
with the old group of monomanias. In all these cases of moral psychic
defect prolonged and thorough investigation will show that, though the
ethical defect stands in the foreground, it is still possible to detect
intellectual disturbances. Friedlander fails to add that this view is
nowadays widely accepted even by those who consider it inconvenient
to abandon a properly defined conception of moral imbecility.

In the remainder of the paper, the author discusses these cases in
relation to the German law, and refers to the good effects of specialised
medical and pedagogic treatment. Havelock Ellis.

Cerebral Tumours [“ Tumeur de la dure-mere ” et “ Tutneur cMbrale
latente"\ ( Bull. Soc. Clin. Mid. Merit., No. 6 and 7, 1909.)
Marie , A.

Cerebral tumours are always of interest, and Marie records the
presence of a large one in two patients where nearly all of the cardinal
signs and symptoms were absent.

In one there was a large tumour of the dura-mater about the size of
an infant’s hand. It appeared to be an organised blood-clot with
central trabeculae containing a pale yellow fluid. The alveoli looked
like the grains of white grapes. The tumour lay over the right
Rolandic area, extending towards the right frontal pole, and the
cerebral cortex below it showed superficial areas of yellow softening.
The patient at the onset of the illness had shown signs of mental
weakness, which was followed by a noisy incoherence. With the
exception of some muscular weakness, there was present no other sign
or symptom to point to the diagnosis of the tumour, which was unfor¬
tunate, for it could have been removed by surgical treatment.

In his second case, there was a large, fibrous tumour lying under the
frontal lobes in the middle line, greyish in colour, and of firm consis¬
tency. It was not adherent to the brain-substance save where it was
attached by a small pedicle, and it seems to have originated from the
pia-mater. The tumour had made for itself a large bed in the orbital
surface of both of the frontal lobes by compression of the cortex, and it
caused projections into each lateral ventricle. It was strange that it
was unaccompanied by any signs of paralysis, convolutions, or sensorial
troubles, and even the acute headache was absent. The patient
became a senile dement, which possibly resulted from large areas of
softening which were found in the other lobes.

Sidney Clarke.

General Paralysis and Symmetrical Gangrene of the Extremities [Para-
lysie Glnirale et Asphyxie symetrique des extrimitis\ {Rev. de
Psychiat., March , 1909.) Naudascher, G.

The writer gives the clinical account of two cases of general paralysis
in which gangrene, symmetrical in its distribution and preceded by
diarrhoea, accelerated death.

The first symptom of an abnormal type was diarrhoea, which was
intractable to any line of treatment. In the first case, a month later
oedema suddenly appeared in the legs, followed by the formation of

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bullae containing clear serum. The oedema was followed by a cyanosis
of the skin covering the front of both feet. Later moist gangrene
appeared and sloughing occurred. The lesions were remarkably
symmetrical in every respect. At the post-mortem no arterial lesion was
found to account for the condition.

Diarrhoea was, in the second case the first symptom, and this was
foliowed in two days by oedema of the feet and legs, which in turn was
succeeded by cyanosis. Bullae next made their appearance, a large one
being seen on the sole of the left foot. There was no corresponding
lesion of the right foot. Gangrene of the toes was followed by two toes
dropping oft, and, notwithstanding a large ischio-rectal abscess, the
patient for a time did well. At the end of nine months the oedema and
cyanosis recurred in the right foot, gangrene of the moist type finally
putting an end to life. The post-mortem showed marked endarteritis
with consequent narrowing of the lumen of the femoral and popliteal
arteries. Cohn McDowall.

5. Pathology of Insanity.

Symmetrical Apoplexy in the Region of the Cornti Ammonis in Epilepsy
\Symmetrische Apoplexie dcr Ammonshorngegend bei Epilepsie ].
{Neur. Cbl., 1909, Nr. 7.) Hermann , Dr.

Meynert first drew attention to the pathological changes in the
cornu ammonis in epilepsy. In most cases a condition of gliosis was
found, which showed itself macrosopically in diminution and hardening,
and microscopically in atrophic processes of the ganglionic cells and
filling up of the spaces with neuroglia.

Until now only subjective opinions as to the primary or secondary
nature of the change have been submitted, and some writers have
assigned no special significance to the changes in the cornu ammonis,
contending that they are only part of a gliosis common to the
whole of the cortex. But there have been cases in which thorough
microscopic investigation showed that the signs of gliosis were confined
to the cornu ammonis, and while these cases give the impression of a
primary, perhaps even a congenital disturbance, the cases described by
Alzheimer and others in which a diffuse gliosis of the superficial layers
of the cortex was found point to a secondary disturbance—more an
explanation for epileptic dementia.

It is difficult to determine whether a primary or a secondary role
should be assigned to other changes in the cornu ammonis. In older
works we find cases quoted where there was serous softening, softening
with redness, redness only, with spot-like extravasations of blood, all
accompanied by venous hypersemia of the brain. Death in these
cases having taken place during coma or a fit, the conditions found
may certainly be said to play a secondary role. Other cases are quoted
where one or both cornua had developed tumours. Dot-like haemor¬
rhages in the grey matter of the cortex are often described, and may be
likewise due to passive hyperaemia during a fit. Recent microscopic
examinations have unfailingly discovered some of the vessels in the

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process of gliosis, and in this area especially, if it is in the cornu
ammonis, there is seen a new structure and increase of blood-vessels with
thickened walls and abundant endothelial cells. The vessels are widened
and filled with blood and blood-corpuscles. Hajos found, in early cases,
miliary aneurysms in the cornu ammonis. He was of opinion that the
breaking up of the vessels depicted an inflammatory process. He
emphasised the fact that there was sometimes a serous softening in
the cornu ammonis and its neighbourhood unlike gliosis, and he put
special stress on the fact that this process, which he said was rare,
confined itself to the cornu ammonis. From the development of
miliary aneurysms to apoplexy is only a step. Formerly great import¬
ance was attached to overflow of blood in the cerebral meninges at the
base of the fourth ventricle, and also in the cornu ammonis. In 1862,
Hoffmann described two cases of capillary haemorrhages in the cornu
ammonis as the causes of death in two epileptics. Schrbder van der
Kolk mentions an old apoplectic cavity in the right posterior lobe,
affecting a pillar of the fornix, the gyrus fornicatus and the uncus.

Among later writers, Orloff, in the case of a man, aet. 28, who,
without fits or other physical signs, died in a state of coma, found
extreme fulness in the vessels of the right and of the left cornu
ammonis, and in the cortex of the left hippocampal fissure single tom
vessels with fresh blood extravasation in the perivascular hollow. At
the same time there was gliosis of the cornu ammonis, as also of the
rest of the brain.

The case described by Dr. Hermann is that of a man, set. 28, who had
suffered from epilepsy since the age of twenty-three. In the course of
left-sided exudative pleurisy with diffuse peritoneal tuberculosis, there
was drowsiness on the third day, and the patient died in a state of coma,
without signs of fits, dyspnoeic or cardiac symptoms, on the fourth day

Post-mortem examination showed a red softening, the size of a hen’s
egg, in the neighbourhood of the cornu ammonis (left side), and numerous
extravasations of blood, from the size of a pin-point to the size of a
grain of rice, in the hard part of the cornu ammonis at the right side.
Both haemorrhages had a fresh appearance, and we may take it that the
sleepiness resulted from haemorrhage, the direct cause of which might
be the large exudation with its pressure working on the upper vena cava.
There were no clinical or anatomical signs of a larger engorgement, and
all the more on this account the vessels of the cornu ammonis represent
a locus minoris rcsistentice. Even if the disease and haemorrhage of the
vessels of the cornu ammonis are of a secondary nature, the relation of
the cornu ammonis to genuine epilepsy on account of these conditions
is quite apparent. Hamilton C. Marr.

On the Pathology of Dementia Prcecox and on the Acute Phases Present
\Sulla patologia della Detnenza Precoce e sulle fast acute che in essa
si presentano], ( Riv. Sper. di Freniat , vol. xxxiv, fasc. Hi, iv,
December, 1908.) Pighini, G.

The clinical unity of dementia praecox with its rich variety of forms is
by many held to be one of the finest conquests of modern psychiatry,
but it must be conceded that this unity is but the outcome of the happy
constructive mind of an acute observer, and is not based on the recog-

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nition of a well-defined and distinct morbid agent. A pathological basis
for the disease would certainly be the ideal one, and Kraepelin himself
has frankly admitted as much.

In the present communication, Pighini gives the result of his attempts
to arrive at a definite finding. He is forced to confess that the primary
and essential morbid agent is still wholly unknown, but he gives a con¬
tribution to the pathology of dementia praecox that promises to lead to
a clearer understanding of the disease, He holds that, with the excep¬
tion of the morbid alterations in the brain (cell atrophy, chromatolysis,
increase of neuroglia in the various zones and especially the deeper
layers of the cortex), all the hitherto published anatomical alterations
may be regarded as purely secondary. He has certainly, in numerous
autopsies, found thickened meninges, cerebral swelling, various altera¬
tions of the thyroid, parathyroid, liver, pancreas, kidneys, adrenals,
ovaries, testicles, etc. (for almost every organ and tissue in the body
has been included in the pathological literature of the disease), but he
has even more frequently found the cerebrum normal in appearance and
every organ in a healthy state, always excepting, of course, the specific
lesions of the causa mortis , such as tubercle, pneumonia, etc.

In studying the metabolic processes in various cases of dementia
praecox, Pighini was struck by the fact that whilst in some there was
evident an accumulation and retention in the balance of nitrogen and
phosphorus, in others there was an increased elimination of these
elements. These apparently contradictory findings were explained
away by a careful study of the clinical course of the disease. Pighini
believes tnat insufficient consideration has been given to the features
that distinguish the initial and acute from the subsequent and more
chronic phases of the disease. In the acute stage, the characteristic
features are motor agitation, quickened pulse and respiration, elevation
of temperature, dilated pupils, exaggerated tendon reflexes, muscular
tremors, acetonic breath, frequent sitophobia, excretion of urine rich in
nitrates, phosphates and sulphates, and rapid loss of weight. To these
physical signs are joined mental confusion, hallucinatory delirium and
psychic excitement. He gives a minute account of thirteen cases in
which he has investigated the metabolic processes and studied the
clinical course, and arrives at the conclusion that in the acute phases
there is a destruction of nucleo-proteids (phosphates and sulphates)
not present in the chronic phase. The loss of weight and the increased
temperature found in the acute phase probably result from the proteid
decomposition in the organism, due to morbid conditions as yet unknown.
What tissues or cells are precisely the seat of this destructive process
we do not know, but the evidence we have suggests that at least the
nervous tissue is involved. While symptoms of nervous excitement or
irritability of the cerebral nervous tissue dominate the acute phases of
dementia praecox, the symptoms of mental deficit which soon follow and
initiate the true dementia indicate something more than the effects of
a simple irritation, rather a true organic deficit , or in other words, a
material alteration in the tissue. Histological examinations agree in
showing systematic lesions in the cerebral cortex of the subjects of
dementia praecox, even in the early stages. Koch, investigating the sulphur
compounds in the cerebral cortex of precocious dements, found a marked

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diminution of neutral sulphur and an increase of the inorganic sulphur as
compared with the normal—a very important finding, which, if confirmed
and followed up, may yet let us know what constituent of the nervous
system is the elective seat of the unknown destructive quid. Pighini
suggests that the destructive process may not be limited to the cerebral
substance. The marked daily loss of nitrogen, phosphorus and sulphur
indicate an extensive dissolution of proteid substances over a wider base.
Some part may be played by the blood-forming organs and the blood,
in which various observers have noted a marked hyper-leucocytosis,
precisely in the acute stage of the disease. To sum up we would have
in the primary phases of dementia praecox a destructive process in
action. In the later stages this process would be spent and we
would have left only anatomical and functional lacunae.

J. H. Macdonald.

Neuroglia in the Brains of the Insane \Ncurogliabefunde in Gehionen
von Geisteskranken]. {Psych. Neur. JVochcns.) Von Elimger.

From various parts of the brain small pieces of tissue were taken
and hardened in io per cent, formalin. Subsequently the staining by
Weigert’s method for neuroglia was employed. Fifty-seven brains were
submitted to this process, the majority of which were taken from
cases of dementia praecox (twenty-three). Others included thirteen
several forms of insanities. The ages of the cases of dementia praecox
ranged from seventeen to seventy-four, and the duration of the disease
varied from three months to thirty-seven years. In thirteen cases there
existed distinct thickening of the neuroglia in the cerebral cortex. This
consisted in an increase in the glia-fibres, the glia-cells being scarcely
at all increased in number. In the great majority of these cases the
disease had lasted for over ten years and had passed into dementia.
In ten out of the twenty-three cases there was absolutely no increase of
neuroglia. These were cases which lasted from a few months to, at
most, a few years.

The author concludes from an examination of the cases of dementia
praecox that there is no proliferation of the neuroglia in the early years
of the disease. After it has lasted ten years there occurs thickening of
the cortical neuroglia. The same holds good of the other varieties of
the insanities examined. In progressive paralysis and senile dementia
there is marked proliferation of the neuroglia when the disease has
existed for only a short time. J. R. Sutherland.

The Fissures and Convolutions of the Insane Brain [Sillons et Circon-
volutions du Cerveau des Alilnts\ {Arch, de Neur., Jan., 1909.)
Mingazzini, G.

. . « •

Professor Mingazzini publishes his studies of the fissures and con¬
volutions of the brain, giving also the opinions of other authorities. It
has been questioned whether such studies are of great value, but the
problem nevertheless remains, and is of morphological interest. His
paper contains a large amount of detailed information.

Discussing the fissure of Rolando, he states it is poorly developed in

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idiots, and sometimes an interruption of this fissure has been observed
through one of the frontal convolutions passing directly into the parietal
lobe. The fissure in certain of the insane lies nearer to the frontal pole,
similar to the position seen in apes, indicating a poor development of
the frontal lobes. Normally in the male this fissure is absolutely and
relatively longer than in the female, but it may not be of equal length in
each hemisphere. In idiots the frontal lobe is very simply marked,
especially the lower gyrus, but the parietal lobe shows but few variations.
The opercula in idiots do not often completely cover the island of Reil.

From his observations he divides these anomalies into two classes.
The one indicates arrests of development to which he assigns the in¬
complete sulci, which divide the frontal convolutions, and the tendency
of the fissure of Rolando to keeps its infantile type—that is, a diminu¬
tion in its length and the disappearance of the differences pertaining to
the sex. The other class embraces those of philogenetic origin, and to
this group belong anomalies, as the absence of communication of the
calcarine with the parieto-occipital fissure, a rudimentary development
of the third frontal lobe, of the anterior branch of the Sylvian fissure, of
the fissure of Rolando, and of the convolutions of the island of Reil.

Finally, he says these anomalies, especially those appearing in the
second group, predominate in idiots when compared to those observed
in the other forms of insanity, and the brains in idiots often present
relics of morbid and rudimentary processes dating from foetal life.

Sidney Clarke.

The Persistence of the Neuro-fibrillic in General Paralysis [La persis-
tance des nenro-jibrilles dans la Paralysie Genlrale\ (Bull. Sot.
Clin., Feb., 1909.) Dagonet, J.

By special methods of staining, a fibrillation of the protoplasm of
nerve-cells has been demonstrated, which according to some authorities
is an artefact. The writer considers them, however, to be paths of
conduction common to several cells; the neuro-fibrillae traverse several
cells and their protoplasmic prolongations form an extraordinary rich
extra-cellular network. When passing through the nerve-cell, the
principal fibrillae anastomose by secondary fibrillse or by an extremely
fine network. From an investigation of these neuro-fibrillae, Cajal’s
silver method being employed, the writer finds that the results of his
researches in cases of general paralysis are not in agreement with other
workers. The neuro-fibrillae were not thickened save where they joined
together, nor was their coloration more intense, and they were con¬
tinuous. They persisted in badly damaged cells with the exception of
the pyramidal cells, for in these the lesion is generally diffuse.. All the
nervous elements are altered and disappear in general paralysis, and
the neuro-fibrillse are really no exception to this statement, but their
changes are of small import, being secondary. The neuro-fibrille in
general paralysis is the ultimum tnoriens. Sidney Clarke.

On Epilepsy in Senile Dementia [De I'epilepsie chez les dhnents seniles\
(Rev. de Psych., Feb., 1909.) Marchand, L., and Petit, G.

Since the epileptic fit may appear in every form of cerebral disease, the
authors consider it now out of place to call epilepsy an idiopathic

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disease, but it should be regarded only as a symptom. Epilepsy
appearing after the age of thirty {ipilepsie tardive), even if unaccompanied
with mental disorders, always permits a diagnosis of cerebral lesions as
a cause of the onset.

From their observations, the authors say that epilepsy may appear in
the course of senile dementia, just as it does in the other varieties of
dementia. The fits are few in number, generally appearing in the last
stage; vertigo, the trance-like condition and the automatic post-epileptic
actions, are but rarely seen. Disorders in speech are very common
after the epileptic attacks in these aged patients, but they are not the
result of localised lesions in the speech area, but arise more probably
from an increased state of dementia. The cerebral lesions of senile
dementia with epilepsy consist of a superficial diffuse sclerosis of the
cerebrum with marked alterations in the tangential fibres, and of patches
of sclerosis following atheroma of the cerebral vessels.

Sidney Clarke.

Statistics relating to the Percentage Incidence of Intra-cerebral and
Subdural Hcemorrhage and Deposit in the Insane. {Arch, of Neur.
and Psychiat., vol. iv, 1909.) Mott, F. IV.

Dr. Mott has collected the statistics relating to the above subject
from the records of 1,926 necropsies conducted at Claybury Asylum
during the last ten years, and deduces the following conclusions from
the table he has compiled. The total percentage of intra-cerebral
haemorrhage was i - 2 per cent. Except in two cases of doubtful general
paralysis the haemorrhage occurred in cases other than of that disease.
There appeared to be, especially in males, two separate morbid con¬
ditions as regards subdural haemorrhage and deposit: (a) Cases of

undoubted subdural haemorrhage in elderly people (among females this
class was not in evidence) associated with arterial degeneration and
cardiac hypertrophy; (b) cases of membrane formation of a similar
nature to that found in general paralysis. Combining the intra-cerebral
and subdural types of haemorrhage in all the necropsies made, he found
these cases numbered about 2 per cent. Chronic vascular and renal
disease were associated with these cases in practically every instance.
This is a condition markedly different, he points out, from that found
in cases of chronic pachymeningitis, in which the heart, together with
the other viscera, usually showed some wasting, especially in cases of
general paralysis. A. W. Wilcox.

6 . Treatment of Insanity.

The Psychological Principles and Field of Psycho-therapy, (fourn. of
Abnorrn. Psychol., June-fuly, 1909.) Prince, Morton.

In order to employ psycho-therapy in an efficient manner it is
necessary to clearly understand the underlying psychological principles.
These may be described under the following headings:

(1) Complex formation. —A “complex” consists of a number of

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associated ideas, emotions, sensations, etc., linked together into a
system, so that stimulation of one element of the group stimulates the
activity of the rest of the group. Such complexes may be either normal
or morbid, e.g., phobias, fixed ideas, etc. The process by which certain
of these syndromes are created is educational. Hence it should be
possible by educational methods to disintegrate complexes which have
become harmful to the personality.

(2) Conservation .—Complexes tend to be conserved. They may be
conserved in the unconscious, and only be actually reproduced at
intervals, e.g., obsessions, phobias, etc. A complex may be perfectly
conserved, although we are unable to voluntarily reproduce it. This is
shown by its appearance in hypnosis or in dreams—in the latter case it
expresses itself in a distorted form. A complex may be organised and
conserved whether it is formed in the waking state or in hypnopsis. In
the latter case the elements of the hypnotic complex may enter the
stream of everyday life and modify it.

(3) Dissociation. —Dissociated systems of ideas explain somnam¬
bulisms, paralyses, anaesthesias, etc. The important fact here for
psycho-therapy is that it is frequently possible to produce dissociation
and synthesis by artificial means, eg., suggestion.

(4) Sub conscious ideas. —The dissociated systems function indepen¬
dently of the personal consciousness, as a “ subconscious,” or, better,
“co-conscious” system, eg., hysterical anaesthesia. To re-synthesise
these systems with the personal consciousness is to make the patient
aware of the dissociated ideas, and hence to remove the anaesthesia, etc.

(5) Automatism. —This plays a large part in normal life—for example,
habit-actions, and absent-minded acts. The automatic activity of
complexes of ideas has been demonstrated by Freud, Bleuler, and Jung.
This automatic activity affects the personal consciousness in various
ways—sudden appearance of ideas without relation to remainder of
conscious stream, hallucinations, etc. Morbid phenomena arising in
this way can be removed by the re-associating of the split-up
personality.

(6) Emotional energy ’.—Exalting emotions have an invigorating,
synthesising effect, while depressing emotions produce disintegration.
It is possible to modify the personality at will by measures which make
use of this principle.

All the above tendencies govern normal functioning; it is only their
perversion which constitutes functional disease. All these principles
are made use of in psycho-therapy.

If we are dealing with a case exhibiting unhealthy ideas, habits of
morbid introspection, baseless apprehensions of disease, then the method
employed is the organisation and substitution of healthy complexes for
the unhealthy ones actually present. Old ideas are modified by being
interwoven with new. Finally the therapeutic complex thus formed is
conserved in the unconscious, ready to be reproduced when necessary.
It matters little whether these complexes are organised in the w'aking
state or in hypnosis. Hypnosis is only necessary in a minority of cases
where it is considered that suggestibility should be increased.

When dissociation exists, re-association must be employed. There
are various methods—Freud’s psycho-analysis, suggestion in waking

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state, hypnosis, hypnoid states, etc. The autonomous complex must
be broken up, or its elements re-synthesised into a healthy complex, or
antagonistic ideas must be suggested.

All psycho-therapeutic measures pre-suppose a thorough study of the
individual psychology of the patient. Bernard Hart.

Psycho-Analysis in Psycho-Therapy. ( Journ. of Abnormal Psych., June-
July, 1909.) Jones, Ernest.

Psycho-therapy is a means of alleviating certain disorders by purely
mental methods. Formerly such methods were employed empirically,
no real attempt being made to explain the modus operandi of the treat¬
ment. Owing, however, to the psycho-analytic methods formulated by
Freud, a more complete understanding of the nature and origin of
abnormal mental states has been gained and the treatment placed on a
scientific basis.

The author proceeds to describe the essential features of Freud's
psychology, which may be summarised as follows. The various sym¬
ptoms observed in the psycho-neuroses result from two groups of ideas
which cannot be brought into harmony with each other. The person¬
ality is unable to assimilate a certain “ complex,” with the result that
the latter is suppressed from consciousness and takes on an independent
existence, its activity being represented indirectly and in distorted
form. This distortion in the manifestation of the complex is often
exceedingly involved, the connection between it and the symptom
being therefore correspondingly difficult to unravel.

Every psycho-neurotic symptom may thus be said to result from a
submerged mental complex or wish. The affect of the original complex
being unable to find direct expression becomes transposed to some
indifferent mental (phobia, obsession) or bodily process (paralysis,
tremor). The symptom is thus the unconscious gratification of the
suppressed wish.

The aim of the psycho-analytic method is to enable the patient to
discover the significance of the mental process manifested as a sym¬
ptom. The author details the various procedures which may be
adopted. Such are, hypnosis, “ free association,” and Jung’s word-
reaction association method. Hypnosis is now but seldom employed.

The writer points out that these procedures are the reverse of sug¬
gestion, in which the physician adds something to the patient’s mind—
belief, confidence and the like. In psycho-analysis he takes something
away, viz., inhibition. The chief aim is to give the patient self-mastery
and an understanding of the confusions of his mind, contrasting thus
with the dependence fostered by crude suggestion. H. Devine.

Therapeutic Indications for the Treatment of Insotnnia [les Indications
Therapeutiques dans le Traitement des Insomnies]. {Le Prog. Med.,
Oct. 2, 1909.) Baufle, Paul.

The sedatives of the opium group have been known for centuries; to
these modern pharmacological progress has added two additional main
groups, chloral and its derivatives, and the sulphonal, trional and
veronal group; in fact, we have now so many sedatives at command
that we can rarely fail in ordinary cases to secure sleep for a night or

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two. But, the author goes on to point out, sleep thus obtained is
artificial; it is a sleep of intoxication and is, therefore, far less recupera¬
tive than natural sleep. cannot suppress the nervous irritability
which is the immediate cause of the insomnia without inducing in the
nerve-cells functional troubles, which may be and often are, worse than
the insomnia itself. Moreover, all sedative drugs produce functional
troubles by their effects on other organs than the cerebral cells, more
marked in proportion to the magnitude of the dose administered;
whilst if we try to avoid these by giving minimal doses, we find that
our would-be calmative has an exciting influence. Finally, we have
to take into consideration, first, the loss of effect which commonly
results from repeated administration, and secondly, the various incon¬
veniences and dangers of habituation—the most obvious and familiar
of these being chronic morphinism. For these and other reasons, in the
treatment of insomnia we must, as far as practicable, avoid merely
symptomatic treatment by means of sedatives and hypnotics; we must
search for the causes of the insomnia and grapple with these. The
author then proceeds to the application of this sound principle. It will
not be possible here to give more than the outlines of his classification.

The first and one of the most important groups of cases is consti¬
tuted by the insomnia consequent upon pain. Here, of course, the
therapeutic indication is clear whenever the source of pain is manifest
and remediable. When sedatives are used the opium group is alone
available, since the hypnotics of the other two groups have little or no
analgesic influence. But we must always be on our guard against
the false appearance of safety which may result from the adminis¬
tration of opium (in appendicitis, for example). The next group
is that of the insomnias occurring in the acute infective disorders.
Here the insomnia, like the primary disease, is necessarily of limited
duration, and measures directed against the primary disorder are more
useful than hypnotics (hydrotherapeutic procedures, for example, in
typhoid fever). The writer’s next group is that of the insomnias
occurring in connection with the chronic intoxications, with alcohol,
morphine, etc. To the readers of this Journal, the most interesting
paragraphs of this section will be those relating to the insomnia of
delirium tremens. Every experienced practitioner will endorse the
writer’s statement that in many cases of delirium tremens the physician
will essay in vain all the resources of hypnotic medication. Physical
methods should first be tried, wet pack, cold baths, prolonged tepid
baths ; of hypnotic drugs, chloral and opium 1 are the most useful;
in some cases cannabis indica has given good results; the tincture may
be used in doses of one to 20 minims, but the correct dosage is
difficult to determine since the activity of the drug varies greatly in
different specimens, and individual idiosyncrasy is marked in regard to
it. Finally, there is the old English method of administering heroic
doses of digitalis ; and the recently recommended hypodermic injection
of scopolamine in doses of to of a grain, but this last-named
drug he considers untrustworthy and dangerous. The next group of

1 I cannot agree with Baufle here, for I consider the use of opium extremely
dangerous in alcoholic deliriants. In them, alarming symptoms of morphine
intoxication sometimes rapidly ensue from ordinary medicinal doses.—M. E. P.

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insomnias comprises those that occur in meningo-encephalic affections.
I pass over the insomnia of organic brain disease to speak of the
author’s views regarding the treatment of insomnia in the insane.
Insomnia is often an early symptom of insanity, and may at times be
be an isolated symptom ; in such cases, since protracted insomia is
disastrous to the cerebral functions, the question may arise whether
the sleeplessness is to be regarded as cause or as effect. Insomnia may
also be persistent in advanced mental alienation, and it then aggravates
the mental and physical troubles of the sufferer. We must contrast
those suffering from acute mania, who may be sleepless for weeks or
even months, with those suffering from dementia, who sleep by day as
well as by night. Where, as so often in cases of mental disorder, the
causes of the trouble are beyond our reach, the use of hypnotics is
imperative. Opium, often valuable in depressive cases, must be
avoided in those with cerebral excitement; in these latter, chloral and
its derivatives are often valuable. Sulphonal is a rather uncertain drug
in its influence on the insane. Paraldehyde is one of the most rapid
and certain hypnotics in the sleepnessness of the insane, and it does
not, like chloral, lower the blood-pressure ; but its disagreeable taste
and the odour it imparts to the breath render its use difficult; and
though successful at first in doses of 30 to 90 minims, it soon loses its
effect by repetition. It may advantageously be combined with the
bromides, which, if less rapid than other hypnotics, do not so soon
induce toleration.

Hitherto the writer has been concerned with symptomatic insomnias,
the cause of which is usually manifest. In many other cases, in which
the patient consults us on account of sleeplessness, apparently “ idio¬
pathic,” careful investigation will nevertheless reveal the constitutional
cause, and furnish the true indications for treatment. Thus insomnia
may be the chief, or even the sole, symptom of many digestive dis¬
orders ; and this is above all apt to be the case in the digestive disorders
of childhood. Other symptomatic insomnias are those that result from
respiratory affections, from cardio-vascular disorders, from renal troubles,
and from syphilis. Fournier, in especial, has drawn attention to the
persistent sleeplessness that sometimes occurs in the late secondary
stages of syphilis, often in cases in which the symptoms of the under¬
lying disorder are masked. Ascertain the true cause and the physician
can work marvels. These are patients for whom mercury and iodide of
potassium are powerful hypnotics.

The insomina of elderly persons is often due to one of the before-
mentioned disorders, and with especial frequency to chronic arterial and
renal changes. It is in these patients, and also in the last to be men¬
tioned and most troublesome of all the symptomatic insomnias—the
insomnia of neurasthenia—that the greatest caution has to be exercised
in the use of hypnotics, since the underlying causes are long-enduring
and drug habits are so easily induced.

Finally we have to recognise the existence of constitutional insomnia ,
in persons who sleep only three or four hours a night, and even less,
without suffering physically or mentally. For this, of course, treatment
is not requisite, nor is it likely to be effective. M. Eden Paul.

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the patient for his anticipated return to the realities of ordinary life.
Instead of solitary confinement for our psycho-neuropaths, we endeavour
to secure a progressive re-education of their will, whereby they will be
enabled to take their places side by side with normal members of
society.

With this end in view, the technique of the suggestive method has
been re-modelled. Not only do we endeavour by this means to procure
sleep and rest, to relieve physical pain and mental distress; we now also
employ a mode of “ mental orthopaedics.’’ A dialectic at once
sympathetic and firm, infrangible and supple, adroit and persuasive;
such is the method initiated by Dubois, of Berne, and now utilised by
the great majority of psycho therapeutists. The re-education of the
patient must be adapted at once to the special psycho-affective type of
the individual patient, and to the conditions of life to which he will
have to return. It is needful that the patient should have absolute
confidence in his physician, and that the latter should himself have
sufficiently broad knowledge of general pathology, literature, history, art,
and above all of philosophy; for nothing will be more effective for the
correction of the ego-centric error of the neuropath than to introduce
him, even in a fragmentary and superficial manner, to a positive
knowledge of man and the universe.

Before returning to normal social life the patient should pass a period
of probation in family life under continued medical supervision.

[English experience of the application of psycho-therapeutic methods
to the insane has been far less encouraging than would appear from the
above paper to have been the case in France.] Dr. Paul Valentin con¬
cludes what most English alienists will, I think, be inclined to regard as
a somewhat fanciful essay in the following terms:

“ I conclude, therefore, that the maison de sante of the future for the
use of psycho-neuropaths will bear no resemblance whatever, either from
a distance or on close inspection, to a convent or to a prison—nor,
indeed, will it resemble, as some hypnotists appear to wish, the Palace
of the Sleeping Beauty. It will be a medical home, part hospital, part
school, and part private house, in which the effects of isolation will be
tested by a preliminary experience of social life ; it will ultimately attain
the rank of a true ‘ institute for the accomplishment of human per¬
fection.’ ” M. Eden Paul.

7. Sociology.

On Penal Responsibility \De la Responsabilite Penale\ (Bulletin de la
Societe de Medecine Mentale de Belgique , No. 144, April, 1909.)
Francotte.

In this paper, read as the introduction to a discussion on criminal
responsibility in mental disease, Dr. Francotte has dealt chiefly with the
question as it regards the feeble-minded or the “borderland cases” of
Maudsley. The author goes over very much the same ground as was
covered in the debate between Ballett and Grasset at the Congress of
Geneva, his conclusions agreeing in the main with the views put forward
by the second of these alienists. He proposes that the law should
explicity recognise the existence of what Grasset has termed the “ demi-

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fous,” and that it should sanction in their favour the principle of
diminished responsibility. To give practical effect to this principle, it
is suggested that such criminal defectives should be subjected to a
modified asylum treatment “instead of or concurrently with legal
punishment ” (en place de la peine ou concurrement avec celle-ci). and
further, that their liberation should be at the discretion of the judicial
authority acting with medical advice, and should be on conditional
licence, with some arrangement for regular supervision. By these
means the author considers that it should be possible to avoid the
dangers which attend the admission of the principle of partial responsi¬
bility in the existing state of the law ; and this admission, as he rightly
points out, however objectionable on theoretical grounds, is certainly
inevitable in practice. W. C. Sullivan.

The Relation of Alcohol to Feeble-Mindedness. {Brit. Journ. of Inebriety,
vol. vi, No. 3, January , 1909.) Potts, IV. A.

In this paper, read as an introduction to a discussion at the Society
for the Study of Inebriety, Dr. Potts summarises some of the many
discordant opinions which have been advanced with regard to the influ¬
ence of ancestral alcoholism in the production of mental defect, and
refers to his own very interesting observations on the subject which
have been published in the records of evidence taken by the Royal
Commission on the Feeble-minded. Dr. Potts worked out the family
histories of 250 mentally defective children in the special schools at
Birmingham, and as a control made similar inquiries regarding 100
normal children from the same districts in that city. While the result
of his investigations led him to take the generally accepted view that
the origin of congenital defect is usually complex, he also satisfied him¬
self that parental—or rather ancestral—alcoholism is one of the more
important causative agencies. Thus he found an alcoholic heredity in
the direct line in 41 6 per cent, of the feeble-minded children, but only in
22 per cent, of the ordinary children of the same social status. In 5-2
per cent, of the former group both parents were intemperate, while in
only 1 per cent, of the normal children was this convergent heredity
observed. The author’s general conclusion is “ that the evidence is not
clear that alcoholism, by itself, in the father will produce amentia; but
it is quite plain that in combination with other bad factors it is a most
unfavourable element, while maternal drinking, and drinking continued
through more than one generation, are potent influences in mental
degeneracy.”

A number of interesting criticisms of Dr. Pott’s paper, contributed
by Dr. Claye Shaw, Dr. Harry Campbell and others, give further proof
of the wide differences of opinion which still prevail on this question.

W. C. Sullivan.

Feeble mindedness and Juvenile Delinquency. {Reprint from Charities
and the Commons, May, 1908 ; published by the Wright and Potter
Printing Co., Boston.) Evans, E., and Dewson, M.

The ladies who have written this paper have given to it the sub¬
title of “A Study from Experience,” the experience having been
acquired in connection with the work of the Waverley School for the

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Feeble-minded, in Massachusetts. This institution posseses a custodial
department to which any person who has been certified as a “ suitable
subject ” may be committed by a judge of probate. What constitutes
a “ suitable subject ” has not been defined by statute, and is apparently
settled in each case at the discretion of the committing authority. It
is the aim of the writers of this paper to show that lack of capacity for
self-direction and self-support rather than mere lack of scholastic
capacity should be the proper ground for custodial care.

Particulars are given regarding 150 feeble-minded girls from the
I^ancaster Industrial School, of whom 45 were sent to Waverley for
permanent care, while the others either remained in the Industrial
School or were tried at large on parole. It is found that the girls sent
to Waverley can be detained with a minimum of restraint; they live
contentedly, and under direction do work of distinct economic value.
Of the others the large majority, including practically all whom the
parole officer would have put in the category of “ suitable subjects,”
have gone to the bad when allowed at liberty ; they have become
prostitutes, criminals and drunkards, and have been prolific breeders.

Quite different results were found in the case of feeble-minded boys.
In the first place their number was much smaller : of 1,625 boys in the
Lyman Industrial School at Westborought only 26, or a little more
than 1*5 per cent., were found to be so defective as to be considered
incapable of self-direction, while the corresponding ratio in the
Lancaster girls was over 5-5 per cent. Again, while the experiment of
trying the defective girls at large generally resulted in failure, many of
the more distinctly defective boys showed a quite unexpected capacity
for making their way in the world. Thus of the 26 already referred to,
7, though considered suitable cases for Waverley, were not sent there
but were liberated on parole, and all but one of them became fairly
steady wage-earners. Moreover, several boys of this class who were
actually sent to Waverley ran away, and in some instances at all
events proved themselves capable of earning a livelihood at large. It
is interesting to note that amongst feeble-minded boys those who did
worst and showed actively antisocial tendencies were those who were
least feeble-minded.

Commenting on these results the authors point out that the experi¬
ence of Waverley goes to show that custodial treatment is both
easier and more necessary for feeble-minded girls than for feeble¬
minded boys. The inert and passive type of defective can be kept
under detention with little trouble, and this applies, of course, to both
sexes; but while in the case of the boy the absence of such care is
likely to lead only to his being an under-fed loafer or thief, the girl in the
same circumstances can support herself by prostitution, or—what is even
worse for the community—by marriage, becoming in either alternative
a source of danger to society and deteriorating morally and physi¬
cally; the struggle for existence might be a useful stimulus to the feeble¬
minded boy, but it is never so to the girl. “ All of which,” the authors
affirm, “ goes to justify the conclusion that the feeble-minded problem
may almost be disregarded in connection with a boy’s reform school,
while in connection with a girl’s reform school it takes on very large pro¬
portions.” W. C. Sullivan.

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The Beginnings of Criminal Antropology [Des Origines des rAntropologie
Criminelle\ {Bull, de la Soc. de. Mid. Ment. de Belgique , Feb.,
1909.) Meeus.

In his presidential address to the Belgian Society de M^decine
mentale, M. Meeus, the well-known physician to the colony of Gheel,
has set himself the task of tracing out in the medical literature of the
last century the rudimentary form of those ideas which in their later
developments have become familiar as the theories of criminal anthro¬
pology. M. Meeus deals chiefly with the writings of the French
psychiatrists, and appears to be less well acquainted with the works of
the English and German observers. He shows, however, a due appre¬
ciation of the immense influence which Maudsley’s teachings have had
on the scientific study of crime. An address of this kind cannot be
expected to contain much that is novel; but English students of
criminology will be grateful to M. Meeus for calling their attention to a
comparatively unknown precursor of Lombroso, a Dr. Barbaste, who in
1856 published a work under the title of De fhomicide et de I'anthro-
pophagie , in which he appears to have anticipated in a very curious way
several of the ideas of the Italian master, including even the famous
atavistic theory of crime. Judging from the extracts given by M.
Meeus, Barbaste’s views on the psychology of the criminal would seem
to have shown remarkable originality and acuteness.

W. C. Sullivan.

8. Asylum Reports issued in 1909.

Some English County and Borough Asylums.

Cardifl. —We congratulate Dr. Goodall on his new asylum, which
appears to have been designed conveniently. No doubt in its ultimate
shaping it has improved under his experienced judgment. He is proud
and thankful for the fact that over 600 patients were transferred from
thirteen asylums by the new and untried staff without hitch or accident.
The subjoined remarks made by him are, indeed, true and to the
point.

The Institution is equipped much above the average in respect of scientific
apparatus for clinical and pathological research. Such equipment is necessary in
every hospital for mental diseases if the medical spirit, without which these
institutions would rank merely as places of detention, is to be fostered, and young
medical men of a desirable stamp are to be attracted. More than ever is it
incumbent to have such in a mental hospital in touch with a town possessing
medical laboratories and trained workers in all departments of medicine, which
provides post-graduate instruction, and which aims at possessing a complete
medical school. These facilities offer a golden opportunity for that collaboration
of workers in different departments of medicine which is so essential to progress in
knowledge and treatment, and which becomes increasingly necessary with the
growth of specialisation. I must here express my indebtedness to Dr. Scholberg,
of University College, Cardiff, for the very valuable guidance and assistance he
has given us in bacteriological work. I would point out that all these considerations
respecting medical and nursing work have a bearing on the question of main¬
tenance rate. When we read of this or that asylum having a remarkably low rate
of maintenance, we are not therefore to envy that institution forthwith, and to set
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it up as a model to be followed. Before congratulating the authorities we require
to be satisfied upon a few points. What, in brief, are their ideals? Is the
institution merely a home of rest, where the “patients” are clothed, fed and
amused, where the medical service, as on board ship, wholly or mainly consists in
a perfunctory round, and attention to the “ prim® vise ”; where employees, to
whom courtesy accords the designation of “nurse,” patrol the wards in the pro¬
portion of one to ten or twelve ? Are the people whom the asylum serves ready
and willing to place their relatives as soon as possible in its care? What is the
average duration of residence of those who recover? How many of the patients
drift into dementia because they have not, for reasons of want of confidence, been
sent in early enough, and because they have received no treatment worthy the
name, in order that expenses may be kept down ?

Carmarthen .—The subjoined directly enforces the arguments put
forward in support of superannuation. The Commissioners report:

The staff of attendants and nurses is of sufficient strength, and as regards length
of service their record stands high, not more than 13 per cent, having served less
than a year, while as many as 45 per cent. (60 per cent, of the men and 30 per cetU.
of the nurses) have served over five years. We fear, however, that the state of
things thus disclosed is not entirely satisfactory. Some of the male attendants
who have done many years of excellent service have become, by reason of age or
infirmity, too feeble to continue to discharge their duties with efficiency, and we
are strongly of opinion that the time has arrived when they should be allowed to
retire on liberal pensions. This is to be desired, not merely on their behalf, but in
the interest of the patients and of the good administration of the Asylum.

Two years ago we remarked on the criticism which the Com¬
missioners found it necessary to apply to the proceedings of the
Committee of Visitors. The same condition of affairs appears still to
exist, due entirely to dissensions between the authorities in union.
The worst thing that can happen to patients and all connected with an
asylum is dual control.

Derby Borough .—Influenza has been a sore trial in this asylum. One-
third of the patients, one-fifth of the male attendants, and more than half
of the nurses were attacked. Of the patients twenty-four were males
and eighty-five females. The disproportionate incidence between the
sexes is contrary to usual experience.

In about 50 per cent, of the cases the symptoms were of the gastro¬
intestinal type, and it is remarkable that of the patients who presented
these symptoms sixteen (one male and fifteen females) subsequently
developed dysentery, from which one woman died, well-marked patho¬
logical features of the disease being observed at the autopsy.

The Committee has wisely awarded gold medals to all attendants
having more than fifteen years’ service. We have sometimes wondered
that in asylums there is no mark showing the length of service ; such is
seen in some other services. A ring on the cuff for every five years
served would perhaps tend to make a man a little proud of being able to
show that he is not a new-comer.

Dorsetshire. —Dr. MacDonald attaches much importance to the full
tracing of heredity in a family. He very rightly claims that the sane as
well as the insane of a family should be accounted for. That seemed
also to be the view of the Statistical Committee, who provided for this
purpose the optional Table B 11.

Solaria have been introduced with good effect.

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Lincolnshire , Kesteven .—In the Commissioners’ report we are very
glad to see some personal commendation of Dr. Wilson, who, in the
absence of Dr. Ewan, accompanied them on their rounds. They
speak of the interest and knowledge that he displayed in regafd to
the patients under his care. A few words of this nature on a subject
that is quite as important as the usual points of remaik are the proper
acknowledgment of a right feeling of responsibility and cannot fail to
be useful. It is curious to read, in the .Etiological Tables, of influenza
exceeding the activity of alcohol in producing insanity. It stand»third
on the list of agencies when considered as both a principal and contri¬
butory factor. We note that Dr. Ewan prints by the side of the table
the full table of factors as published by the Association. This has the
advantage of showing to the casual reader the factors which do not
appear in the year’s calculations.

London City. —Dr. Steen is able to say that, with an average residence
of more than 550, tuberculosis caused no death on the male side and
but two on the female side. No doubt the incidence of the disease has
been modified by patients showing signs of this disease being kept out
of doors in verandahs continuously day and night, winter and summer.
A lady unattended came to the door and asked to be admitted. Of
course she had to be refused. The extension of the powers, already
possessed by institutions for private patients, need most urgently to be
extended to those maintained out of the public funds. Now that
pensions are out of the way perhaps the Association may be fortunate
enough to get some other of its just demands met. This is one of
them. Independently of the welfare of such an applicant herself, it
must be a matter of considerable responsibility to the medical man who
has to make the refusal. He may see signs of impending danger which
he cannot legally prevent, and yet he would not be held altogether
blameless by the public should an accident occur. Alcohol is by far
the most active among the factors. It would be interesting to know
whether there is any difference in its incidence on the private and
pauper patients.

Sussex {East), Hellingley. —Dr. Taylor notes that there is a large
increase in the number of general paralytics admitted. They were
twelve males and four females in 346 cases. This is a heavy rate
indeed for such a pastoral area. As might be expected with its border
of sea, Brighton has more than twice this rate.

I would again point out the importance in my opinion of special supervision of
the education of children with a family history of insanity, and the necessity of not
forcing those who are neurotic and nervously unstable. The mental health of the
children should be as important to the State as their physical condition, and should
receive as much, if not more, attention. Many cases of insanity that occur in early
adult life do not recover, and remain to fill our asylums ; it therefore seems to me
most necessary to take all possible precautions to avoid a mental breakdown in
these young cases. For the obviously feeble-minded the only form of treatment
possible is to educate them in special schools where the training imparted is suit¬
able to their mental capacity. It is a much more difficult matter however to
advise in the case of the nervously unstable child, the potential lunatic, and the
education of these cases requires the greatest care.

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We notice that the farm and garden account is drawn up on lines
more resembling such an account as a farmer would present for income
tax purposes than the usual bald statement. In an agricultural area the
profit generally shown must rankle in the minds of farmers who see the
latter, and who do not know that it is a mere statement of certain pay¬
ments in and out, and is not a true profit and loss account. Here the
interest (at 3^ per cent.) on the capital expenditure incurred by the
Asylum Committee as tenants is shown. Also rent, rates, and insurances
for fire and compensation are detailed, and, further, a sum of ^£546 is
entered as value of the labour given by the patients and their attendants.
The estimate of this is made on returns furnished by the bailiff and
head gardener. The balance in favour of the farm is brought down to
^97, as against many hundreds, if we remember rightly, on the pre¬
ceding year’s working. We like the idea for two reasons : First, it
must be more satisfactory to those who are responsible that comparison
should be made on a natural basis with the experiences of neighbours.
Of course, it may be said that with so good a customer on the spot any
farm should do well, but on the other hand, the circumstances of an
asylum, the need to work under conditions imposed by responsibilities
of the tenant and so on, must hamper the actions and plans of the
occupier. Secondly, we think that it serves to bring out the fact that
there exists a considerable reserve of man-power in an asylum, if only it
can be properly evoked and regulated. Here and there an asylum is
shown to make certain products quite remunerative by paying special
attention to them. The farm and garden offer an opportunity to all,
especially in rural parts. If it can be shown by such accounts that the
labour of the inmates has a tangible value, will it not suggest to com¬
mittees that more profit may follow more expenditure ? We know that
the readiest means of developing labour by the payment of patients for
work done has not commended itself to our Association. But times
alter; intensive culture is making its way. This involves a certain
amount of minute but simple work, for which, under intelligent super¬
vision, the minds of many patients are particularly adapted. We hear
a good deal about the dignity of labour, which is chiefly a matter of
obtaining so much an hour. But we believe that there is still some
honourable desire for honest labour everywhere, even in the asylum.
It does need, however, some proper acknowledgment on the part of
those who benefit by it. It seems to be quite a matter to which the
Association could well give some serious consideration, and possibly
thus remove the reproach that an asylum is, to too great an extent, a
home of mischievous idleness and apathy.

Some English Registered Hospitals.

Barnwood House .—In speaking of the accommodation in his out¬
lying villas Dr. Soutar says something that is quite true, and applicable
to detached houses belonging to public asylums, unless these have been
erected for special purposes. The designers of schemes providing for
an undue amount of segregation sometimes look at the subject from the
point of what they themselves would like, rather than from that of

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persons who are, by their illness, bereft of many of the mental conditions
which suggest separation from the bulk.

We continue to find great difficulty in filling up the accommodation available at
these separate houses. Acute cases cannot be treated as efficiently there as in the
hospital; to fill them with demented patients would effect no good purpose, and
our experience is that those who have passed through their illness to the stage of
convalescence generally prefer the full and active life of the hospital to the neces¬
sarily less varied interests of these small separate houses. While friends of
patients are often greatly attracted by the accommodation offered at North Cottage
and the Wilderness, those patients who are capable of deciding generally show a
strong preference for residence in the main building.

Wonford House .—Some years ago, as we then pointed out, this
institution was in dire pecuniary straits. It required much energy to
keep itself to the mark of efficiency. A brave fight has been made, and
each year prosperity has been more marked. At last the Committee is
able to say, with thankfulness, that it is entirely free from outstanding
liabilities. It is surely remarkable that when, overborne by long and
trying service, Dr. Maury Deas signified his desire to retire, he should
have the great satisfaction of being able to say that he leaves the Hospital
free of debt, he himself having been, by his strenuous endeavour, the
chief agent in bringing about this happy condition. It is very pleasing
to note that the Committee have marked their appreciation of his
services by voting him a substantial pension.

York, The Retreat ,—It is curious that this pioneer of right treatment
of the insane should still witness a practice which, in these enlightened
days, almost amounts to a barbarity. Those patients who decide to
exercise their rights under Section 8 of the Lunacy Act are, except in
case of illness, compelled to make their appeal at the magistrate’s court.
One would have thought that the spirit which led one hundred years
ago to the abolition of all physical wrong-doing would have secured
freedom from moral indignity. We believe that we are right in saying
that at Bethlehem, with its many admissions, the visiting of the patient
by the justice is the invariable rule. The Commissioners speak strongly
on this matter, pointing out the danger of a possible idea of criminality
engendering permanent delusion.

The remarkable healing powers that are sometimes shown by even
advanced paralytics is well illustrated by a case related by Dr. Bedford
Pierce, in which accidental falls resulted in first a fracture of the femur
and at some months’ interval of the tibia. In both instances union
took place in the ordinary course.

Some Scottish District Asylums.

Ayr. —Dr. McRae points out that the question of heredity should
not cause undue despondency on the part of the public, since it
is not too much to hope that a better knowledge of how heredity
really does act and a more scientific provision of suitable environment
will assuredly check its baneful influence. In the proper understanding
of several diseases, heredity has, in the past, been a stumbling block,
the removal of which in the light of fuller knowledge has proved of
immense benefit to suffering humanity.

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We note among forms of mental disease in the admissions that under
both mania and melancholia there is a subclass, “delusional.” Ten
out of fifty-three cases of mania are thus denoted, and one among forty
melancholiacs. It is inconceivable that among so many of the latter
there should be delusion in one only. On the other hand, it seems diffi¬
cult to think that delusion should in any case of melancholia be so
dominant a characteristic as to justify its being marked off from all others.
We prefer the Association’s method of classing all delusional cases
together.

Aberdeen, Kingseat .—The remarks made before concerning the
absence of provision for the voluntary admission of patients into rate-
paid asylums in England apply to Scotland. Two men walked out from
Aberdeen and requested admission ; one of them contemplated suicide
and the other suffered from epilepsy. The friends were communicated
with, and they were subsequently admitted under the usual provisions.
The former distinctly raises the question of the medical superintendent’s
responsibility for the safety of a suicidal man, aggrieved probably by
a refusal of instant help.

There is no special form of insanity attributable to influenza. One of our cases
was admitted in a condition resembling delirium tremens, and recovered his mental
balance in forty-eight hours. It is better for a predisposed person to have his
insanity during his influenzal attack than after it, as there is probably no disease
which possesses a convalescent stage so unresistive to serious mental affections.
We have several incurable cases in the institution, due to the insidious onset of
insanity—particularly melancholia—during the convalescent period of influenza.
A printed card with detailed questions regarding the personal and family history
was forwarded to the relatives of every patient admitted during the year, and it
was returned in every instance more or less fully answered. I find the adoption of
this system extremely useful in many ways, and it is appreciated by the relatives
of the patients.

Lanark .—On the estate there are fifty cottages for the nursing staff
and artisans. The Commissioner attributes to this fact much of the
stability of the staff. In addition to a bonus for obtaining the Associa¬
tion’s certificate, attendants are allowed extra holiday in lieu of the
time spent in studying.

In connection with epilepsy Dr. Neil writes :

We are fortunate in having a most complete and conscientious record by the
charge attendants in the various wards of all epileptic seizures for years back. It
would be of interest to go into many cases, noting their gradual increase or decrease
in the number of attacks, and their change of type from petit mat to grand mat or
to mixed type.

As a case in point, we have a male patient who, to those seeing him daily,
appears to have little changed in bodily or mental condition since admission in
1902, yet he had 100 fits during his first twelve months, and 240 during his last
twelve months here, showing that the cerebral (?) deterioration is much in advance
of the mental or physical.

The microscopic examination of the blood of epileptics is a fascinating field, but
one full of disappointments and contradictions. After paying considerable atten¬
tion to this branch, one is forced to conclude that pure epilepsy (so-called) is not
accompanied by any change in the number or character of the white blood-corpuscles
or of any other of the blood elements.

We cannot, however, get past certain cases where there is a definite leucocytosis
corresponding to each increase in the number of seizures. This is usually accom-

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panied by an increase in the number of eosinophiles. These conditions may be due
to some extraneous factor (perhaps that which causes the mental symptoms), but
it is tempting to include a toxic type in our classification of epilepsy.

Auto-intoxication from constipation is without doubt an exciting factor; this is
demonstrated by the marked improvement in many cases immediately on admission
to asylum regime. Oral sepsis is also an enemy that requires much more fighting,
and one which is exceedingly difficult to combat in the mentally deficient, where
reactions are sluggish and the patient is indifferent as to the condition of his
teeth.

Roxburgh District , Melrose. —Dr. Carlyle Johnstone relates a most
interesting criminal case with which he had much to do. An imbecile
lad attempted to rape his mother, who had herself been in the asylum
three times. He was sent to the asylum by the Procurator-Fiscal.
He stayed there for five years, and was then removed with the consent of
the authorities and placed with a farmer. He earned a little money for
the next ten years as a labourer, and then made another criminal
assault on a girl. He was returned to the asylum by the Fiscal. It
was then discovered that his settlement was in England, and he was
sent to the English union with a view to being placed in the Morpeth
Asylum. But the Union Medical Officer refused to certify him. So
back he came to Melrose. The Scottish parish authorities would not
consent to remain liable for a life-long lunacy for which they were not
responsible, and made a stir, with the result that the man was taken to
Edinburgh to be placed on his trial for the last offence. Dr. Johnstone
and others gave evidence that after repeated examinations they were of
opinion that the man was a congenital imbecile and unfit to plead.
Notwithstanding this he was put on his trial and actually put into the
witness box, and asked a few simple questions. The jury found that at
the time of the trial he was sane, that he committed the offence, that he
was sane at the time of committing it,and he got twelve months imprison¬
ment. One wonders who had the courage to propose that such a man
with such a history should be allowed to submit himself to any
examination at all. Practically the examination must have been an
inquisition.

Part IV.—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT
BRITAIN AND IRELAND.

Adjourned Annual Meeting.

The Annual Meeting, adjourned from July, 1909, was held at the rooms ot
the Medical Society of London, Chandos Street, W., on Tuesday, 23rd November,
1909, Prof. Bevan-Lewis, President, in the chair.

Members present—See list of attendance at Quarterly Meeting.

The President said the meeting now being held was the annual one, as
members would remember that the Annual Meeting in the summer was adjourned
to this date because the provisions of the nursing examinations were not then

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ready for discussion. They had since been circulated to each member of the Asso¬
ciation and opinions could now be expressed upon them. It was necessary that
those regulations should come into force on November 30th, so that all the teaching
centres should be able to have their course of training in accord with the regula¬
tions. He proposed taking the regulations seriatim, not having each item read,
but taking the clauses by numbers.

No. 1 and No. 2 were agreed to.

Dr. Urquhart asked for some explanation of Clause 3, page 1. The first final
examination under the new regulations was to be held on the second Monday in
November, 1911, and he wished to ask whether that examination included the
old regulation nurses coming up then for the single examination for the first time.

The President said he took it that the single examination would be held in
November, 1911 ; but after 1911 all candidates who presented themselves would
not be able to escape the dual examination.

Dr. Mercier said that was not the intention of the rule. It was that after May,
1911, no candidates would be able to present themselves under the old rule.

Dr. Urquhart : So no single examination is to be held in November, 1911 ?

The President: No.

Clauses 4 to 14 inclusive were passed.

Dr. Stoddart, speaking on Clause 15, said he spoke merely to have things in
order. This Clause stated : “ Every candidate for the final examination must
obtain from the Registrar a schedule, which must be filled up and signed as
required, and returned, with the voucher of having passed the preliminary examina¬
tion, to the Registrar at least four weeks before the final examination.” The
Association would not require this voucher from nurses exempt under Regulation
6, who possessed a certificate of having trained in a general hospital.

Dr. Mercier replied that that was an oversight in drafting, and could be
remedied by inserting after “ Every candidate ” the words “ except as provided in
Regulation 6 ” He moved that alteration.

Dr. Stoddart seconded, and it was carried.

Clause 16 and Clause 17, Section d, were agreed to.

Dr. Urquhart, on 17 b, said the first examination was to be held on the first
Monday in May, the first Monday of November; and, in c, the final examination on
the second Monday in May and second Monday in November. He asked why the
preliminary and final examinations were fixed for different days. That meant an
unnecessary attendance in the examination room, and unnecessary travelling and
waste of time for the examiners.

Dr. Percy Smith said that he supposed it was quite impossible for all the
attendants in asylums to be examined on the same day; there were a large
number of candidates for the Preliminary and for the Final.

Dr. Mercier said he thought Dr. Urquhart was under a little misapprehension.
It was the written portion alone which was to be held on those separate dates, and
that did not require the attendance of the coadjutor, so that there was no question
of travelling twice over. The reason given for the second day w>as as stated by
Dr. Percy Smith ; it would abstract too many attendants from their duties to have
it on the same day.

Clause 17 b was agreed to.

Dr. Steen moved, in regard to Clause 17c?, that the practical part be ten
minutes instead of fifteen. The oral, he thought, should be decreased to five
minutes. If there were twenty candidates, that would occupy six and a half hours,
and that makes the examination a very long one.

The President : Had we so many candidates at one time ?

Dr. Steen : Yes.

Dr. Thomson said the question of ten minutes against fifteen was discussed
by the Educational Committee, and it was pointed out that in the practical part in
the wards candidates were set to do things which they might be doing simul¬
taneously under the examiner’s eyes. That suggestion was considered, and it was
thought that in order to be thorough it would take fifteen minutes when one
considered the making of beds and the taking of temperatures, etc.

The clause was agreed to as it originally stood.

Dr. Dawson, speaking on Clause 17c, said he supposed those provisions
supplemented each other to some extent, but it was right that the practical portion

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should be passed in separately. The oral and the papers of questions were of
much the same character; and he did not see any reason for the oral if it was
not allowed to supplement the papers to some extent. If the examiner were
allowed to put the + mark after a paper which was exceptionally good, or a - if
it meant the paper was not quite so good as it should be, that could be taken
account of in the final award. Many of the candidates were not able to express
themselves very well on paper, whereas they might do very well in the oral and
show sound knowledge of the work.

Dr. Mercier said he thought he could satisfy Dr. Dawson. There was before
the Educational Committee a scheme of instruction to examiners, in which was
included the proviso that where a candidate's work was marked excellent in his
oral and practical examination that was to count three marks on the written.
That would help a very large number of candidates. There were many who just
failed to pass the written who got perhaps 47, 48, or 49 per cent., and if the value
of the oral were allowed to supplement the written in that way many candidates
would be helped.

Dr. Dawson : That is quite satisfactory.

Dr. Thomson : If that is so, should not e be re-drafted ?

The President said he did not think it required re-drafting.

The clause was agreed to.

Sub-clauses /to m were also agreed to.

Clauses 18, 19, 20, 21.

Dr. Miller read several letters which he had received on the subject:

He added that they were not the only letters which he had received on the
subject, but they were the only ones which he had received permission from the
writers to make public. There were letters in his possession against the provision
as to passing with distinction, and the writers in each case raised strong objections
against the inclusion of the clause.

Dr. Spence said that if a full discussion were allowed on those letters they
would not be able to finish that afternoon.

The President asked Dr. Miller to say what were the chief contentions of the
writers of the letters.

Dr. Miller replied that they were strongly opposed to the provision regarding
passing the examination with distinction.

Dr. Mercier asked if any reason was given for objecting to the distinction.

Dr. Miller said no reason was given in the letters, except that the writers
foresaw some upsetting among the members of their staffs. One writer said—
and Dr. Miller thought with truth—that unless separate examinations were held
the special distinction was unnecessary.

Dr. Mercier said perhaps he could remove the fears of those who had sent
those letters if he said, as an examiner, that the number of persons who would
obtain that distinction would be very small. It required at least 70 per cent, of
the maximum marks in both examinations to get it. The number of candidates
who reached 70 per cent, was microscopically small. There would be no chance
of a number of junior nurses flaunting before the others the fact that they had
passed the examination better than their colleagues. He did not think more than
two or three would get it in any year, and it would be a very rare and valuable
distinction.

Dr. Dixon asked whether in this matter the distinction to the nurse would be on
her recognised capabilities of dealing with patients, or would it be on the marks
she would get at the examination ?

The President replied that it would depend on her marks altogether.

Dr. Percy Smith asked whether there was before the meeting any amendment
to that clause.

The President replied that apparently there was not.

Dr. Longworth said the first letter which Dr. Miller read was one in which he
and his chief contended that there were reasons against granting a certificate of
distinction. They thought it would create a good deal of invidious distinction
which would not be justified by the merits of the prospective holders of those

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certificates. Their experience of ten or twelve years in training nurses at the
Suffolk Asylum for the certificate was such that they had frequently come across
members of the staff who had passed the examination only with the utmost diffi¬
culty, but were otherwise excellent nurses; they had shown capabilities which
could not be estimated by means of examination ; and on those grounds they
thought the granting of the mere pass would be preferable. He moved that the
certificate of distinction proposal be not received. This meant a motion that
Clause 20 be omitted.

Dr. Morrison seconded the amendment. He thought it would create un¬
necessary difficulties, without any real accompanying superiority.

Dr. Macdonald said he was sure there was no superintendent and no medical
officer who did not wish to encourage work on the part of any member of the
staff. Looking at the question from a practical point of view, he thought it was
a mistake to go about it in the way now proposed. If it was wished to grant a
special distinction, it should be by a separate examination, and he wished that had
been the amendment. He was sure it was not the wish of the mover of the
amendment that it should be regarded as deprecating better, higher, and more
meritorious work on the part of any member of the staff. He cordially supported
the suggestion that the provision should not be passed in its present form, and he
hoped the meeting would take that view.

Dr. Thomas Donelan said he thought that what Dr. Macdonald had said
would certainly meet the case. The class of nurses and attendants in private asylums
was different from the class of those in public ones. Some of the latter were
recruited from the ranks of ordinary domestic servants. If there were a special
examination for the former, and a special merit standard, it would meet the case
completely. The same applied to male attendants, for in country asylums they
came largely from among farm hands.

Dr. Steen said he hoped the Association would approve of the clause providing for
distinction. In every examination there was an “ honours” and a “pass,” and he
did not see why nurses should be deprived of the opportunity of taking “ honours.”
He had not heard any argument up to the present which was convincing, and he
hoped the Association would pass the clause.

Dr. Dixon said he understood that the certificate was given for efficiency in
mental nursing. If certain candidates proved their efficiency by examination and
showed they could reach a very high standard, there ought to be some recognition
of that high standard. At the same time he doubted whether high efficiency
in mental nursing could be gauged by an examination. That was really the
question.

Dr. Bedford Pierce said he had heard that the possession of the distinc¬
tion certificate might cause jealously among the staff. At the “ Retreat ” they had
for several years had a method of distinction in operation. The “ Retreat ”
examination had been on a higher plane than that of the Medico-Psychological
Association, and those who passed it well received a special medal. He was not
aware that any unpleasantness had ensued among the staff on that account; the
nurses generally had been proud that a colleague had been sufficiently well up to
receive the honour.

The President said he was in accord with what Dr. Bedford Pierce had said.
He was himself connected with a large county asylum, and could confirm the
statement that the nurses and attendants were drawn from a comparatively un¬
educated class. That seemed the basis of the objection to Clause 20. But at the
same time, the Association must be progressive, and he was fully of opinion that
the trend of the clause was towards progress, and therefore should be adopted.

The amendment was put, and declared lost.

Clauses 21, 22, 23, 24, 25, 26, 27, 28, and 29 were passed.

Dr. Stoddart said, in regard to Clause 30, he would like to move an amend¬
ment. As Secretary of the Educational Committee he would not have moved an
amendment to those regulations, but Dr. Mercier gave him to understand he
would be in order in doing so. His own feeling was that the fee of 10s. for the
second examination was too high for nurses coming from the class from which
nurses were drawn, because many of them already found that even the 5 s. fee was
rather a strain upon them ; and many hesitated about paying the 5s. fee to go in
for the examination at present. If the fee were 5s. for the first examination, and

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55. for the second, that would add to the Association’s income a sum of ,£250. If
the second examination fee were raised to ios., that would increase the income
of the Association by another ^250, the total increase being ^500 a year. As far
as he was aware—the treasurer would be able to correct him if he was wrong
—the Association did not need that money, which would be lying idle; and it was
not fair to the nurses to charge them so heavily. Another point to be considered
was that a general hospital nurse got her training, examination and certificate
free, without any fees whatever, and those general hospital nurses, who often came
from a class who could afford to pay very much better than the asylum nurses,
entered into competition with asylum nurses, and hence mental nurses were
placed at a disadvantage. He therefore moved that instead of the words “ and
for the final examination ios.,” the rule should read, “and for the final examina¬
tion 5s.," and so forth.

Dr. Percy Smith asked whether it was not the fact that people who entered as
probationers at general hospitals usually paid something to the hospital on
entering to be trained. If so, they did invest some money. And the ios. in the
present case was an investment for the nurses with regard to that examination.
The nurse who obtained the certificate got her name on one of the nursing
associations as a private nurse, and was able to earn ^100 or ^150 a year.
Therefore, although ios. might seem a large amount for some of the nurses who
were at county asylums, he thought they did receive considerable value for their
investment when they took the certificate.

Dr. Spence said it might seem unkind not to support the generous intentions
of Dr. Stoddart, but in the majority of county asylums, directly a nurse passed
that examination she received an additional £2 a year ; and it was surely worth
her while paying ios. to get that. But, apart from that, he thought the Associa¬
tion should make the certificate not only worth having, but worth paying for,
and worth working for. He therefore strongly supported the retention of that
paragraph.

Dr. Mercier said, with regard to the financial position, he understood Dr.
Stoddart to say the Association was so wealthy that it did not require the larger fee
from the nurses. The financial position of the Association, favourable as he was
glad to say it was, was due entirely to the dreadful system of sweating the
examiners which was carried on. The examiners, at the recent nurses’ examina¬
tions, assessed with the greatest care 10,000 questions at one-third of a farthing
per question.

Dr. Wolseley-Lewis seconded Dr. Stoddart’s amendment. He said he hoped
the day was not far distant when those examinations would become compulsory in
all the public asylums, and that when superintendents would engage nurses it
would be understood they would be obliged to pass at all events a preliminary
examination before being regularly taken on the staff. That meant to say that
nurses in asylums were put on all fours with nurses in ordinary hospitals, who had
to go through a course of training before they could be considered nurses.

Dr. Mercier : Pay a premium ?

Dr. Wolseley-Lewis said he meant they would be paid at a considerably lower
scale as probationers than when they claimed the full position of recognised nurses
in an institution.

The President said that when the clause presented itself to him at first he was
rather astonished; he thought ios. was rather high, especially for the class of
nurses in county asylums. But he found that his feeling was not shared generally,
and when he looked into the question he confessed he had been converted. The
nurses had three years’ extremely good training, which was very valuable to them.
They had the examinations, and an enormous amount of trouble was taken with
their tuition, and the extra 5s. was not too much to ask. He was now very
strongly in favour of it, and he looked upon himself as a convert to the clause
itself. But he thought good would come out of the discussion. Many nurses
received an addition to their wages when they obtained their certificate. Another
point he wished to indicate was that during the three years of training the wages
of the nurses were going up, and they were therefore better able to pay the sum.

Dr. Mercier : What is the amendment ?

The President : That it be reduced to 5s. for the second examination.

There voted in favour of the amendment 19; against, 23, and—

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The President declared the amendment lost, and said that the Association
would now proceed to the discussion of the schedules.

Forms A and B were agreed to.

Dr. Mercier said a little discretion might be allowed with regard to those
forms. The number was placed in a different position from that on the present
certificates; and it might be convenient to leave it where it is.

Agreed.

The Preliminary Examination portion was likewise agreed to.

The President asked whether there were any comments upon the Final
Examination portion.

Agreed. *

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT
BRITAIN AND IRELAND.

The Quarterly General Meeting of members of the Association was held in the
rooms of the Medical Society of London, on Tuesday, 23rd November, 1909,
Prof. Bevan-Lewis, President, in the Chair.

Present—The President, and Drs. S. Adair, H. F. S. Aveline, J. L. Baskin,
Fletcher Beach, C. Hubert Bond, David Bower, J. F. Briscoe, P. E. Campbell,
J. Chambers, L. Coupland, M. Craig, W. R. Dawson, A. De Steiger, H. Devine,
J. F. Dixon, T. J. O’C. Donelan, E. L. Dove.T. Drapes, F. H. Edwards, F. M. Elkins,
C. H. Fennell, S. J. Gilfillan, T. D. Greenlees, H. E. Haynes, C. R. Hitchcock,
David Hunter, J. H. Johnston, W. B. Keith, H. Kerr, H. A. Layton, S. G.
Longworth, J. R. Low, W. H. C. Macartney, P. W. MacDonald, T. W. McDowall,
M. E. Martin, C. Mercier, J. Middlemass, A. Miller, C. S. Morrison, H. Hayes
Newington, H. J. Norman, F. O’Mara, D. Orr, M. E. Paul, Bedford Pierce, E.
Powall, N. Raw, H. Rayner, R. G. Rows, G. H. Savage, J. G. P. Shera, G. E.
Shuttleworth, J. G. Smith, R. Percy Smith, J. B. Spence, T. E. K. Stansfield,
R. H. Steen, R. C. Steward, A. H. B. Stoddart, D. J. Thomson, T. Seymour
Tuke, P. M. Turnbull, A. R. Urquhart, F. Watson, G. B. Whitcombe, G.
Williamson, H. Wolseley-Lewis, and T. Outram Wood. Visitor: Staff-Surgeon
R. St. G. S. Bond, R.N.

Attendance at previous Council meeting—The President, and Drs. H. F. S.
Aveline, T. S. Adair, C. Hubert Bond, W. R. Dawson, C. H. Fennell, P. W.
MacDonald, C. Mercier, A. Miller, D. Orr, R. H. Steen, A. H. B. Stoddart, W.
Vincent, and H. Wolseley-Lewis.

The President said that before proceeding to the agenda of the ordinary
meeting he felt impelled to deal with a subject which at all events ought to be
uppermost in the minds of members. They met there that day at quite an
eventful epoch in the history of the Association, and it was fitting that they should
congratulate each other upon the passage through the House of Lords of the
Asylum Officers’ Superannuation Bill. (Applause.) Their very hearty congratu¬
lations were also due to the Executives of both the Asylum Workers' Association
and the Medico-Psychological Association, which had so happily joined hands
together and brought about a piece of work which was very important and of
mutual benefit. After years of futile labour on the part of the Association the
important measure had won success—that success which it so richly deserved.
And he thought all would agree that the magnificent headway which it had made
throughout its career through both Houses of Parliament was of sufficiently happy
augury for its eventual triumph, and of the very beneficent future which was in
store for it. Their first duty that day was to convey to Sir William Collins and
to Dr. Shuttleworth their keen sense of appreciation of the ceaseless efforts which
those gentlemen had made to secure success to the Bill, and their unbounded
admiration of the skill, tact and discretion, and address which had been displayed
by Sir William Collins in carrying the measure forward, and in guiding the Bill
through the troublous waters of the Scylla and Charybdis of parliamentary pro¬
cedure. He felt bound to say that the intrinsic merits of the Bill seemed from the
first to have demanded for it universal recognition and confidence; and that could
only be due to the fact that such extreme care had been taken in modelling and

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setting out its provisions. Among its chief merits were the contributory clauses,
which clauses fixed the Bill on a financial basis, and at the same time encouraged
so much that feeling of self-dependence which was the all-important moral element
in the measure. It was very important in every sense, and at the same time swept
away, once for all, that most undesirable undercurrent of suspicion and distrust
which was such a demoralising feature in all non-contributory and permissive
schemes of superannuation. He did not think it was necessary for him to dilate
further upon the merits of the Bill; they were so manifest to all. He asked
the meeting to signalise, with no uncertain voice, its very high appreciation
of the work done for the Association by Dr. Shuttleworth (much applause), for
he had borne practically the whole of the labour upon his shoulders, and had
exerted himself to an enormous extent in the interests of asylums throughout
England at large. (Loud applause.) It had been proposed that a more substantial
recognition of Dr. Shuttleworth's services should be made by the Association.
He was looking forward to a dinner to which Sir Wiliam Collins and all concerned
would be invited. He felt it was fully in accord with the ideas of members that
that should be done.

Dr. Shuttleworth desired to say a word of recognition of the extreme kindness
with which the Association had recognised any little service he had been able to
render in a course which was an important one, and in which the Asylum Workers’
Association had done its share. It must not be forgotten that the idea of pensions
originated with the Medico-Psychological Association and the question was very
ably worked at by the Treasurer, Dr. Hayes Newington, many years ago. It had
been their good fortune to secure an exceptional year in order to get the measure
through as a private member’s Bill. And it was to Sir William Collins having
taken advantage of the opportunities which had presented themselves that the
success of the Bill up to the present point was due. At the same time, one should
not lose sight of the very valuable services which Lord Monk Bretton had accorded
to the promoters in taking over the personal conduct of the Bill in the House of
Lords, and of the public debate which took place in that Chamber. There was
also much private debate, which was not recorded in the Press, and negotiation
with Government departments. But all through there had been abundance of
debate on the measure, and Lord Monk Bretton had been most skilful and tactful
in guiding the Bill through with a minimum of mutilation. And though the
Bill did not now comprise all that his friends desired, it yet contained a very fair
instalment. And if at a future time it was found that the Bill did not work as
satisfactorily as was wished, he hoped there might be an opportunity for amend¬
ment with the view of getting a little more. He personally very highly appreci¬
ated the expressions which had been uttered concerning his own efforts. It had,
of course, not been an easy task, and it had taken up a good deal of time ; but
what he had done had been freely rendered. He looked back upon what he had
been able to accomplish with very great satisfaction.

Dr. Spence suggested that the thanks of the Association to Sir William Collins
should be emphasised by the passing of a special resolution directing the General
Secretary to forward to Sir William a formal letter expressive of the Association’s
warmest thanks for his skilful pilotage of the Bill.

Dr. Hayes Newington thought that a formal letter should also be sent to
Lord Monk Bretton and Dr. Shuttleworth, and on the motion of Dr. Mercier it
was agreed that a resolution to this effect should be entered in the minutes.

Sir James Moody’s Knighthood.

The President said he thought it right he should bring another matter before
the meeting. Since the Association last met a great distinction had been conferred
upon a member of the Association—an old official in asylum life. His Majesty
had bestowed a knighthood upon Sir James Moody, and it was only right to ask
the General Secretary to write a letter of congratulation, including therein Lady
Moody. He asked Dr. Thomson to speak to the proposal.

Dr. Thomson said that, as Dr. Moody’s first assistant medical officer of twenty -
three years ago, he had much pleasure in seconding the resolution of congratula¬
tion which it was proposed to send to Sir James and Lady Moody.

The resolution was agreed to.

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Election of Candidates for Membership.

Dr. Bond (Secretary) mentioned that in respect of one of the candidates, Cecil
Johnson, the proposers were Dr. Shuttleworth, Dr. Crookshank, and himself.
But on looking at the register he was reminded that Dr. Crookshank had recently
resigned, and therefore his name should not appear there. Dr. Hayes Newington
was willing to fill the gap, and, with the permission of the meeting, he took it
that the election might go forward.

Agreed.

The President nominated Dr. Thomson and Dr. Steen as scrutineers.

The following candidates were duly elected ordinary members :

George Henry Adam, M.R.C.S., L.R.C.P.Lond. (Manager and Medical Superin¬
tendent), West Mailing Place, Kent. Proposed by T. Claye Shaw, Henry
Rayner, and Hayes Newington.

Gilbert Kennedy Aubrey, L.M. & S., S.A., Assistant Medical Officer, Darenth
Asylum, near Dartford. Proposed by A. Rotherham, H. Hallet, and R. H. Steen.

Percival Charles Coombes, M.R.C.S., L.R.C.P.Lond., Assistant Medical Officer,
Surrey County Asylum, Netherne. Proposed by F. C. Gayton, J. E. Barton, and
H. N. Cappe.

Frederick Douglas Crosthwaite, M.B., Ch.B.Edin., Assistant Medical Officer,
London County Asylum, Horton, Epsom. Proposed by John R. Lord, David
Ogiivy, and Samuel Elgee.

Rae Gibson, M.B., Ch.B.F.din., M.R.C.P., Assistant Physician, Royal Asylum,
Morningside, Edinburgh. Proposed by Geo. M. Robertson, R. Dods Brown, and
W. Ford Robertson.

Cecil Johnson, M.B., Ch.B.Vict., 6, Palewell Park, East Sheen. Proposed by
G. E. Shuttleworth, H. Hayes Newington, and C. Hubert Bond.

Roger Aiken Rankine, M.B., B.S.Lond., M.R.C.S., L.R.C.P., Assistant Medical
Officer, Earlswood Asylum, Redhill. Proposed by Charles Caldecott, H. Hayes
Newington, C. Hubert Bond.

Dr. Sidney Coupi.and, F.R.C.P., then read a paper entitled “ The Causes of
Insanity, with special Reference to the Correlation of Assigned Factors: A Study
of the Returns for 1907 ” (see p. 1).

The paper was well illustrated by admirably clear statistical diagrams. It was
followed by a lengthy discussion, in which the President, and Drs. Mercier,
Hayes Newington, and Bond took part. Dr. Coupland replied.

Drs. David Orr and R. G. Rows then read a paper (supplemented by a lantern
demonstration) upon “ The Histological Evidence that Toxins reach the Spinal
Cord via the Spinal Roots, with Special Reference to Plasma Cells ” (see page 86).

The President and Dr. Scott Williamson discussed the paper, and their
remarks were replied to by Dr. Orr.

Owing to the lateness of the hour, Dr. Harvey Baird's paper, “ Alterations in
the Ependyma in General Paralysis ” ; 11 A Case of Mania relapsing into Uncon¬
sciousness, lasting Seven Months,” communicated by Dr. Nathan Raw; and Dr.
Scott Williamson’s paper, entitled “ Typhoid Carrier Infection,” were adjourned.

About thirty of the members afterwards dined together at the Cafe Monico.

COMMEMORATIVE DINNER.

In celebration of the passing of the Asylums Officers’ Superannuation Act,
members of the Association and guests dined at the Gaiety Restaurant, Strand, on
Monday evening, December 20th, 1909, the President of the Association, Prof.
W. Bevan-Lewis, M.Sc. in the Chair.

The guests included: The Right Hon. Lord Monk Bretton; Sir William
Collins, M.P.; Dr. Shuttleworth; Mr. J. M. Henderson, M.P., Chairman of the
Select Committee of the House of Commons to which the Bill was referred ;
Mr. R. Charlton Palmer, Lord Chancellor's Visitor in Lunacy ; Dr. F. Needham,

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Dr. E. Marriott Cooke, Mr. A. H. Trevor, Mr. Fraser Macleod, K.C., Commis¬
sioners in Lunacy; Sir George O’Farrell, Inspector in Lunacy for Ireland; Mr.
I. B. W. Wilson, Mr. W. Morgans, The Rev. H. Whittaker, M.D., of the Asylum
Workers’Association ; Mr. H. F. Keene (Clerk of Asylums Committee), Mr. R. H.
Curtis, Mr. W. C. Clifford Smith, Mr. Valentine Browne, of the staff of the
London County Council; Mr. M. L. Waller, from the Home Office; Dr. Dawson
Williams, Editor, British Medical Journal.

Expressions of regret were received from the following: His Grace the Arch¬
bishop of Canterbury, the Earl of Halsbury, Viscount Cross, Viscount Hardinge,
Lord Ashbourne, Lord Donoughmore, Sir John Jardine, M.P., Sir James Crichton-
Browne, Mr. Charles Roberts, M.P., Mr. Helme, M.P., the Scottish Commissioners
in Lunacy, Dr. Clouston, and several others.

Toasts.

After the customary loyal toasts had been duly honoured, the President
proposed : “ The Passing of the Superannuation Act and Those who contrived it.’’
He said: My lord, lady, and gentlemen, there can be no more pleasant task than
that which has been assigned me to-night, of placing upon record the united
testimony of grateful hearts for the great boon conferred upon asylum workers
throughout the kingdom when the Asylum Officers’ Superannuation Act became
inscribed upon the Statute Book. Our minds to-night are wholly centred upon
those champions of our cause (hear, hear) who have with such rapid intuition
realised the inadequate rewards meted out to a large section of the nursing
community throughout the country. I do not know that there is anything which
approaches nearer to real genius than this same intuitive realisation of the
disabilities of our fellow men, more especially when such realisation is immediately
translated into action for the total removal, or amelioration, at all events, of the
conditions existing. (Hear, hear.) But when this native genius is coupled with
those noble moral sentiments of disinterestedness, an unselfish devotion to the best
interests of a worthy cause, a keen sense of justice, and unflinching tenacity of
purpose, we not only admire, but we begin to revere—nay, to worship—the lofty
altruism of our fellow man. I do not think that there is, among the sad visitations
entailed by natural forces, any more touching sight than that of a once gallant
barque, rudderless, with splintered masts and creaking timbers, driven by the gale
helplessly and relentlessly to its certain doom. And surely, gentlemen, in the realms
of consciousness and of conscious activity, there is no more pathetic sight than
that of the rudderless mind, tossed hither and thither by the storms of conflicting
passions and emotions, bereft of the one and only light—that of reason—which
Nature has bequeathed it whereby to pierce the gloom of this only too sad life of
ours, drifting helplessly to be engulfed in the vast inane, or to be left like the ship¬
wrecked barque, or like the whitened skeleton on the sands of time. Yet this is
insanity; such is the chosen sphere of our activities, and all asylum workers, from
the topmost to the bottom rung of the ladder, are banded together with one fixed
and determined purpose—that of the cure or the amelioration of one of the saddest,
one of the most terrible scourges that fall to the lot of man to endure. I know
no nobler vocation than that of ministering to the mind diseased, than that which
aims at the cultivation of those noblest moral qualities which are so absolutely
essential to the making of every good nurse, as of every good physician, tact, self-
control, gentleness, self-abnegation, and, far above all these, that wide-reaching
sympathy with mental suffering which seems almost to “ Spring from the depths
of some Divine despair,”—moral qualities of the very highest kind, which them¬
selves have been touched and tried by fire, and which no gold can purchase, and to
which no adequate value can be assigned. To you, Dr. Shuttleworth, I turn first
(applause) to offer you the heartfelt thanks of every member of this Association.
You, sir, with happy genius, were among the very first to recognise the crying needs
of the asylum worker; were among the very first to conceive the legislative
machinery adequate to their removal. With unshrinking courage and the confidence
which the merits of every good cause inspire, your ceaseless efforts were exerted
upon their behalf, always keeping in view with clear prophetic vision the happy
future you had mapped out for so many of your fellow men. (Hear, hear.) I
know, sir, that no words of mine can adequately express to you the sentiments we

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would utter; we feel that those pleasures which arise from the gratitude of one's
fellows for services rendered such as yours, so nobly and so unselfishly, can in no
way compare with those which issue from the accomplishment of a noble act,
and we would therefore turn to you with our very sincere congratulations at the
attainment of your lofty ideal, and at your inward realisation of that eternal law
that every good act is its own and its best reward. (Applause.) To you, sir, it
must be a source of infinite satisfaction that you have lightened the burden of so
many hearts ; that you have raised the cloud which obscured their future ; and that
you have gladdened the eventide of their life with the rays of setting suns. Whilst
acknowledging the great services we, as a profession, owe to Sir William Collins
in the past (applause) for his ever lively interest in the asylum worker and his
environment, for his establishment of that great pathological department at
Claybury, from which has emanated such great and brilliant work under the
directorship of Dr. Mott (applause), we wish more particularly to-night to
emphasise his latest and his greatest services to asylum workers throughout the
Kingdom. (Applause.) It is useless building a stately craft unless you have an
able crew wherewith to man it, or unless you have a skilful pilot to take it through
the narrow waterways or hidden shoals, or unless the wayward winds and currents
can be met by clever seamanship. But far more than this has been done for
the Superannuation Bill by Sir William Collins, in concert with Lord Monk
Bretton (applause), in safely conveying this measure through its perilous career in
Parliament. No one who has followed the course and progress of this Bill
through both Houses of Parliament, or who is at all familiar with the intricacies
of Parliamentary procedure, or who can realise in any way the glare of those great
searchlights of publicity which are at once turned on such a measure as this, can
for a moment doubt the infinite tact and address, the ceaseless watchfulness, the
great resourcefulness, which must be in request by him who takes such a measure
to its final and successful issue. But one fact in the history of this Bill, gentlemen,
which has given us all extreme gratification, is that of the instantaneous recognition
by great statesmen in both Houses of Parliament of the intrinsic merits of the
Bill (hear, hear); of the very keen, the intense, the enlightened interest shown
by almost all in the welfare of the asylum worker and his surroundings. How
very different all this, gentlemen, from what occurred in the early days of the third
and fourth decades of the past century, when the eloquent and pathetic appeal on
behalf of the hapless lunatic by such statesmen as Lord Shaftesbury and Lord
Ashley met with such cool comfort. Is it that the cloud of ignorance and
prejudice which so long has brooded over the domain of the insane and their
guardians is about to take its final flight before the rising sun of sympathy and
enlightenment? Let us at least hope that this is the case. Just as those two
Bills which Lord Ashley introduced into the House, and which were made law
in 1845, have been called the Magna Charta of the liberties of the insane, so
this Act, whose passage we celebrate to-night, might well be cited as the
Magna Charta of the liberties of the asylum worker throughout the Kingdom.
And just as a great statesman, Lord Shaftesbury, and an eminent physician,
Dr. Conolly, were mainly instrumental in emancipating the insane from his
centuries of cruel treatment, nay, torture, so now two great physicians, Dr.
Shuttleworth and Sir William Collins, in concert with a noble Peer, have
been mainly instrumental in emancipating the asylum worker from his dubious
position, and establishing the true dignity of his labour, and the recognition of his
manhood. (Applause.) It may appear very strange to some that we have departed
from the usual course of giving the time-honoured toast of “ The Church and The
Houses of Parliament,” but, on this particular occasion, we felt that the Church and
the Legislature have been so happily and so intimately blended with the subject
that we celebrate to-night, that we ventured to embrace in one toast one and all who
have been instrumental in furthering the good cause. (Applause.) I do not know if
his Grace the Archbishop of Canterbury has the slightest realisation of the warmth
which he kindled in the breasts of those whose defence he so stoutly maintained.
(Applause.) His noble sentiments on behalf of the hapless lunatic and the asylum
worker, uttered in the House of Lords when he gave his final benediction to this
Bill, still ring in our ears, and are the surest pledge to us of the sanctity and the
sweet reasonableness of our claims. To Lord Waldegrave, Lord Hardinge, Lord
Ashbourne, and other noble Peers and Commoners, our very hearty acknowledg-

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ments are due, for they really stood out as burning and shining lights upon the
advancing line of a progressive cause, and they did not fail to link themselves
with our cause by the golden and silvern threads of a practical and outspoken
sympathy. I must not fail to recognise the strenuous efforts of his Majesty’s
Commissioners in Lunacy (applause), who have at all times, during the last twenty
years certainly, publicly avowed their hearty sympathy with the main principles
which are now embraced by this Act. Especially do we admire the sturdy
support they have always given us in advancing the comfort, the status, and the
future welfare and prospects of the asylum worker. Nor, gentlemen, must we
fail to acknowledge the efforts of that gallant crew who so very ably manned the
legislative barque, the executives of the Asylum Workers’ and the Medico-
Psychological Associations conjointly. They have stood the heat and burden of
the day with remarkable fortitude and in a quiet and unostentatious manner, but
at the same time with most wonderful harmony and singleness of purpose. It
would be wrong of me not to mention such names as those of Mr. Morgans
(hear, hear), Dr. Pasmore, Dr. Robert Jones, Dr. Greenlees, Dr. Harding, Dr.
Nicholl, Dr. Carlyle Johnstone, Dr. Urquhart, Dr. Nolan, Dr. Bower, Dr. Wolseley
Lewis, Dr. Hubert Bond. (Applause.) But, gentlemen, there is yet one name I
fain would utter, for he is one who has associated himself with this question in
the years of long ago and up to the present time ; and if I could 1 would mention
that name. But my lips are sealed, and by himself. I must leave it for your
instincts to divulge to whom 1 refer. Suffice it to say that I know sufficient of
him to be quite well aware that if I were to obtrude his personality here beside
that of Dr. Shuttleworth’s bright and particular star now in the ascendant my
life would not be worth a moment’s purchase. (Laughter.) For, gentlemen,
the nameless one is muscular, the nameless one is strenuous, and unless any of
you wish your President to be sacrificed, as Agag of old was, and hewn to pieces
at your feet, you will not press me to name him whom I now refer to, especially
on this auspicious occasion, when our happy Christmas bells are about to—

" Ring out the old, ring in the new;

Ring out the false, ring in the true.”

(Cheers.) Gentlemen, my very pleasant task is done, and it is your duty now to
honour the toast which I have given you, that of “ The Passing of the Superannua¬
tion Act and Those who contrived it,” coupled with the names of Sir William
Collins, Lord Monk Bretton, and Dr. Shuttleworth. (Cheers.)

Sir William Collins, M.P., in responding to the toast, said : Professor Bevan-
Lewis, my Lord, lady, and gentlemen, it is with no ordinary feelings of mingled
gratefulness and diffidence that I rise as the first of the trio who are, by your
order, asked to respond to the toast that you, sir, have proposed with such eloquent
expressiveness, and with such a delightful and poetic imagery. I feel that the
hypercritical might find fault with the order in which that trio of response was
arranged. (No, no.) I feel, at any rate, that I ought not to precede the noble
Lord who so ably conducted this Bill in which we are all interested—now, happily,
an Act—through the Upper House. But I perceive that the order is a historical
one, at any rate in the first instance, and that the last, and naturally not the least
important, to respond to the toast is the true inspirer of the whole movement, the
urger-on of many a stage when the Bill might have been thought to flag, and the
true Moltke-like organiser of victory, our friend, Dr. Shuttleworth. It has been
my privilege, as you, sir, indicated, during my public life to be associated to some
extent with the work which your Medico-Psychological Association has to deal
with, both in regard to the science and the service of psychiatry. The small efforts
to which you referred in connection with Claybury Asylum, as long ago as the
early nineties, are, I think, at any rate an indication that a great democratic body
like the London County Council was not anti-scientific, but quite prepared to do
what was necessary so as to wipe out the reproach under which psychological
medicine then laboured in London, in not having adequate means of pursuing
pathological and scientific work in connection with diseases of the mind. And
now, instead of being behind, it is in the very forefront of any such research in any
part of the civilised world. In regard to the services of psychological medicine, of
which this particular Act, whose passing you are so handsomely commemorating
this evening, has to do, 1 recall the fact that the late Sir William Hamilton used
to say that in the world there is nothing great but man, and in man there is nothing

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great but mind ; and, as you, sir, fitly quoted, you may well admire both the calling
and the devotion of those who seek to minister to the mind diseased. And if that
statement of Sir William Hamilton’s be true, we can realise the greatness and the
importance to the community of the sphere of work to which you have devoted
your lives. It requires qualities of both heart and head, and we have only to look
back, as you have indicated, to recognise the great work of Tuke, and Conolly,
and Pinel in France, to recognise the enormous strides in the humane and scientific
treatment of the insane, in which this country has, happily, played such a dis¬
tinguished part. I had early imprinted upon my mind that picture which Hogarth
painted somewhere about 1750, I suppose, showing the condition of the insane in
Bethlem in his day, where he exhibits, with the truth of a great artist, the condition of
the melancholiac, the general paralytic, and the maniac. I allude to that picture
called “ The Rake’s Progress,” that picture in Bethlem which serves to show the
horrors, and the neglect and apathy, and indifference, even contempt, with which
the insane were treated 150 years ago. I was early led to take some little interest
in the work of asylums, and I was deeply impressed by the fact that there was a
devotion and a service in connection with the asylums of this country, not only
those which are rate-supported, but others, like Earlswood, services which no
money can measure and no salary or superannuation can adequately requite. And
1 learned this, that the service was not only arduous but often repulsive, and not
infrequently perilous; and that if any class of public servants had such a claim
upon public recognition as to deserve greater stability, greater honour, and greater
ease in the declining years of their service, no others stood out more exceptionally
qualified for such public recognition than the workers in our great public asylums.
(Applause.) Indeed, as you, sir, in your most eloquent speech indicated, there
are two features which arc specially striking to anyone who looks in perspective,
as it were, at the great work of a public asylum. The work is, on the one hand,
most exacting, a strain alike upon body and mind. But besides being most
exacting, it is capable of bringing out the most admirable qualities which are
possible in humanity; and I remember, in an address I gave at the Asylum
Workers' Association, I recalled the old mediaeval painting representing at one
and the same time two events—the Transfiguration on the Mount, and the healing
of the epileptic at the foot of the Mount, the epileptic gnashing his teeth and
pining away in the manner so truly described by the Evangelist. And I cannot
help thinking sometimes that this asylum work does bring together both the
exacting work of attending to the epileptic and paralytic and those least able to
help themselves; and, by its disinterested service, calls out those higher ideals
of human devotion which happily transfigure and transform our lives. (Cheers.)
I have sometimes asked myseif in public life, If one cannot be the friend of the
most pitiable of mankind, can one not at least befriend those who do ? And when
I had brought to my knowledge by Dr. Shuttleworth the condition of things in
regard to the evening of the days of those who had laboured in asylums, I confess
I felt that a real case had been made out for public recognition of the great service
to which you gentlemen belong. The salary of such services was not by any
means always commensurate with the importance and the disagreeableness of the
service which was rendered; and there was not provision made for old age. And
it is good to know in this age, which has a tendency to materialism, that we
nevertheless have this redeeming virtue, that we have a growing reverence and
regard for old age. And it seems in harmony with the spirit of our statutes at
the present time to see that, at any rate, no service such as this should be left
unprovided for. These, I take it, were the moving forces which led to the intro¬
duction of this Bill. And, if I am not speaking at too great length (No), I
should like to allude to one or two incidents which occurred during the passage of
this Bill through the House of Commons in its later stages.

After recounting these incidents Sir William Collins added : It will always be a
matter of satisfaction to me to have been permitted, at the request of the Asylum
Workers’ Association and the Medico-Psychological Association, to bear a
humble part in the passage of this Asylums Officers’ Superannuation Bill. (Cheers.)
Wc may differ, and probably do, around this table upon political matters; but it
is pleasant to me to know that to-night, to the right and left of you, Professor
Bevan-Lewis, are representatives of both Houses who have taken their fair share
—I am not sure that the Lords have not taken the larger share—in passing this

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Act. We may differ in political opinions—man’s opinions must ever be liable to
error; it is by the motives which sway his heart that he can alone be judged, and
the motives of those who introduced this Bill and those who have humbly
endeavoured to make it law and have succeeded, have not been low, mean, or
sordid motives, but they have been motives animated by the highest desire to do the
best, not only to the great service to which you belong, but to the larger number
of those who belong to the most pitiable and most helpless class of the com¬
munity. (Cheers.)

Lord Monk Bretton : Professor Bevan-Lewis, lady, and gentlemen. I am
very much obliged to you, as the Chairman, for the very kind and all too-flattering
words which you chose to use about myself in regard to the passing of this Bill.

1 feel that, so far from being associated with this toast, 1 really hardly have any
right to be here at all. (No, no.) I believe there are some of you here present
who have laboured for the principles of this Bill for something like twenty years.
I have not borne the burden and heat of the day ; 1 did not come in at the eleventh
hour even ; I came in at about three minutes to twelve. (Laughter.) I think it
was in September that Dr. Hayes Newington introduced me—and I am very
much obliged for the introduction—to this Bill. And in the following month Dr.
Shuttleworth asked me to chaperone it in their Lordships' House. I can only say
1 am very proud to have served, even indifferently, in so good a cause. Some¬
times one finds oneself engaged in a cause about which one has misgivings; one
is not so sure that what one’s opponents say has not a great deal in it. That was
not the case in reference to this Bill. (Applause.) The asylum worker is engaged
in a very noble profession, in a very important profession, and in a very trying
profession. And it is a profession with which the public are unacquainted. I sup¬
pose, in its lower ranks, it may be compared either with the prison service or with
the police. Well, the prison warders are the proteges of the Government, and the
Government has a large and inexhaustible purse, and can see that these employees
have all their requirements. In the police, a service which may be compared with
the asylum service in its lower hierarchy, they are under the local authority. But
the police, after all, is a favourite of the ratepayer. When the most parsimonious
ratepayer wakes up in the morning and sees the policeman outside his front door
he does not grudge the rates which are paid to the police. And when, for instance,
at this festive season, this policeman asks for a subscription to the Widows and
Orphans Fund, that ratepayer gladly contributes. And the Government does
something too ; the Government contributes money to the police pensions, which,
alas, it does not even now to the asylums pensions. 1 am glad to think that we
have done away to a great extent with an injustice by the passage of this Bill;
and I trust that by doing so we have conferred a benefit on the asylum service.
(Applause.) But I cannot allow this opportunity to pass, with Sir William
Collins here, with his great political influence and his great diplomatic ability,
without suggesting that he should push these energies even further, and obtain
from the Treasury some grant, comparable to that given under the Police Act,
for the purposes of the asylums officer. And he might go even further, and
on the analogy of the prison warder, allow the asylum service to be, as it has
been lately borne in upon my mind it ought to be, a wholly Government
institution. (Applause.) But I cannot help feeling that this may be some¬
what of a historic occasion ; that this may be, perhaps, if Sir William Collins
has his way, the last private Bill that will ever pass through their Lordships’ House.
(Laughter.) It is an epoch in constitutional history, not because there may not
be other private Bills, but because there may not be another Lordships’ House.
(Laughter.) And perhaps when the chronicler jots down the whole of these
events he may compare their Lordships’ House to a great criminal who has been
engaged in a number of crimes, and upon whose death-bed there was just one
little flicker of virtue, the consciousness that in his last moments he passed the
Asylum Workers’ Superannuation Bill. (Laughter.) I know that perhaps every¬
body is not quite pleased with their Lordships’ House. I know that they made
amendments, that they even made privileged amendments; they amended the age,
they amended the scale of contributions. I might, in their defence, say that there
is a very large army in this country, and in every country, of men, women, and
children who do not get all they w'ant in this world. I belong to that catholic
army myself (laughter), but I will not take hat for my defence. I desire to say

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that I think their Lordships’ House did extremely well by this Bill. (Applause.)
They received it in a very sympathetic spirit. I know that they made amendments
with regard to these particular matters, but I must ask you to remember the
circumstances. This was a private members’ Bill; it was an extremely important
measure to be a private members’ Bill. It was a Bill in which any legislative
assembly must be guided by the attitude of the Government. The Government
was an exceedingly taciturn Government. It said absolutely nothing in the House
of Commons; it began by being very reserved in the House of Lords, and it was
only quite at the end that it began to be loquacious. We had to guess what it
wanted; but it did tell us that if we did not do what it wanted the Bill would
be wrecked. We did what we thought best; we accepted the amendments
which we thought best, and we were told afterwards we had been very wise. There
were further amendments, which I may designate the machinery clauses, made
by their Lordships’ House which will prove valuable in the working of this
measure. And so I claim for the House of Lords that when’some future
Gibbon shall write on the causes of the decline and fall of their Lord-
ships’ House, he need not head one of the chapters “ Asylum Officers’
Superannuation Bill.” (Laughter.) I have seen, during the time I had the
privilege of being in charge of this Bill, some of the rocks around which the ship
had to be steered. From that point of vantage I desire to say that nothing could
exceed the diplomatic skill with which Sir William Collins piloted the Bill.
(Applause.) But Sir William Collins not only navigated his barque through
many rocks, but he also took it a very long journey. I believe this ship started
somewhere near the offices of the London County Council, and before it concluded
its vovage it had travelled all round England and Wales and Ireland and Scotland.
And if you consider, as Sir William Collins has mentioned, that the position of the
law in Scotland was very much more retrograde than in England, that there was
not even the optional power of giving these pensions in Scotland, and yet if you
came to London or Lancashire you found extremely progressive bodies which had
already scales in existence, and if you realise that he brought all these different
societies into line, you will appreciate the extent of his diplomatic ability and the
success with which he applied it to this Bill. (Applause.) The ordeal is past,
and the iron has come out of the furnace as moulded steel. And now I do most
confidently hope that the effect of this Bill is going to be to raise the profession of
the asylum workers all round. (Hear, hear.) I hope it will benefit them in all
their classes; and if there be, on the part of any, disappointment as to this or that
amendment, I hope when, next April, this Bill comes into force, it will be found that
those amendments were not so important as some of us consider them ; and that
this law is going to be one of real benefit, a statute for the good of the asylum
worker. (Cheers.)

Dr. Shuttleworth, in responding, said : Mr. President, my lord, lady, and
gentlemen, I need hardly say that this evening's gathering in commemoration of
the passing of the Asylum Officers' Superannuation Act has been most gratifying
to me, and I have been much touched by the very kind reference which has been
made to my humble share in the matter by our President and the several speakers
who followed him. Let me, then, thank you at once for the grateful recognition
of such share as it has been my privilege to take in the promotion of this Bill.
At the same time I wish you to remember that I was only one out of many who
really bore part in the work and heat of the day. It might be invidious, perhaps,
where so many did good service, for me to mention names and particularise workers,
but I think, acting as I was, at first chiefly in my capacity of Honorary Secretary of
the Asylum Workers’ Association, I ought not to take to myself all the credit that
really belonged to the Committee of the Association, which spent many afternoons,

I may say almost many days, in finding out, first of all, the sort of Bill which would
be acceptable, and then drafting it into more or less parliamentary shape. There
were so many helpers that I could not mention all their names; Scotland was
worthily represented before the Select Committee by Drs. Urquhart and Carlyle
Johnstone, and Ireland by Dr. Nolan ; but I cannot help speaking of one who, not
only in drafting the Bill, but in the subsequent career of that Bill through Parlia¬
ment, and more especially before the Select Committee of the House of Commons,
was supremely serviceable to our cause; I mean Mr. Morgans. (Applause.)
Also we must not forget that as soon as the Medico-Psychological Association was

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satisfied that we were on the right track, that our Bill was such as they would be
justified in approving, we had the very cordial and valuable co-operation of this
Association; and I may again, perhaps, venture to mention one name—I amount
bound over to reticence by any threats of personal violence (laughter)—and that
is the name of, shall I say our venerable ? at any rate venerated, Treasurer,
Dr. Hayes Newington. (Cheers.) He most kindly placed at my service the
many investigations he had made in former years, and indeed up to a quite recent
date, with regard to the pension privileges of certain public officers and others who
were, in some sense or other, analogous to asylum workers in reference to position.
And then again, I have had the cordial and ready assistance, and the valuable
co-operation of the Secretary of this Association, and of the Chairman and
Secretary of its Parliamentary Committee. In fact one may look upon the Bill as
ultimately a joint product. There are many names that I should like to mention—
some of them the President has already alluded to—but I must not weary you with
repetition. I will only say that, having obtained the inestimable services of the
President of the Asylum Workers' Association, Sir William Collins, to in¬
troduce our Bill into the House of Commons, we found many good friends
in both Houses of Parliament. (Hear, hear.) First of all let me mention,
in addition to Sir William Collins, our good friend Mr. Charles Roberts,
M.P. He it was who first suggested the idea that, as we found after
waiting year after year, that no progress had been made with any Government
measure for the regulation of lunacy, it would be better for us to venture upon the
experiment of getting a private member to introduce the Bill into the House of
Commons. We were most happy in our choice, and we have been most happy in
the result. And we owe, I think, a debt of gratitude to Mr. Roberts. We have
had, also, the cordial help of his Majesty’s Commissioners in Lunacy, and, let me
say also, of the officers of the London County Council; and 1 may specially
mention the name of Mr. Keene, who has been a very kind and able co-operator in
the progress of the Bill. But to our Parliamentary leaders, of course, Lord Monk
Bretton and Sir William Collins, we owe immense gratitude, a gratitude most
sincerely felt, I am sure, by members of both the Associations—the Association
which I more immediately represent, and by this senior body, the Medico-Psycho¬
logical Association. And the words of appreciation which have fallen from our
President will, I am sure, find an echo in thousands—nay, I may say tens of
thousands—of grateful hearts in the various asylums scattered throughout the
length and breadth of the three Kingdoms. Personally we owe what has been so
aptly cal led the working part of the Bill to the consummate tact and great ability of
Sir William Collins and Lord Monk Bretton’s unwearying industry and diplomatic
treatment of the numerous difficulties which arose in the Upper House. Perhaps
his lordship will excuse me if 1 mention in passing that, if the handling of our Bill
may be taken as a fair specimen of the legislative thoroughness of the Peers, there
can be no doubt whatever of the effectiveness of even our unreformed Second
Chamber (applause); for at every stage of the Bill, from the Second Reading on¬
wards—the Committee stage, the Report stage, and the Third Reading—we had
copious sheaves of amendments—I think six or seven pages even at the Third
Reading—and these were duly discussed pro and con on either side; and the
merits of the Bill were most thoroughly threshed out in their Lordships' House.
Before passing from that subject I must not omit to mention the debt of gratitude
we specially owe to, amongst others, the Archbishop of Canterbury in the Upper
House. (Applause.) His Grace was good enough, though through the duties of
his high office exceedingly occupied with other matters, to throw his heart and
soul into our cause. Well, the Bill is through, and we rejoice therein. It is
true we have not got all that we asked for, but we have got a very considerable
amount towards it, and, above all, the principle of assured pensions on a definite
scale has been secured for asylum workers, and the principle of aggregation of
service is now an enactment on the Statute Book. At length, and after very
long waiting, the State has recognised her duty towards this most useful, most
patient, and ofttimes self-sacrificing class of public workers, who will now
increasingly feel, I have no doubt, their corresponding duty towards the public in
devoting their best years and their best energies to the service of the insane.
(Cheers.)

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Telegram to the Lord Chancellor.

Dr. Percy Smith : Mr. President my lord, lady, and gentlemen, our indefatig¬
able Secretary, Dr. Bond, has laid upon me a duty which I think ought not to
be neglected. Many important personages have been alluded to in connection with
the passing of this Bill; but there is one most important person, so far as lunacy
matters are concerned, who has not yet been referred to by name, and that is the
Rt. Honourable the Lord Chancellor. All recognise, I think, that if it had not
been for the sympathy of the Lord Chancellor in this matter this Bill might have
been wrecked; and it is a matter of great satisfaction that his Lordship and the
Upper House felt so disposed towards this very important measure. We have
been looking, expecting, and hoping that His Lordship would at some time
bring forward a very important measure of reform in connection with the lunacy
laws. I think that for something like ten years we in England have been hoping
that we should at least have the same privileges that exist in Scotland with
regard to the treatment of early cases ; but apparently this is not to be yet. It
has been suggested that a telegram should be sent to the Lord Chancellor,
thanking him for the cordial support which he gave to this Bill, and for his
assistance in enabling it to become law. The telegram which has been proposed
runs : " The Presidents, councils, and members of the Medico-Psychological and
Asylum Workers' Associations, assembled at the Gaiety Restaurant to celebrate
the passing of the Asylum Officers’ Superannuation Act, respectfully convey their
profound appreciation and warm thanks for the sympathy and support which
your lordship gave to the Bill.” (Applause.)

The Visitors.

Dr. Savage, in proposing the toast, “ The Visitors,” said : I need scarcely say,
Mr. President, my lord, lady, and gentlemen, that the submission to you of the
toast of ” The Visitors ” affords me very great pleasure. I feel that we are highly
honoured in having the support of so many distinguished guests, who have all
taken a genuine and deep interest in our work. We have representatives, as you
have already heard, of both Houses of the Legislature, and we have the official
heads of our own branch of medicine. I would most heartily press upon you our
good wishes towards those who have joined us this evening. I take the greatest
possible pleasure in coupling with this toast the name of my very old friend, Dr.
Needham. (Applause.) He represents not only the Commissioners in Lunacy,
but one who has gone through the mill himself, one who has raised one of the
registered hospitals to the highest possible pitch of perfection. (Applause.)

Dr. Needham, in responding to the toast, said: Mr. President, my lord, lady,
and gentlemen, I am here to-night with very great pleasure because I considerthat
the fact which this great meeting celebrates marks an epoch in the history of asylum
administration in this country. It is well known, I think, that the Commissioners
have always had a very strong feeling that a scheme of assured pensions was the
only way out of a very great difficulty in asylum administration. In 1900 we said
that " we have no doubt that the asylum services generally can only be maintained
at a high, and therefore economical, level by such an advance in salaries and
wages as have been made in other branches of highly skilled and responsible work,
or by the less costly and more satisfactory plan of deferred pay in the form of
assured pensions. The salaries of the superior officers, and indeed of all the
staff, are very moderate ; their work is anxious and responsible, and frequently
repulsive, and under it a not inconsiderable number of persons break down.”
Those are the views which have been held by the Commissioners for a great
number of years; and I think I need not say that the desire of the Commissioners
has been all along that an assured system of pensions should be provided. What
one has to deprecate so very much, what superintendents of asylums have depre¬
cated so much, have been the frequent changes in the subordinate staffs of asylums
as influencing the patients in a very undesirable way, as diminishing very largely
their comfort, and diminishing greatly the means of successful treatment of them.
And we hope sincerely, and trust and believe, that the passing of this most impor¬
tant Act will give assurance to people who are in the asylum service, which will

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enable them to retain their offices very much longer than they have been in the
habit of doing. And I have no doubt whatever that this will result in a benefit to
the asylum workers throughout the country—a very large class; that it will also
result tremendously in the direction of advantage to the insane; because what
benefits workers among the insane must enormously benefit the insane. (Applause.)

I need hardly repeat that the sympathy of the Commissioners is very warm indeed
towards this Act; and I think that 1 need not give a greater illustration of that than
the fact that every Commissioner who is not having his winter holiday, having been
in London during August and September, is present here to-night. I greatly
appreciate the kind way in which this toast has been proposed and received, and
on behalf of the visitors I beg to tender my very hearty thanks. (Applause.)

Dr. Hubert Bond : At your request, Mr. President, I have to communicate to
you, my lord, lady, and gentlemen, a number of regrets which have been received
from those who are unable to be with us this evening. But at this late hour I
take it that it is not your desire that I read all of them out. I have quite a number
here from those who, except for Parliamentary and other duties and the proximity
of Christmas, would have been with us to-night.

Letters were read from His Grace the Archbishop of Canterbury, the Earl of
Halsbury, Sir James Crichton-Browne, and Dr. Clouston, and a telegram from the
Irish Division of the Medico-Psychological Association and the Irish Asylum
Officials’ Superannuation Committee.

The Chairman.

Dr. Robert Jones: My lord, Dr. Alice Vance, and gentlemen, 1 have a toast
placed in my hands this evening which, though the last, I am sure you will agree
is not the least, that of our distinguished President, Professor Bevan-Lcwis.
(Applause.) So far, only half the term of his office has expired. We know what
a brilliant success the annual meeting was at Leeds, and we have heard to-night
his most poetic speech upon the whole question of asylum administration and
asylum workers, a speech which I know comes from his heart. We are fortunate
in our President; that is the theme of this last toast. We have a President who
is second to none in scientific attainments (hear, hear), in distinguished administra¬
tive ability, second to none in the unstinted and full devotion of his mind and
heart to the work of his life. His acts speak for themselves. I know him
privately, as many of you do ; and you all know his public record. An after-
dinner speech is not the occasion for entering into his qualities and his acts, but
1 may be allowed to refer to one or two. First, the obligation we are under to
him for the best standard text-book in the English language on mental diseases ;
secondly, his researches into the comparative pathology of the cerebral cortex.
Our President has been elected by the unanimous voice of our Association to the
position which is the highest and most distinguished, and the most cherished of
all the positions that any private member of our Association can aspire to. I
give you, gentlemen, the health of our distinguished President, Dr. Bevan-Lewis.
(Cheers.)

The President: I am extremely obliged to you for the way in which you have
received this toast. It is particularly gratifying to myself that it has been proposed
by Dr. Robert Jones, whose friendship has always been warmly appreciated by me.
I thank him for his sentiments, which are distinctly far above anything I deserve;
and I can only rejoice that the accident which makes me your President for this
year has placed me in the Chair on an occasion which 1 regard as one of the most
auspicious in the history of the Association. (Applause.)

SOUTH-EASTERN DIVISION.

Autumn Meeting.

The Autumn Meeting of the South-Eastern Division was held by the courtesy
of Drs. Adams and Johnston at Brooke House, Upper Clapton, N.E., on Wed¬
nesday, October 6th, 1909.

Among those present were Drs. J. O. Adams, R. R. Alexander, P. J. Baily,
D. Bower, A. N. Boycott, A. W. Daniel, A. C. Dove, F. H. Edwards, F. W.

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[Jan.

Edridge-Green, J. G. Gordon-Munn, T. D. Greenlees, H. E. Havnes, J. W.
Higginson, G. H. Johnston, G. H. Keene, W. B. Keith, H. Kerr, R. Langdon-
Down, Mary E. Martin, A. S. Newington, E. S. Pasmore, G. E. Peachell, G. H.
Savage, G. E. Shuttleworth, R. Percy Smith, R. J. Stilweli, F. R. P. Taylor,
F. Watson, J. Kennedy-Will, and R H. Steen (Hon. Sec.).

The House and grounds having been visited, the members were entertained to
luncheon. At the termination of the lunch Dr. Bower proposed a vote of thanks
to Drs. Adams and Johnston for their kindness in so hospitably receiving the
Division.

The meeting of the Divisional Committee was held at 2.15, Drs. Taylor,
R. Langdon-Down, Pasmore, Greenlees, Peachell, and the Hon. Secretary being
present.

The General Meeting was held at 2.45 p.m., Dr. Adams in the chair.

The minutes of the last meeting having appeared in the Journal were taken as
read and confirmed.

The following gentlemen were elected as ordinary members of the Association :

John Bain, M.A., M.B., B.Ch.(GIas.), Assistant Medical Officer, Northampton
County Asvlum.

James Kilian Clarke, M B., B.Ch., B.A.O. (R.U.I.), House Physician, Bethlem
Royal Hospital, London, S.E.

Frederick J. Stuart, M R.C.S., L.R.C.P., Senior Assistant Medical Officer,
Northampton County Asylum.

The invitation of Dr. Percy J. Bailv to hold the Spring Meeting (1910) at the
London County Asylum, Hanwell, was unanimously accepted with much pleasure.

Dr. Bower gave an account of the progress of the Asylum Officers' Super¬
annuation Bill. Dr. Pasmore and Dr. Shuttleworht also spoke on the same
matter.

Dr. F. W. Edridge-Green read a paper on “ The Theory of Vision and Colour
Perception.” The paper was illustrated by numerous coloured lantern slides.

In the discussion which followed Dr. S avage said that he had watched with
great interest the progress made by Dr. Edridge-Green in his work on colour
vision, even though that work had been discouraged by the authorities at the
Board of Trade. Dr. Edridge-Green had produced quite a revolution in the
theories of vision. He referred to the remarkable paper bv Gladstone on
the colour ideas of Homer. He felt very strongly that the Association had
reason to be proud of the good work done by Dr. Edridge-Green.

Dr. Pasmore instanced a case of a woman suffering from tumour of the cere¬
bellum pressing on the right occipital lobe. In this case, though the patient could
match ordinary colours, she was unable to always name them correctly.

Drs. R. Langdon-Down, A. N. Boycott, and R. H. Steen also spoke.

Dr. Edrioge-Green in his reply answered the numerous questions which had
been put to him by the various speakers. He stated that he agreed with
Gladstone that Homer saw two colours only, namely, red and violet.

Dr. T. Duncan Greenlees read a paper entitled "Lunacy Matters in Cape
Colony.”

The Chairman (Dr. Adams) opened the discussion, and expressed his interest
in the account given of the lunacy legislation in Cape Colony. This was probably
the latest legislation of the kind in the British Empire. He could not help
contrasting the present system of certification with the condition of things which
existed in the earlier days of Brooke House.

Drs. Shuttleworth, Boycott, and Steen also spoke, and Dr. Greenlees
replied.

Nine members dined together in the evening at the Cafe Monico.

SOUTH-WESTERN DIVISION.

The Autumn Meeting of this Division was held, by kind invitation of Dr.
Blachford, at the City and County Asylum, Fishponds, Bristol, on Friday,
October 22nd, 1909.

The following members were present:—Drs. Ballard, Harvey Baird, Baskin,
Bazalgette, Blachford, Cotton, Richard Eager, Glendinning, Kough, Norman

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Lavers, MacBryan, Macdonald, Marnan, Morrison, Phillips, Pope, Rorie, J. M.
Rutherford, Soutar, Thomas, and the Hon. Divisional Secretary (21).

There was also one visitor.

The chair was taken by Dr. Blachford.

The minutes of the Spring Meeting were read and signed.

The following candidates were elected members of the Association :

Ernest Fryer Ballard, M.B., B.S.(Lond.), Assistant Medical Officer, Somerset
and Bath Asylum, Wells. Proposed by Drs. Pope, Shera, and Aveline.

John Robert Parry Phillips, M.R C.S., L.R.C.P.(Lond-), Assistant Medical
Officer, Bristol City Asylum, Fishponds. Proposed by Drs. Blachford, Bazalgette,
and Aveline.

Dr. Morrison then read an exhaustive criticism on the Report of the Royal
Commission for the Care of the Feeble-minded.

This was followed by a paper from Dr. Ballard on " A Case of Aggravated
Hysteroid Movements ” (this paper will be published in the April number of the
Journal).

Dr. Pope made some remarks on the Asylum Officers’ Superannuation Bill.

Each of these communications elicited a short discussion.

Dr. Norman Lavers kindly invited the members to meet at Bailbrook House-
on the occasion of their visit to Bath in the spring—an offer which was cordially
accepted. The proceedings terminated with a vote of thanks to Dr. Blachford
for his hospitality.

A large number of the members dined together subsequently at St. Stephen’s
Restaurant, Bristol.

NORTHERN AND MIDLAND DIVISION.

The Autumn Meeting of the Northern and Midland Division was held at the
kind invitation of Dr. Douglas at the Royal Albert Asylum, Lancaster, on
Thursday, October 21st, 1909.

Dr. Douglas presided.

The following fifteen members were present:—Drs. M. A. Archdale, D. M.
Cassidy, A. R. Douglas, J. S. Farries, J. W. Geddes, S. A. Gill, C. L. Hopkins,
W. Hunter, G. F. May, T. McDowall, J. Merson, B. Pierce, R. G. Rows,
C. T. Street, T. S. Adair, and two visitors, Dr. Coupland and Mr. Wearing.

Apologies were received from the Right Honourable the Earl of Lathom, who
was prevented by illness ; Dr. W. Bevan Lewis, the President of the Association ;
and many others.

The minutes of the last meeting were read and confirmed.

Dr. Hopkins proposed, and Dr. Geddes seconded, that the same three members,
Drs. Hitchcock, T. McDowall, and Bedford Pierce, form the Divisional Committee
for the next twelve months. This was unanimously agreed to.

Dr. Douglas then read his paper entitled, "The Care and Training of the
Feeble-minded’’ (this paper will appear in the April number of the Journal).

Some discussion followed, in which Dr. Gill, Dr. McDowall, and Dr. Pierce
took part.

Dr. Pierce referred to the question of heredity, and said one felt one did not
know the extent of heredity of sound people. He wished someone would take
the matter up and get some accounts of the family history. If this were
done, he thought that they would find that the percentage of heredity would be
much greater.

Dr. Douglas replied.

Owing to the short time at his disposal, Dr. W. Hunter was unable to read his
paper on “ Mongolian Idiocy.” He showed, however, a series of photographs
illustrative of the condition. His conclusions briefly were—That Mongolian
Idiocy is not an entity, that the characteristics of the condition can all be
paralleled in the foetus, that in short the Mongolian idiot is a grown-up foetus.
He also demonstrated some morphological aspects of the Mongolian idiot,
suggesting that the orang possibly approaches much nearer the line of human
ancestry than does either the gorilla or chimpanzee.

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Dr. Rows made some remarks with reference to the brain photos shown by Dr.
Hunter.

A very pleasant meeting was brought to a close by an adjournment to the
Winmarleigh Hall in the Asylum, where the Right Hon. Lord Muncaster un¬
veiled a Memorial Window in memory of the late Sir John Hibbert.

SCOTTISH DIVISION.

The half-yearly Ordinary Meeting of the Scottish Division of the Medico-
Physiological Association was held at Bangour Village, on Friday, 19th November,
1909, Dr. Carlyle Johnstone in the chair.

The following members were present:—Drs. Alexander, Dods Brown, Lewis
Bruce, R. B. Campbell, C. G. H. Gostwyck, Hotchkis, Jeffrey, Carlyle Johnstone,
Keay, Kerr, T. C. Mackenzie, J. H. MacDonald, Douglas Macrae, K. D. C.
Macrae, Richard Steele, and Marr, Divisional Secretary.

Mr. Gibson, Chairman of the Edinburgh Lunacy Board; Mr. Johnston, Vice-
Chairman of the Edinburgh District Lunacy Board; Mr. Hippolyte Blanc, and
Mr. Kidd, Inspector of Poor, were present.

Letters of apology were intimated from the President, Dr. Bevan-Lewis, Drs.
Clouston, Yellowlees, Easterbrook, Reid, Parker, Havelock, Watson, Urquhart,
and Turnbull.

Dr. Carlyle Johnstone, on behalf of the Superannuation Allowances Com¬
mittee, explained that the Superannuation Bill had passed its Third Reading in
the House of Lords, and gave the gist of the amendments proposed by the House
of Lords. He expressed the hope that in a short time the Bill, as amended,
would pass into law.

The following were admitted to membership of the Association:

William Gilfillan, M.B., Ch.B.(Glasg.), Assistant Medical Officer, Woodilee,
Lenzie. Proposed by Drs. Marr, Parker, and Baugh.

Charles Armit Masson, M.A., M.B., Ch.B.(Aberd.), Assistant Medical Officer,
Inverness District Asylum. Proposed by Drs. Mackenzie, Marr, and Watson.

Alexander Cameron McKillop, M.B., Ch.B.(Edin.), Assistant Medical Officer
Inverness District Asylum. Proposed by Drs. Mackenzie, Marr, and Watson.

John Ernest Middlemiss, M.R.C S.(Eng.), L.R.C.P.fLond.), Assistant Medical
Officer, Gartloch Asylum, Glasgow. Proposed by Drs. Parker, Baugh, and
Marr.

Hugh Morton, M.B., Ch.B.(Glasg.), Assistant Physician, Glasgow Royal
Asylum, Gartnavel. Proposed by Drs. Oswald, Marshall, and Yellowlees.

Alexander W. Neill, M.B., Ch.B.(Edin.), Assistant Physician, Royal Asylum,
Edinburgh. Proposed by Drs. G. M. Robertson, Ford Robertson, and Dods
Brown.

Jane I. Robertson, M.B., Ch.B.fGlasg.), Assistant Physician, Royal Asylum,
Glasgow. Proposed by Drs. Oswald Marshall and Yellowlees.

Joseph Roderick Sutherland, M.B., Ch.B.(Glasg.), M.R.C.S.Eng., L.R.C.P.
(Lond.), Assistant Medical Officer, Woodilee, Lenzie. Proposed by Drs. Marr,
Parker, and Baugh.

Arthur L. Taylor, B.Sc., M.B., Ch.B.(Edin.), Assistant Medical Officer, Lanark
District Asylum, Hartwood. Proposed by Drs. G. M. Robertson, Kerr, and
Dods Brown.

Dr. John Keay, Medical Superintendent, gave an interesting account of the
History and Inception of Bangour Village, and explained the plan of it in detail.
Thereafter the members were conducted by Dr. Keay through the several parts of
the Institution.

The members were entertained to lunch by the Edinburgh District Lunacy
Board.

A vote of thanks to the Edinburgh District Lunacy Board and to Dr. and Mrs.
Keay for their hospitality and to Dr. Carlyle Johnstone fpr his conduct in the
chair concluded a most interesting Meeting.

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THE INTERNATIONAL CONGRESS OF PSYCHOLOGY.

The sixth International Congress of Psychology was held at Geneva from
August 3rd to August 7th under the presidency of Prof. Flournoy. It was
attended by some 500 representatives from the most various countries. Prof.
Claparede, the general secretary, is to be congratulated on the excellence of the
general arrangements.

To obviate certain inconveniences of former Congresses it was decided that on
this occasion the various papers should be printed in advance, in order that the
members might be better prepared to take part in the discussions. The subjects,
moreover, were limited to certain definite themes—the proceedings being therefore'
less disconnected than is usually the case. A certain number of individual com¬
munications dealing with subjects other than those officially announced were,
however, permitted. The majority of the Sections presented features of more or
less interest to alienists—and Psychiatry was well represented. Another innova¬
tion was the introduction of Esperanto among the officially recognised languages.
A somewhat heated discussion upon the merits of the new language took place in
the Terminology Section, but the majority of those present were in favour of its
recognition.

The Section dealing with " The Psychology of Religion ” was presided over by
Prof. Hoffding, of Copenhagen. The proceedings were interesting—more particu¬
larly the delightful contribution of the Abb6 Pacheu—but many of the speakers
tended to transgress the limits of the psychological aspect and to wander into
metaphysics.

A Section was devoted to the consideration of alleged spiritualistic phenomena
—the first time that this subject has been treated in a Psychological Congress
The principal event was a paper by Dr. Alrutz (Upsala) upon Morselli’s medium
Eusapia Paladius.

The discussion upon “Tropisms” acquired an added interest from the presence
of Prof. Loeb (Berkely), who first applied the term to the phenomena of animal
life. This question has considerable bearing upon psychology, but the conception
has not yet become sufficiently definite for any direct application to be made. The
discussion showed a great discrepancy of view among the leading authorities.

Prof. Thauzi^'s paper upon “The Remote Orientation of Pigeons” contained a
critical review of the various theories which have been held to account for this
remarkable phenomenon. He considers that memory, sight, and increased atten¬
tion are altogether inadequate to explain the facts—they can, moreover, be
excluded by careful experimentation. The hypothesis of a sixth sense is not very
illuminating. Prof. Thauzi^ reaches no definite conclusion, but he is inclined to
think that the phenomenon is most probably due to some kind of electro-magnetic
action.

In the Section on "The Subconscious,” Prof. Dessoir (Berlin) discussed the
general conditions under which an element of consciousness can become disso¬
ciated from the personality. Dr. Morton Prince (Boston), who has published
numerous well-known works dealing with this subject, pointed out that the term
subconscious is employed by different authors in very different senses. He
proposed that the word should be altogether discarded, and suggested “co-
conscious”as a substitute. Co-conscious implies co-activity—that is to say, the
activity of certain elements of consciousness which are independent of the ego-
complex. Dr. Prince considers that dormant ideas, i.e. ideas which are not at the
moment active, have no psychic aspect, and should be regarded merely as physio¬
logical brain dispositions.

Various short interesting papers were read in the Experimental Psychology
Section—and the perennial question of the “ Coenesthesia ” was dealt with by
Mm. Sollier (Paris), Kulpe (Wurzburg), and Leroy (Paris).

The next Congress of Psychology will be held in America in 1913, under the
presidency of Prof. William James.

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THE LIBRARY OF THE MEDICO-PSYCHOLOGICAL ASSOCIATION.

The Library is open daily for reading, and for the purpose of borrowing books.
Books may also be borrowed by post, provided that at the time of application
threepence in stamps is forwarded to defray the cost of postage. Arrangements
have been made with Messrs. Lewis to enable the Association to obtain books
from the lending library belonging to that firm, should any desired book not be in
the Association’s Library.

It is hoped that it will be possible to keep the Library up to date, and the
Library Committee will be glad to receive suggestions concerning new books. A
list of new additions will be published from time to time in the Journal.

Applications for books should be addressed to The Resident Librarian, Medico-
Psychological Association, 11, Chandos Street, W. Other communications should
be addressed to the undersigned at Long Grove, Epsom.

H. Df.vine, "1 Hon. Secretaries,

B. Hart, j Library Committee.

NOTICES BY THE REGISTRAR.

The next examination for the Certificate in Nursing will be held on May 2nd,
1910.

Essays for the bronze medal must reach the Registrar before June 15th, 1910.

The examination for the Certificate in Psychological Medicine and fortheGaskell
Prize will be held the first week in July, 1910.

All information may be obtained from the Registrar, Dr. A. Miller, Hatton
Asylum, near Warwick.

- *

NOTICES OF MEETINGS.

Quarterly Meeting. —The next quarterly meeting will be held, by the courtesy of
Dr. R. C. Stewart, at the County Asylum, Narborough, Leicestershire, on Thursday,
February 24th, 1910.

South-Eastern Division. —The Spring Meeting will be held, by the courtesy of
Dr. Percy J. Baily, at the London County Asylum, Hanwell, on Tuesday, April
26th, 1910.

South-Western Division. —The Spring Meeting will be held, by the courtesy of
Dr. Norman Lavers, at Bailbrook House, Bath, on Friday, April 29th, 1910.

Northern and Midland Division. —The Spring Meeting will be held on Tuesday
April 19th, 1910.

Scottish Division. —The Spring Meeting will be held on Friday, March j8th,
1910.

Irish Division. —The Spring Meeting will be held on Thursday, April 2ist,
1910.

APPOINTMENTS.

Adderley, Miss Annie E., M.B., Ch.B., Assistant Medical Officer at Springfield
Asylum of the Fife and Kinross Lunacy Board.

Boyd, William, M.B.Edin., Assistant Medical Officer to the Derby Borough
Asylum.

Lee, Septimus, M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical Officer to the
Wye House Asylum, Buxton.

Hunter, G. F., M.B.Aberd., Junior Assistant Physician to the Ayr District
Asylum.

McDowall, Colin, M.D.Durh., M.R.C.S., Senior Assistant Medical Officer of
Cheddleton County Asylum, Staffordshire.

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Original from

PRINCETON UNIVERSITY

THE

JOURNAL OF MENTAL SCIENCE

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

No. 233 [To'"'"] APRIL, 1910. VOL. LVI.

Part I.—Original Articles.

Electric Bath Treatment in 108 Cases of Mental
Disorder , controlled by Warm Baths in 16 cases ;
and the Results of an Inquiry into the Influence of
the Baths upon the Excretion of Creatinine in
certain of these. By R. L. Mackenzie Wallis, B.A.
Cantab., Lecturer in Chemical Physiology, University
College, Cardiff, and Edwin Goodall, M.D.Lond., B.S.,
F.R.C.P., Medical Superintendent, Cardiff City Mental
Hospital.

I. —By Edwin Goodall.

As long ago as 1901 my attention was called to the thera¬
peutic value of electricity administered through the medium of
warm water in a bath by my friend Dr. Lewis Jones, Physician
in Charge of the Electrical Department, St. Bartholomew’s
Hospital, London. He considers this is the best means of
employing electricity for general therapeutic purposes, describ¬
ing it in his work on medical electricity as a method of great
value whenever general stimulating and tonic effects are
required. In this work will also be found reference to the
treatment, some years since, of eighteen males and five females
at Claybury Asylum by Dr. Robert Jones, with results which
he considered satisfactory. In these induction coil currents
were used in the bath. The method appeared to me likely to
prove much more convenient and practical than the vv.al
methods of faradism and galvanism, which do not lend thevn-

LVI. 1 3

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190 ELECTRIC BA-TII TREATMENT, [April,

selves to the purposes of general as apart from special and
local application. Largely, I think, for the lack of a con¬
venient method of general application, electrical treatment has
been almost discarded, at any rate in this country, in mental
diseases. I hope in this communication to show that this
therapeutic means is one which should not be neglected.

The form of current employed in this series of cases is that
known as alternating and sinusoidal, in which the electrical
current rises, not abruptly, but at a certain rate of progression,
from zero to the maximum, falls again to zero, and flows in the
opposite direction, the direction being altered several times a
minute. Continuous current, obtained from the main or other¬
wise, is passed through a motor-transformer, rendered alterna¬
ting, and thence through a sliding coil, whereby a low voltage
(from 5-15 volts in the bath) is ensured.

Between 1901 and the summer of 1906, during which period
I gave these baths in the course of my service as Medical
Superintendent at the Joint Counties’ Asylum, Carmarthen, I
used no further modification, but during the past one and a half
years, at the Cardiff City Mental Hospital, I have employed,
in addition, the method of rhythmical variation recommended
by Dr. Lewis Jones, and which he has lately described in the
Lancet, November 13th, 1909.

Dr. Jones is of opinion that the results obtained are improved
in this way. The mechanism I employ was contrived by our
engineer. The current as it comes off the transformer is
passed through a platinum wire, which is caused by means of
a wheel-mechanism to dip slowly into water contained in an
inverted funnel, and then is withdrawn. The current reaches
its maximum when the point of the wire is in the widest
portion of the funnel, where the resistance is lowest, and falls
gradually to a minimum as the point recedes towards the top
of the stem of the funnel, where the resistance is highest. The
cycle is completed about fifteen times a minute. I need not
go here into details of application ; it suffices to say that the
water in the bath is merely kept at a comfortable temperature,
the patient’s feet are in contact with a broad copper plate (the
lower electrode), but his head is separated from the upper
electrode by means of a back-rest of webbing. Each bath lasts
twenty minutes, and for half this period I have been in the
habit of changing the lower electrode to one of a paddle shape,

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PRINCETON UNIVERSITY

JOURNAL OF MENTAL SCIENCE, APRIL, 1910.

Apparatus for supply of sinusoidal current, with rhythmic variation, to bath,
showing transformer on the right, wheel-mechanism, dipping wire, and
inverted funnel in the centre, and sledge-coil on the left, from which current
is taken to the bath.

To illustrate Mr. R. L. Mackexzie-Wai.i.is’s and Dr. Edwin Goodall's paper.

PRINCETON UNIVERSITY

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BY EDWIN GOODALL, M.D.

191

which is passed up and down between the legs, between the
arms and body, and about the body of the patient. After the
bath the patient is kept in bed for at least an hour. Each
course has consisted of eighteen to twenty baths. Patients
are weighed once a week during the course. I have given
these baths in 120 cases, making, I should say, some 2,000 baths
in all. I now communicate observations made upon cases from
the clinical point of view. In conjunction with my friend, Mr.
Mackenzie Wallis, observations have been conducted from the
purely scientific aspect, with a view to ascertaining the effect
of the baths upon metabolism, as shown by the excretion of
creatinine. Details of the cases treated are given at the close
of this article in tabular form under the headings “ Class of
Case,” “ Weight Changes in Connection with Baths,”
“ No. of Baths,” “ Results as regards Mental Recovery or
Improvement.”

Out of the 108 cases here dealt with, 62, or 57^4 per cent .,
recovered, or showed mental improvement (as evidenced by
speech and conduct) in connection with, and, as I believe,
largely in consequence of, the baths. Of these G2 cases, 28
recovered and 30 improved, so that they in many cases became
useful members of the asylum community, and 4 were
discharged relieved.

As regards the kinds of mental disorder; 30 of the 62 which
either recovered or improved showed varying degrees of melan¬
cholia, 9 acute or subacute mania, 5 melancholia with stupor,
5 stupor, whilst such conditions as post-maniacal confusion,
delusional, hallucinatory, confusional states, and alternating
states (mania—melancholia—stupor) claimed the remainder
about equally. The bulk of the patients, therefore, were cases of
melancholia. Of the 46 cases which did not improve 22 had
melancholia, 11 showed degrees of stupor, 4 acute or subacute
mania, 3 melancholia with stupor, 3 delusional insanity; the
remainder were merely individual cases of mania, melancholia
and confusion. Here again melancholia claimed the bulk of
the cases.

In respect to age, all the patients were between the ages of
18 and 40, and mostly under 30.

Of the 62 cases with favourable results, 39, or 63 per cent.,
were reduced generally as regards physical state, and 16 well
nourished ; no statement as to this point is made in 7.

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192 ELECTRIC DATII TREATMENT, [April,

Of the 46 not improved, 20, or 43 per cent., were reduced,
and 21 well nourished ; no record made as regards 5.

In the cases with favourable results, therefore, the physically-
reduced were more than twice as numerous as the well
nourished, whilst in the unfavourable as many were well
nourished on starting the baths as were reduced.

Of the 62 cases which did well, 50 showed again in weight, 9
a loss, and 3 no change in weight. Whilst in 19 the gain was
less than 5 lbs., in 31 it was 5 lbs. or more, and in the bulk of
these a good deal more. Of the 9 cases in which there was a
loss this was less than 5 lbs. in 4 ; and where the loss was 5 lbs.
or more the highest amounts lost were in two cases, 10 lbs. and
8 lbs. respectively. Further, of the 9 cases which lost weight
4 were persons well nourished at the outset. Of these 9 cases
only 1 recovered, the others improving.

The gist of these figures, therefore, is that the great majority
(8o*6 per cent.) of cases which did well (recovered, improved)
under this treatment gained weight, whilst 19*3 per cent, lost
weight or remained stationary. Only 1 case which gave a
recovery (as distinct from improvement) showed loss of weight.

Turning now to the 46 cases which did not improve, 15
showed a gain in weight, 26 a loss, and 5 no change. Whilst
in 7 the gain was less than 5 lbs., in 9 it was 5 lbs. or more, but
the maximum gain was net more than 7 lbs., and this in only
2 cases. The amounts gained were not comparable with
those noted in the cases which did well. Of the 25 cases in
which there was a loss, this was less than 5 lbs. in 13, 5 lbs.
and over—in several a good deal over—in 12.

Then, the number of cases showing no change in weight
numbered 5, or io’8 per cent, of the total, as against 4'8 per cent.
amongst the favourable cases.

The upshot, therefore, is that 6y'4 per cent, of the cases
which did not improve under this treatment lost weight or
remained stationary in weight, whilst 32’6 per cent, gained
weight.

It is to be observed, as Dr. Lewis Jones pointed out, that in
electric bath treatment the patient’s condition will often con¬
tinue to show improvement after the baths have been left off.

I have further remarked in some cases that a second course
of baths, given after an interval of a few weeks, has been attended
with better results than were obtained after the first course.

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HV EDWIN G 00 DALL, M.D.

193

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The observations made upon the excretion of creatinine in
certain of these cases, and which are referred to below, indicate
that the baths are best given in successive short series of about
ten baths each, with intervals of about a fortnight between. I
am now giving the baths in such series.

It is worth noting that in many instances patients on their
discharge have expressed their belief that the electric bath
treatment was a factor in promoting their recovery.

As to duration of residence of those who recovered, the
average was six and one-third months. In a large number of
my earlier cases this period was reckoned from the date of
admission; had it been calculated in all cases, as it properly
was in the later ones, from the date of commencement of the
baths, the period would have been shorter.

Apart from the 108 electric bath cases dealt with above, I
have given in 16 cases simple warm baths at the same tempera¬
ture as the electric baths, under the same conditions and in
the same number. The patients were of the same class in the
two series, and no distinction was of course made as to diet.
And it may here be stated that no special diet was given to the
patients who had these kinds of baths; special diet was served
only to the series of cases to be mentioned later, in which the
creatinine excretion was estimated. Of these 16 control cases
10 gained weight; below 2 lbs. in 4 cases, 2 lbs. in 3 cases and
up to 6, 8 and 9 lbs. in 3 cases. That is, the gain was 5 lbs. or
more in 30 per cent, as against 62 per cent, in the electric bath
cases. Five lost weight up to 2 lbs. in 4 cases, 4 lbs. in 1 case,
and in 1 there was no change. As regards mental improve¬
ment, 2 showed improvement, of whom I later recovered,
and 14 showed no change. So that I2’5 per cent, showed
improvement amongst the controls, as against 57*4 per cent.
showing recovery or improvement amongst the electric bath
cases.

It is obvious that the number of controls had to be limited.

The conclusion I have come to from my experience is that
short courses of electric baths, of the kind described, constitute
a useful means of treatment in cases of the kind above men¬
tioned. They may advantageously be combined with measures
such as Swedish movements and massage, though of course
such combinations of treatment are not dealt with in this

paper.

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Original from

PRINCETON UNIVERSITY

194

ELECTRIC RATH TREATMENT,

[April,

It is well known that a few physicians have brought about
cures by suggestion in the waking state in patients on or about
the borderland of sanity and insanity, and in such electricity
might well act beneficially as a means of suggestion. I am,
and surely all of experience must be, of the belief that the
personal influence—which is really suggestion—of the physician
and the nurse are of very great importance in dealing with
many patients definitely insane, especially, of course, at certain
periods in the malady, when they are more amenable to
suggestion. I should be quite prepared to learn that in such
cases electricity in the shape of faradism, electric bath, high-
frequency or spark-discharges had been the means of com¬
pleting cure, the applications having been accompanied with
appropriate verbal suggestion. In the cases I have reported in
this paper no suggestions were made. I might perhaps mention
two cases, not included in the above series, in which the effects
of auto- and verbal suggestion were observed; one was that of
a youth in a state of stupor (at other times he was maniacal),
who after the third bath suddenly improved, and later recovered.
He spoke of the “pain” produced by the current as having
been the means of bringing him round. The other case was
that of a female, set. 39, who was brought from another asylum
unable to walk or to lift her left arm. She had been lying
paralysed for six years, and was brought to us in an ambulance.
As the result of one electric bath with emphatic use of sugges¬
tion she became somewhat collapsed; she was put to bed in
hot blankets. On recovering, the temperature rose to ioi‘4° F.;
she was flushed and excited, and began running up and down
the dormitory. She was put to work in the laundry, and was
discharged within a few weeks of admission. This result is of
course strictly comparable to what is witnessed at religious
shrines, and in connection with faith-healing agencies.

I had for some time been desirous of ascertaining whether
any evidence could be obtained of the effects of electricity
administered through the medium of a bath upon metabolism,
and shortly after coming to Cardiff my friend, Mr. Mackenzie
Wallis, of the Physiological Department, University College,
Cardiff, now lecturer in physiological chemistry there, suggested
that we should record the changes, if any, produced upon the
excretion of creatinine by electric baths in some cases. As a
control the changes produced by warm baths alone were noted.

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PRINCETON UNIVERSITY

i9io.]

BY EDWIN GOODALL, M.D.

195

We have accordingly for the last nine months made a large
number of observations, a great number of which we have
unfortunately had to discard, because of the failure to collect
the whole of the twenty-four hours’ urine, notwithstanding every
care, in the insane with whom we had to deal, because of the
rapid decomposition which the urine in several cases unaccount¬
ably underwent, and because of the difficulty of getting the
patients to keep to a fixed diet. We have, however, succeeded
in obtaining some reliable records, which it is hoped may here¬
after be added to. In these cases a fixed diet was given. Our
results are here communicated by Mr. Wallis.

Cases zvhick Recovered or Improved under Electric Bath

Treatment.

Class of case.

Weight-changes in connection
with baths.

No. of
baths.

Mental recovery or !
improvement, and in
what time recovered. |

I. Puerperal; post-

Slight losses, then gains,

Recovered in 6 '

maniacal confu¬
sion ; much physi¬
cal reduction.

finally gained 5 lbs.

mos.

2. Puerperal.

Stationary, final gain 1} lbs.

Recovered in 4$
mos.

1 3. Puerperal, post-

Progressive gains, ending in

Recovered in 7I

maniacal confu¬
sion.

gain of 9 lbs.

mos.

4. Acute melan-

Progressive gains, final gain

Recovered in 13

cholia, much phy¬
sical reduction.

of 9 lbs.

mos.

1 5. Acute mania.

Practically stationary till
nearend,when gain of 5 lbs.

•5

Recovered in 11
mos.

6 . Adolescent mania
with exaltation ;
well-nourished.

Gains and losses of a few
lbs., final loss of 5 lbs.

Improved.

7. Delusional; well-
nourished.

Stationary till towards end,
then gain 5 lbs.

Improved.

8. Melancholia; re-

Gain in weight; final gain,

Recovered in 7

duced.

12 lbs.

mos.

9. Primary demen-

Slight gains ; ultimate gains

Recovered in 9

tia; reduced.

of 3 lbs.

mos.

j 10. Melancholia ;
well-nourished.

Loss of 3 lbs.

Slight improve¬
ment.

ii. Mania at pu-

First series : first losses,

Some improve-

berty ; reduced.

finally gain of 4 lbs.

ment.

Second series : progressive
gains to final of 9J lbs.

Much improved,
discharged re¬

lieved in 5J mos.

12. Melancholia ;
some dementia;
reduced.

Losses ; finally lost 8 lbs.

Improvement, re¬
covered several
months after.

1 13. Melancholia ;

Constant gains; final gain,

Recovered rr 7

very reduced.

1 st. 1$ lbs.

mos.

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PRINCETON UNIVERSITY

jq6

ELECTRIC BATII TREATMENT,

[April,

Class of case.

Weight-changes in connection
with baths.

No. of
baths.

Mental recovery or
improvement, and in
what time recovered.

14. Stupor ; re-

Lost to 13 lbs., picked up,

Improvement, more

duced.

finally loss of 4 lbs.

marked 24 mos.
after cessation of
baths.

! 15. Melancholia ;

Slight losses, final loss of

Great improve-

fairly nourished.

3 lbs.(in very fine condition)

ment.

16. Melancholia ;
poorly nourished.

No change in weight.

Discharged im¬

proved in 8 mos.
after baths began.

17. Acute melan-

Progressive gains, finally of

Recovered 3 mos.

cholia; reduced.

9 lbs.

after baths began.

18. Acute melan-

After gaining a stone, ended

Improved, working

cholia; well-nour-

with gain of only 3 lbs.

in ward.

ished.

19. Melancholia

Lost, gained slightly, final

Recovered in 5

with stupor; thin,

loss (uncertain amount)

mos.

anaemic.

20. Acute melan¬
cholia ; fairly well

Gained 3 lbs.

Recovered in 5
mos.

nourished.

21. Fairly acute

Gained to 3 lbs., final gain

Recovered in 6

melancholia.

i4 lbs.

mos.

22. Melancholia

1st course : lost 54 lbs.

Some improvement.

(subacute) ; re-

2nd course: progressive

Much physical im-

duced.

gains, final 8 lbs.

provement.

23. Delusional ;

Gradual gains, to final of

Recovered in 4

fairly well nour-

64 lbs.

mos.

ished.

24. Mania ; re¬
duced ; anaemic.

Gains ; final gain, 74 lbs.

Recovered 4 mos.
from admission, 3 :
mos. after baths
started.

25. Acute melan-

Gains to 54 lbs.; final gain,

Improvement; 1

cholia; reduced

24 lbs.

working.

physically.

26. Melancholia ;

Gained 9 lbs.,sunk, final gain

Recovered in 4

thin and poor

14 lbs.

mos.

physique.

27. Mania; reduced.

Gained 6 lbs.

l 6

Discharged, re¬

lieved, in 9 mos.

28. Melancholia
with stupor; re-

First course: progressive
losses to final of 6 lbs.

No change.

duced.

Second course (2 yrs. later):
gains to final of 4J lbs.

Improved, helps in
work.

29. Mania: good

Progressive gains ; final of

Recovered in 11 1

condition.

5 lbs.

mos.

30. Melancholia ;

Progressive gain ; final of

Improved, removed

good condition.

4 lbs.

by friends.

31. Mania—stupor
(juvenile demen-

Gain, loss, final gain, 4 lbs.

Some improve- 1

ment.

tia) ; reduced.

32. Melancholia ;

Gain of 24 lb., finally of

Some improve- j

! reduced.

1 lbs.

ment.

33. Stupor—melan-

Gain to first 2i lbs., finally,

Recovered in 64

cholia ; reduced.

* '

134 lbs.

mos.

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HY EDWIN GOODALL, M.D.

197

Class of case.

Weight-changes in connection
with baths.

No. of
baths.

Mental recovery or
improvement, and in
what time recovered.

| I

34. Melancholia

1st course : lost 7 lbs.

•5

No improvement.

with stupor; re-

2nd course : lost 5 lbs.

Some improvement.

duced.

Left, recovered, 7
mos. after last
bath.

■ 35. Melancholia ;
good physical

Progressive gains to final of

Reported brighter

12 lbs.

and working as

state.

result of baths; re¬
covered in 9 mos.

36. Stupor ; fair

Gained 2 lbs.

Recovered in 6

condition.

mos.

37. Melancholia ;

Progressive gains to final of

Recovered in 3

reduced.

6* lbs.

mos.

38. Melancholia ;

First course: loss of 2j lbs.

•7

Improvement under

^ good condition.

baths, later relapse
after cessation.

’

Second course : gain of 2J

Recovered in 10

lbs.

mos.

39. Mania—melan-

Progressive gain to final of

30 in 2

Recovered in 9$ |

cholia ; reduced.

2i lbs.

courses,

mos.

14 days'
interval.

40. Mania—stupor;

Slight losses, increased

Recovered in 6

reduced.

finally by y\ lbs.

mos.

41. Acute melan-

Progressive gains to final of

Improved, became

cholia; well nour-

6i lbs.

tidy, and began to 1

ished.

work, but some j
mental enfeeble- I
ment remained

42. Melancholia,
some congenital

Progressive gains, final of

•5

Improvement, got

3 lbs.

to work, more \
orderly.

basis ; reduced
physically.

43. Melancholia,

Gained -J lb. (* no change).

Improved.

with some de¬
mentia.

44. Confus ional

Progressive gains to final of

First

Improved, brighter,

state ; reduced

5 lbs.

course

more rational and

physically.

20,

second

amenable, does
some work.

course

18, 1 mo.
between.

45. Stupor—melan-

First course : progressive

Improved, started

cholia.

I gains to final of 3^ lbs.

work, discharged

Second course: at close

i >3

relieved in 11

gained iii lbs. on original
weight.

mos.

46. Melancholia ;

Progressive gains to final of

Slight improve-

much reduced.

5 'bs.

ment.

47. Melancholia

1 First, loss, ti lbs., finally

1 14

1 Considerable im-

with stupor; re-

gained $k lbs.

provement,

duced physically.

brighter, started
working. Later
relapsed, and died

1 (2yrs.) of phthisis.

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198 ELECTRIC BATH TREATMENT, [April,

Class of case.

Weight-changes in connection
with baths.

No. of
baths.

Mental recovery or
improvement, and in
what time recovered.

48. Melancholia ;
reduced.

Losses to final of 10 lbs.

Some improve¬

ment, went out
working.

49. Melancholia ;

Gained 4 lbs.

Recovered.

reduced.

50. Melancholia ;

Gained 8i lbs.

Recovered.

fairly well nour¬
ished.

51. Melancholia ;

Gained 6 \ lbs.

Improved.

reduced.

52. Hallucinatory
insanity (insane

Lost 3 lbs.

1 mproved, work¬
ing, sane conduct.

conduct) ; well

nourished (too

stout).

53. Delusional ; re¬
duced.

Gains to final of 10 lbs.

Recovered in 3}
mos.

54. Some demen¬
tia; mild delu¬
sions ; reduced.

Gains to final of lbs.

Improved ; em¬
ployed.

55. Melancholia ;

Early losses, final gain of

Recovered in 2i

reduced.

10 lbs.

mos.

56. Hypochondri¬
acal melancholia ;

Progressive gains to final of
4i lbs.

Improvement.

reduced.

57. Melancholia ;

Progressive gains to final of

Recovered in 3

reduced.

10I lbs.

mos.

58. Subacute mania;
fairly nourished.

Progressive gains to final of
4 lbs.

Improved.

59. Acute halluci¬
nations and delu¬

Gained 6J lbs.

«4

Recovered in 3$
mos.

sions; reduced.

60. Acute melan¬

Gained 2 lbs.

Improved.

cholia ; reduced.

61. Acute confu-

Gained 5 lbs.

Improved.

sional state; re¬

duced.

62. Stupor ; re¬
duced.

No change.

Improved.

1 1

Cases not Improved under

Electric Bath Treatment.

Class of case.

Weight-changes in connection
with baths.

No. of .
baths.

(n) Acute mania apparently passing into
dementia: condition fair.

Progressive gains to final of

Si lbs.

I I ,

(£) Delusional insanity of slow growth ;
nutrition fair.

Limited gains and losses;
final loss of 3 lbs.

14 1

(c)-Stupor; reduced.

Slight losses and gains ;

| ended same weight.

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KV EDWIN GOOD ALL, M.D.

199

Class of case.

Weight-changes in connection
with baths.

No. of
baths. !

(rf) Delusional; well-nourished.

Variations ; ultimate loss of

2 lbs.

(e) Stupor; reduced.

Variations; final loss of 3 lbs.

8 1

(/) Melancholia; well-nourished.

Losses ; final loss 3 lbs.

9 1

(g) Melancholia, with persecutory ideas:

Gains, but finally only 1 lbs.

well-nourished.

No change.

1 (h) Stupor; marked heredity.

Lost 12 lbs., and finally

8 i

“ considerable loss.”

(i) Melancholia with stupor; reduced.

Losses, final loss 12 lbs.

26 1

(j) Melancholia ; well-nourished.

Progressive gains; final of

14 1

7 lbs.

(i) Recent dementia : well-nourished.

Gained <; lbs.

(/) Confusional state on congenital

Losses, ending with final

defect.

loss of 2 lbs.

(tii) Subacute mania ; well-nourished.

Final gain of 2 lbs.

I («) Acute melancholia ; poorlv nour-

No change.

>5 1

ished.

(0) Acute melancholia; thin, evanosed.

Gained 8 lbs., then lost, final

loss of 1 lbs.

(p) Acute melancholia ; thin.

Gradual losses; final loss
of 5 lbs.

(9) Acute melancholia; thin, evanosed.

Losses, to final loss of 9 lbs.

(r) Acute melancholia; spare, anaemic.

Gained 9 lbs.; final gain, 5
lbs.

(s) Not stated.

No change.

I (f) Stupor; well-nourished.

Losses, to final loss of 6 lbs.

1 ( u ) Melancholia ; physically not stated.

Final loss of 2 lbs.

•4

(r) Delusional; well-nourished.

Gains, final of 7 lbs.

(to) Melancholia ; fair condition.

1st course: gained 8( lbs.

•4

2nd course : gained 4T lbs.

(x) Acute mania ; good condition.

Losses, final loss of 2 lbs.

• (y) Melancholia; good condition.

Losses, final loss of 1j lbs.

(a) Stupor; good condition.

Losses ; final loss of 6J lbs.
Losses, final 6 lbs.

I I

(a 1) Melancholia; physically not stated.

»4

(b 1) Melancholia ; reduced.

Lost 1 $ lbs

1 (c 1) Melancholia; reduced.

Losses, slight rise, final loss

7 lbs.

15 !

(d 1) Melancholia; reduced.

Losses, slight rise, final loss

7 lbs.

(e 1) Melancholia; spare, sallow.

Gains, to final gain of 6 lbs.

If 1) Melancholia; good condition.

Losses, final loss 2 lbs.

•3

(g-i) Melancholia; reduced.

Slight gain, final loss of 5
lbs.

fA 1) Subacute mania on imbecility;

Lost 3 lbs.

good condition.

(i 1) Melancholia; reduced.

Gained 3$ lbs., final weight
same.

| (j 1) Melancholia; reduced.

Gained 4 lbs., progressively.

(t 1) Mania-melancholia; somewhat

Progressive gains, final 5

reduced.

lbs.

(/ 1) Melancholia; reduced.

Gained 5 lbs., finally lost
9 lbs.

(ml) Stupor-melancholia; fairly good

Gained 6 lbs.

condition.

(hi) Stupor-melancholia; much reduced.

Gained 2 lbs.

1 (0 il Juvenile dementia; much reduced.

Progressive losses, to final

of 1st. 7 lbs.

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200

ELECTRIC BATH TREATMENT

Digitized by

[April,

Class of case.

Weight-changes in connection
with baths.

No. of
baths.

' (^i) Juvenile dementia; good con-

Gained to 4 lbs., final gain 2

j dition.

lbs.

|(yi) Juvenile dementia; fairly good

Gained to final gain of 2 lbs.

condition.

(r i) Some dementia, with delusions (an

Losses to final of 5 lbs.

adolescent), reduced.

(si) Mild melancholia; well-nourished.

Progressive losses to final
of 6 lbs.

(/l) Melancholia; fairly well-nourished.

Gained 3 lbs.

II.—By R. L. Mackenzie Wallis.

Introduction.

The great progress in recent years of electro- and hydro¬
therapeutics is well known, and so far the value of this
treatment has rested mainly on clinical evidence. It is of
interest, therefore, if some confirmatory observations are forth¬
coming from the study of metabolism, since they may add a
further argument in favour of the two forms of treatment.
The study of metabolism in the insane is, however, encompassed
by many difficulties, especially the variations that occur, and
the difficulty of establishing any definite laws for one form of
insanity. The lack of exact data may possibly account for
this. Our present knowledge of metabolism in the insane is
due to Folin and his co-workers in America, and Hoogenhuyze
and Verplocgh, and also Kauffmann, in Europe. Having in
view the valuable contributions of these workers, it seemed
advisable to select one product of metabolism which not only
showed the least variation, but at the same time would
demonstrate any marked changes which were taking place.
The substance which most closely approximated to these
conditions was creatinine, and in consequence it was selected
for the present investigation. Owing to the discovery by Folin
of a very rapid, and at the same time, accurate method of
estimating creatinine, its significance has received unusual
attention during the past few years. The results of a pre¬
liminary investigation of the effects of the two forms of bath-
treatment are given below, and seem to sustain the claims made

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Original from

PRINCETON UNIVERSITY

BY R. L. MACKENZIE WALLIS, B.A.

201

1910.]

by other observers for this body, and justify its use in the
present research.

Historical.

Previous to the work of Folin (2) on this subject, and the
introduction of his method of estimation, creatinine was esti¬
mated by the Neubauer-Salkowski method (1). This method
consisted in forming a zinc chloride compound and estimating
the creatinine as such.

Van Hoogenhuyze and Verploegh (8) subjected this method
to a critical investigation, and strongly advocated the colori¬
metric method of Folin (2). Subsequent workers on this
subject have all recommended the latter method, and employed
it in their investigations.

The absence of a really reliable method for estimating
creatinine possibly accounts for the discordant results of the
earlier workers.

Folin (5) came to the following conclusions : (a) The amount
of creatinine in the urine is independent of the amount of
protein in the food, or the total nitrogen in the urine, (b)
The amount of creatinine excreted is a constant quantity for
each individual, (c) Creatin is not present in normal urine,
and occurs only in minimal quantities after injection of this
substance. As a result of these observations Folin (6) devised
a new theory of metabolism, and assumed that the creatinine
in the urine is a product of endogenous metabolism.

The conclusions of Folin were later confirmed by Hoogen¬
huyze and Verploegh (8), Klercker (10), Closson (9), and
Shaffer (25) ; the latter, however, was not inclined to entirely
accept the view as to the endogenous origin of creatinine.

Since creatinine in the urine is supposed to be directly con¬
nected with creatin in the muscles, it was thought that muscular
activity might influence the excretion of this substance. Folin
admitted this possibility, but Hoogenhuyze and Verploegh
have clearly demonstrated that muscular work has no influence
on the excretion of creatinine, provided the diet is sufficient.

If, however, the diet is insufficient, as, for example, in starva¬
tion, then the output of creatinine is increased, the material
for contraction in this case being drawn directly from the
muscle proteins. Shaffer (25) has obtained similar results.

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ELECTRIC BATH TREATMENT,

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202

[April,

Creatinine is therefore not produced as a result of energy
changes within the muscle.

With regard to the factors which regulate the excretion of
this body in normal individuals, Folin stated that the chief
factor was the body-weight. This relationship has also been
specially emphasised by Closson, Shaffer, and Benedict and
Myers (n).

The ratio of creatinine excreted to the body-weight has been
termed the “ creatinine co-efficient,” and is adopted in the
following observations. The physical condition has also to be
taken into account when investigating creatinine metabolism,
since corpulent persons yield less creatinine than lean ones.
On this observation is based the view that the creatinine excre¬
tion is proportional to the active mass of protoplasmic tissue.

Benedict and Myers (n), working on the creatinine excretion
in women, showed that it was much lower than in men. The
large amount of subcutaneous fat in women may possibly
account for the low values obtained, as sex by itself has probably
no influence.

Age appears to play a part in the output of this body, since
elderly people excrete less creatinine than young people of the
same body-weight.

The remarkable uniformity in the elimination of creatinine
and its constancy from day to day enables us to obtain values
for the normal individual. The “ creatinine co-efficient,” or in
other words, the ratio of creatinine excreted per kilo, of body-
weight, varies from 20 mgrm. per kilo, in corpulent men to 25
mgrm. in lean men. The normal limits seem to lie between 18
and 30 mgrm. per kilo, of body-weight (Folin).

The existence of other factors in regulating the creatinine
output in man has been demonstrated by work on pathological
subjects. The work may be summarised under three headings:

(1) Cases in which cellular activity of high intensity has been
involved, such, for example, as maniacal conditions, fever,
acromegaly, and exopthalmic goitre.

(2) Cases in which cellular activity is depressed, as in
paralysis, fasting, and leukaemia.

(3) Cases presenting deficiencies in the functions of individual
organs, especially the liver and kidney.

Considering the conditions presented in Group (1), a rise in
creatinine excretion has been demonstrated by Hoogenhuyze

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Original from

PRINCETON UNIVERSITY

i9io.]

BY R. L. MACKENZIE WALLIS, B.A.

203

and Verploegh (12) under maniacal conditions and also under
alcohol. Benedict and Myers (11), on the other hand, found no
influence in mania. The effects of fever on the excretion of
creatinine was studied by Leathes (17), who showed that the
creatinine output was increased. With the disappearance of
the fever the creatinine falls below normal. Similar observa¬
tions have been made by Hoogenhuyze and Verploegh, and
also Shaffer. Shaffer and also Froschbach (22) noted a low
output in exophthalmic goitre, where the tissue katabolism
may be much increased.

With regard to the conditions enumerated in the second
group, a diminished output has been observed during fasting
by Hoogenhuyze and Verploegh (8), Benedict (14), and
Benedict and Diefendorf (15), in lymphatic leukaemia by
Shaffer, and in muscular dystrophy by Spriggs (16) (half
normal), and after administration of potassium bromide,
Hoogenhuyze and Verploegh. Muscular rest, on the other
hand, according to Shaffer, produces no change in creatinine
excretion.

The influence of individual organs has been demonstrated by
Mellanby (23) in the case of the liver, where a low excretion of
creatinine characterises disease of that organ. Hoogenhuyze
and Verploegh (12) find, besides a low output, a normal, and
sometimes a high creatinine content as a result of hepatic
disease. Several observers, notably Underhill and Kleiner
(19), Richards and Wallace (20), Leffmann (21), and Lusk (18),
have induced disease in the liver, and find a gradual fall in the
amount of creatinine eliminated.

The elimination of creatinine in the insane has been investi¬
gated by Folin, in collaboration with Shaffer and Hill (3), by
Benedict and Myers (11), and by Hoogenhuyze and Verploegh
(12). These observers find that in accordance with other
pathological conditions the output of creatinine is generally
below normal. Folin concludes from his metabolism studies
on over twenty cases “ that mental disorders do not neces¬
sarily involve great changes in metabolism sufficient to modify
the creatinine output.” The creatinine excretion also bears no
definite relation to the form of insanity.

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204

ELECTRIC BATH TREATMENT,

[April,

Method of Estimation.

Throughout this investigation the colorimetric method
devised by Folin in 1904 has been used. The method is based
on the colour reaction given by creatinine with picric acid in
an alkaline solution. The coloration so produced is compared
with a half normal solution of potassium bichromate in a
Duboscq colorimeter. In general, 15 c.c. of a saturated
solution of picric acid and 5 c.c. of a 10 per cent, solution of
caustic soda were added to 10 c.c. of urine in a 500 c.c. volu¬
metric flask. The volume of urine used had frequently to be
varied to ensure more accurate readings. This mixture was
allowed to stand for at least five minutes, all due precautions
being taken to maintain a constant temperature throughout.
The contents of the flask were then diluted up to the 500 c.c.
mark, and several readings taken immediately. Generally
three persons made separate observations, and the results were
compared. At the beginning of this research a number of
estimations of creatin were made by Folin’s method. The
results obtained were in all cases extremely low, and in many
cases negative. Consequently it did not seem advantageous
to continue the estimation of this substance. The samples of
urine were periodically tested for sugar and albumen. The
reaction, volume, specific gravity, and general appearance, i.e.,
whether clear or turbid, were carefully recorded daily, and these
data are included in the tables below. The deposit on several
occasions was microscopically examined, and revealed numerous
crystals of calcium phosphate and oxalate. Chloroform was
used as a preservative, and soon found to be unsatisfactory, the
creatinine disappearing very rapidly. The great proneness to
decomposition is a very marked feature of the urine of the
insane, and it appears to be due to bacterial contamination.
This contamination I am inclined to think takes place in the
patient’s own body, since the urine as voided was covered with
a cloth and brought to the laboratory to be collected in large,
clean, Winchester quart-bottles. The reaction of the urine did
not seem to affect the estimation of creatinine. Owing to this
ready decomposition, and with it a disappearance of the
creatinine, it was thought advisable to estimate the creatinine
as early as possible after the twenty-four hours’ sample had
been collected. In this way fairly concordant results were

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PRINCETON UNIVERSITY

BY R. L. MACKENZIE WALLIS, B.A.

205

1910.]

obtained. After the estimation the samples were made faintly
acid with acetic acid, and placed in a steam steriliser. They
were then sent by road to the Physiological Laboratory,
Cardiff (about four miles away) for a confirmatory reading.
In many cases I was unable to strike a colour with the picric
acid and alkali, and the colour when present gave a tint
corresponding to just half the amount of creatinine recorded
a few hours before.

For example:

Non-steriliscd sample. Sterilised sample.

1 . 20c.c. urine = 6 mm. . 20c.c.= 15*3 mm.

2 . 10 „ =8'6mm. . 10 ,, = 13-0 mm.

3 . 20 ,, =5-9 mm. . 20 „ = ip5 mm.

It was noted at the same time that on adding the alkali a
mass of yellowish needle-like crystals were deposited, which
only slowly dissolved in water. Now these sterilised samples
have in many cases kept quite fresh for months after collection.
An explanation is therefore required to account for this change,
and at present only a provisional one can be given.

One patient whose urine was examined for creatinine did not
show any creatinine at all, even with a volume of 25 c.c. The
marked feature of this urine was the enormous deposit of
phosphates which settled out daily.

Now the samples which gave the above results after sterilisa¬
tion were all characterised by the same excess of earthy
phosphates. It was consequently thought possible that the
phosphates prevented the alkali or the picric acid from reacting
with the creatinine, and to avoid this larger quantities of these
substances were taken, but without effect. The phosphates
present, if they act at all, must therefore exert their influence
on creatinine itself. As to the nature of this influence, I am
not at present able to state, but the subject is under investiga¬
tion. Possibly the yellowish needles may represent a creatinine
phosphate combination, since after removal of the phosphates
this precipitate does not occur.

4. Dietary and Treatment.

At the commencement of the experiments a creatin-free
diet was adopted, and the patients kept in bed. In view of
these somewhat unsatisfactory conditions, and taking into

Original from

PRINCETON UNIVERSITY

206

ELECTRIC BATH TREATMENT,

[April,

account the previous work upon the subject, it did not seem
necessary to continue this treatment This decision was
further favoured by the results of a metabolism experiment
carried out by the writer upon himself. The results were as
follows:

M. W—, weight 62*5 kilos. Diet: Creatin-free, consisting of
eggs, milk, cheese, bread, butter, and water.

Commenced on Sunday evening,

Monday-Tuesday .

vol.

1030 c

:.c.

. Creatinine

1-30 grm.

Tuesday-Wednesday

1100

• yy

i‘ 3 i „

Wed nesday-Thursday

1050

• yy

i '35 »

Thursday-Friday

1140

• yy

1*36 „

Friday-Saturday

1040

• yy

1*36 »

Exercise was taken 1

each

day,

and

a long walk

of about

twenty miles on the Wednesday afternoon. The creatinine
excretion on an ordinary diet gave an average value of 1^40 grm.
The creatinine co-efficient during the experimental diet period
was about 227 mgrm.

From the above observations it will be seen that the diet
has very little if any influence on the excretion of creatinine,
and similarly the effects of muscular exercise.

The results with the patients are, fortunately, similarly
unaffected by the change of diet. The diet was the usual
hospital diet, but in some cases extra diet was given, such as
eggs, milk, and cheese. Complete records have been kept of
the exact amount of food given and the amounts taken at each
meal.

The treatment adopted was of two forms : electric baths and
warm baths at ioo° F.

The temperature of all the patients under observation was
quite normal and practically unaffected by the treatment.

The patients receiving electric baths improved both mentally
and physically, whilst those having warm baths did not show
the same improvement.

These observations have been fully described by Dr. Goodall,
and it now remains to demonstrate the effects, if any, on the
elimination of creatinin.

Table I.

Electric baths. —A. Le G—, female, set. 28. Melancholia with

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Original from

PRINCETON UNIVERSITY

BY R. L. MACKENZIE WALLIS, B.A.

1910.]

207

stupor. Weight on commencing baths, 50-5 kg.; weight on
finishing baths, 50-2 kg. Height, 1-62 metres.

Diet. — Breakfast: Bread, 170-04 grm.; margarine, 14-17 grm.,-
coffee, o*5b8 lit. Dinner: Bread, 56-68 grm.; meat, 170-04 grm ;
peas, 141-70 grm., or potatoes, 453*44 grm. Tea : Bread,
170-04 grm.; margarine, 14-12 grm.; tea, 0-568, lit.

Twenty-four hours' sample.

1909.

Vol.

Sp.gr.

Creati-

nine.

Creatinine
per kilo.

Water.

Remark!.

May

2020

1015

>143

1480

1540

IOIO

1010

0768

1084

14 mgrm.

Preliminary observa-j
tions, creatin-free

1290

IO15

0842

—

diet.

1150

IO15

0802

—

«s

IO7O

1020

0 70Q

—

11 IO

1025

J -354

—

0-852 lit.

Electric bath.

„

855

1015

••330

—

1420 „

1220

1015

1 039

23 mgrm.

1-420 „

1300

1015

°' 9'5

—

1-420 „

1227

1012

—

1420 „

112s

1015

1*40

—

1-420 „

Last bath.

950

1020

0884

—

1-420 „

—

930

1020

0 865

17 mgrm.

1420 „

—

114O

1015

0847

1420 „

A. le G—. Melancholia with stupor. The effects of the
electric bath treatment on this patient are well shown in the
table. The maximum figure recorded was on May 24th and
the minimum on May 15th. The co-efficient in this case is
practically normal.

Table II.

Electric baths. —M. A. T—, female, aet. 37. Acute melancholia.
Weight on commencing baths, 54-6 kg.; weight on finishing
baths, 55-5 kg. Height 1-67 metres.

Diet.—Breakfast: Bread, margarine, coffee. Dinner : Meat,
fish (alternate weeks), bacon, vegetables. Tea: Bread, mar¬
garine. Daily extras : Milk, eggs, milk puddings.

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208

ELECTRIC BATH TREATMENT

[April,

Twenty-four hours,' sample.

1909.

Vol.

Sp. gr.

Reaction.

Appear¬

ance.

Creati¬

nine.

Creatinine
per kilo.

Remarks.

Nov.

1040

1020

Acid

0-645

960

1020

—

o‘537

11"7 mgrm.

—

1140

1020

—

0752

—

Bath.

IIOO

1020

0-855

14 merm.

820

1020

0 697 ?

—

>345

1020

—

0897

—

820

1020

—

0-885

15-6 mgrm.

I IOO

1020

—

0862

—

Dec.

1410

1015

—

0662

—

1320

1020

—

0712

117 mgrm.

I IOO

1020

—

0550

—

1185

1015

Neutral

—

0-379 l

I2'8 mgrm.

Last bath.

1230

IOI7

Acid

Turbid

11 «4 /

—

1400

1016

Very

turbid

0644

—

1550

1015

Turbid

o-66

—

1120

1015

Alkaline

0425

—

M. A. T—. Compare Table II«.

Table Ila.

Twenty-four hours' sample.

1909.

Vol.

Sp. gr.

Reaction.

Appear¬

ance.

Creati¬

nine.

Creatinine
per kilo.

Remarks.

Dec. 28

1330

1015

Neutral

0611

750

•025

Acid

0612

h i mgrm.

—

800

1025

0712

—

Electric bath.

„ 3 >
1910

Mis

sed

—

Jan.

1500

1015

Acid

—

0675

—

2040

IOO9

—

0693

in mgrm.

1720

IOIO

—

0722

—

860

1015

—

0498

—

1440

1008

0432

12 3 mgrm.

2020

IOIO

o -747

—

*»

2710

1006

—

0-813

—

Last bath.

1900

• 015

—

0874

—

2080

IOIO

—

0728

I2'4 mgrm.

—

1570

IOIO

—

0785

—

1710

IOIO

—

0615

—

1840

1012

—

0754

—

1720

1015

—

0752

—

Electric bath.

2470

IOIO

—

0889

iy 1 mgrm.

•530

1015

—

0765

—

•744

IOIO

—

0643

—

1270

1015

—

0726

—

Last bath.

1700

IOIO

—

0629

—

2170

•015

—

0868

I2"6 mgrm.

—

2150

IOIO

—

0718

—

1370

1015

—

0609

—

Mis

sed

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Original from

PRINCETON UNIVERSITY

i9io.]

BY R. L. MACKENZIE WALLIS, B.A.

209

Electric baths .—Second series. M. A. T—, female, ait. 37.
Acute melancholia. Weight on commencing baths, 58 kg.;
weight on ceasing baths, 58" 1 kg. Height r67 metres.

Diet .—Same as before. Daily extras: Milk, eggs, milk
puddings.

M. A. T—. Acute melancholia with suicidal tendencies. In
addition to the ordinary diet the patient received two pints of
milk, one egg, and milk puddings daily.

The effects of a series of electric baths of short duration are
well illustrated in this table. It will be noted that there is a
gradual increase in the creatinine excretion, which appears to
continue after the baths have ceased. The volume of urine was
considerable, and on most days 20 c.cin. had to be taken to
ensure a reading with the colorimeter.

Table III.

Electric baths .—October 17th to November 1st, 1909. R. R—
female, set. 27. Acute hallucinations, delusions, secondary

Twenty-four hours' sample.

| x 9 ° 9 *

Vol.

Sp. gr.

Reaction.

i Appear-
ance.

Creati¬

nine.

Creatinine
per kilo.

Remarks.

Oct.

880

lOlJ

Acid

0519

»»

1830

IOIO

—

0704

131 mgrm.

—

650

IOIO

Neutral

—

0475

—

Electric bath.

1120

1015

Acid

—

0705

—

9 »

1218

1013

>»

—

0666

I5‘S mgrm.

—

••

1320

IOIO

0673

—

1 „

IOOO

1015

»»

0575

—

1 ..

1340

IOIO

Alkaline

0616

—

1240

IOIO

0'539

13 4 mgrm.

—

j y |

1710

1015

0910

—

#»

Mis sed

—

»>

1270

1015

Neutral

0750

—

760

1015

»»

0-647

17'I mgrm.

1440

1017

Acid

0806

—

„

610

1015

—

0'202

—

3 i

1515

1015

0'42I

—

* -

Nov. 1

620

1015

Neutral

°'339

—

Last bath.

»»

1650

10151

Acid

—

0841

—

»»

840

1025

Neutral

0-823

16 6 mgrm.

—

»»

620

1025

Acid

—

0626

—

790

1025

Neutral

0633

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PRINCETON UNIVERSITY

2 10 ELECTRIC BATH TREATMENT, [April,

depression. Weight on commencing baths, 42*9 kg.; weight
on ceasing, 45*9 kg. Height 1*54 metres.

Diet. —Ordinary female diet.

The amount of the various constituents of the diet as in
Table I.

R. R—. Took food well, and increased in weight as a result
of treatment, viz., 3 kg. This increase in weight is mainly due
to a deposition of subcutaneous fat, as may be judged from the
height of the patient and general appearance. The electric
baths were suspended on the 18th and 19th. The maximum
figure occurred during the baths, viz., 0*910 grammes, and also
the lowest figure, 0*202 grammes. This latter value is possibly
due to an error in collection of the twenty-four hours’ sample.

Table IV.

Electric baths. —D. H—, female, ast. 25. Melancholia with
stupor. Weight 49 kg. Weight on commencing baths, 48*4
kg.; weight on finishing baths, 49*3 kg. Height i - 67 metres.

Diet. — Breakfast: Bread, 170*04 grm.; margarine, I4'i7
grm.; coffee, 0*508 lit. Dinner ; Bread, 56*68 grm.; meat and
bacon, 170*04 grm.; vegetables, peas, 141*70 grm., or potatoes,
453*44grm.; water, 0*568 lit. Tea: Bread, 170*04 grm.; mar¬
garine, 14*17 grm.; tea, 0*568 lit.

Twenty-four hours' sample.

1909.

Vol.

Sp. gr.

Total

creatinine.

Creatinine
per kilo.

Water

consumed.

Remarks.

May 18

0*852 lit.

890

1015

0667

—

1704 ..

—

1180

1015

0 884

—

1700

1015

I 105

16 mgrm.

1-704 lit.

—

750

1015

0*532

—

1*420 „

1140

1018

C941

—

1*420 „

t *

IIOO

1020

0-679

—

1-420 „

Bath.

»}

1270

1015

0-842

—

1704 ..

>»

I IOO

1025

0*947

16 mgrm.

I *420 „

840

1025

0756

—

1*420 „

1980

1015

0*950

—

1*420 „

1700

1015

0688

—

1-420 „

1410

1016

0*465

—

1-420 „

Last bath.

1400

1018

—

1-420 „

—

June

1140

1020

0-684

14 mgrm.

1-420 „

—

»»

1720

1015

0610

—

1704 >.

—

1120

1020

0772

“““

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Original from

PRINCETON UNIVERSITY

>9io.]

UY R. L. MACKENZIE WALLIS, B.A.

2 I I

D. H—. Melancholia with stupor. The patient took her
food well, but did not show the same changes in creatinine
output as A. Le G. (Table I). The daily excretion of creatinine
during the electric bath period was only very slightly
increased.

Table V.

Electric baths. —C. G. H—, male, aet. 29. Acute melancholia.
Weight, 50*2 kg.; weight on commencing baths, 493 kg.;
weight on finishing baths, 493 kg. Height, 1*67 metres.

Diet. — Breakfast: Bread, 22672 grm.; margarine, 14*17 grm.;
coffee, 0*568 lit. Dinner: Bread, 56*68 grm.; meat, 198*38 grm.;
peas, 141*70 grm., or potatoes, 453*44 grm.; water, 0*568 lit.
Tea : Bread, 226*72 grm.; margarine, 24*17 grm.; tea, 0*568 lit.

Twenty-four hours' sample.

1909.

Vol.

Sp. gr.

Creati¬

nine.

Creatinine
per kilo.

Water.

Remarks.

May 10

720

IO25

0806

„ 11

„ 12

1070

550

1015

1030

0-832

0839

17 mgrm.

—

Preliminary ob¬
servations on a

.. 13

750

1030

0*945

—

creatin-free diet.

„ 14

1470

IOIS

0654

—

.. 15

950

1020

0665

—

.. 19

750

1020

0*945

—

1136 lit.

Electric bath.

» 20

900

1020

0*758

21 mgrm.

1*136 ..

»»

.. 21

820

1025

1*418

—

1136 „

.. 22

1180

1020

1123

—

1*420 „

980

1021

0770

—

1*704 ..

>»

„ 24

1170

1020

o *939

—

1278 „

Last bath.

.. 25

940

1025

—

1*420 „

—

„ 26

840

1025

0829

0*994 ..

—

». 27

1620

1015

0830

18 mgrm.

1*278 „

—

„ 28

1220

1020

0*978

I*I 3 6 ..

C. G. H—. This patient took his food very well, and showed
mental improvement as a result of the treatment. The increased
excretion of creatinine on May 21st and 22nd is very striking.

Table VI.

Electric baths. —J. O’B—, male, a;t. 24. Weight, 60*3 kg.;

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Original from

PRINCETON UNIVERSITY

ELECTRIC BATH TREATMENT,

2 I 2

[April,

weight on commencing baths, 58 kg.; weight on finishing
baths, 58‘2 kg. Height, r67 metres.

Diet. — Breakfast: Bread, 22672 grm.; margarine,
I4‘i7 grm.; coffee, 0’568 lit. Dinner: Bread, 56’68 grm.;
meat, 170 04 grm.; potatoes, 453 44 grm., or peas, 14170 grm. ;
water, C568 lit. Tea: Bread, 22672 grm.; margarine,
14-17 grm.; tea, 0-568 lit.

Twenty-four hours’ sample.

1909.

Vol.

Sp. gr.

Creati¬

nine.

Creatinine
per kilo.

Water.

Remarks.

July 24

2940

1015

1-440

1-420 lit.

,, 25

1055

1023

1392

21'3 mgrm.

1420 „

„ 26

990

1020

o - 881

—

1420 „

—

.. 27

1380

1020

1 '324

—

1-420 „

—

1800

1015

1602

22 9 mgrm.

1420 „

—

.. 29

1170

1015

1067

—

1420 „

—

1020

1015

0979

—

1-42° „

—

3 *

1150

1025

1 '449

21'I mgrm.

1-420 „

—

Aug. 1

1250

1018

1-250

1420 „

—

l8lO

1010

0932

1420 „

—

11 3

1090

1015

0773

17*0 mgrm.

1420 „

Bath.

» 4

890

1027

I'04I

—

1-420 „

>» 5

1650

1020

n6i

—

1-420 „

„ 6

960

1020

1-094

15-8 mgrm.

1704 „

870

ioi7\

1-668

—

17°4 ..

1665

1018 J

—

I 704

.. 9

970

1020

I' 2 l 8

J. O’B—. Juvenile dementia; partial stupor. This patient
took his food well, and showed mental improvement. The
creatinine excretion in this patient was normal, but during the
baths it showed a slight decrease. The estimations were made
during a period when the temperature was quite high, the
laboratory temperature being 23 0 C. This table is inserted to
show the difficulties which are encountered and the great
proneness of the urine to bacterial decomposition. An interest¬
ing observation in connection with this patient was the sudden
appearance of appreciable quantities of indican in the urine on
August 4th, which increased in amount on the 5th and 6th.
On August 9th and 10th it was quite absent, and a similar test
applied at the end of the month was also negative.

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PRINCETON UNIVERSITY

1910.] BY R. L. MACKENZIE WALLIS, B.A. 21 3

Table VII. • .

Electric baths (from October 14th to November 1st, igog^
J. L—, male, set. 3g. Melancholia, based on delusions of throat
disease. Weight before commencing baths, 54*8 kg. ; weiwit
on commencing baths, 50 - 2 kg.; weight on finishing batKs,
50*8 kg. Height, r62 metres. ,

Diet. — Breakfast: Bread, 22672 grm.; margarine, 14'17 grm.;
coffee, 0.568 lit. Dinner : Bread, 56*68 grm.; meat, 170*04 grm.;
potatoes, 453*44 grm., or peas, 141*70 grm., water, 0*568 lit.
Tea: Bread, 226*72 grm.; margarine, 14*17 grm.; tea, 0*568 lit.

Twenty-four hours' sample.

1909.

Vol.

Sp. gr.

Reaction.

Appear¬

ance.

Creati¬

nine.

Creatinine
per kilo.

Water.

Oct. 12

850

1020

Acid

0467

1704 lit.

.. *3

690

1020

—

0772

12 mgrm.

1136 ..

» >4

790

1025

—

0481

—

i*< 3 6 ..

.. 15

750

1020

—

0585

—

«*704 ..

„ 16

I 140

1020

—

0855

—

• 704 ..

ft 17

840

1015

°*9 *5

—

1704

800

1025

Acid

0 920

—

1*704 ..

„ 20

740

1025

0 806

—

‘704 „

» 21

650

1025

0780

17 mgrm.

1*136 ..

„ 22

850

1020

0926

—

1*704

» 23

600

1025

>»

0 702

—

1704 ..

470

1026

o <553

—

1136

.. 25

550

1030

Alkaline

0 753

—

1 136

„ 26

550

1030

Acid

o *753

—

1136

„ 27

370'

1030

t»

—

1*136 „

„ 28

420 V

1025

0*453

—

0*568 „

840

1020

0856

—

1*420 „

440

1025

0444

—

1136 „

.. 3 *

410

1030

0618

—

1704 ..

Nov. 1

540

1025

0615

—

1704

,, 2

330

1025

-f

o *547

—

1*136 „

i» 3

440

1030

0646

12 4 mgrm.

1*704 »

.. 4

460

1027

Neutral

0 676

—

1704 ..

500

1030

Alkaline

0665

—

0*568 „

,, 6

0*568 „

J. L—. Melancholia. The patient took his food well, and
at different periods received both electric and warm baths. A
comparison of the tables reveals the effects of the two forms of
treatment. The table also demonstrates the gradual decrease
in the amount of creatinine excreted when the electric baths
extend over a long period.

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PRINCETON UNIVERSITY

214

ELECTRIC BATH TREATMENT,

[April,

Digitized by

Table VIII.

Warm baths , ioo° F.; May igth-25th.—E. M—, female,
set. 24. Acute mania. Weight on commencing baths, 53*4 kg.;
weight on ceasing baths, 52'1 kg. Height, r6o metres.

Diet. — Breakfast : Bread, margarine, tea. Dinner : Bread,
meat, vegetables. Tea : Bread, margarine, tea. Ordinary
female diet. Patient took food well.

Twenty-four hours' sample.

1909.

Vol.

S P . pr.

Creati¬

nine.

Creatinine
per kilo.

Water.

Remarks.

May 10

920

1025

0737

1 Preliminary

II 1 1

520

1025

0676

15 mgrm.

—

J observations.

790

1020

0995

—

860

1015

0662

—

1420 lit.

—

.. 19

1000

1020

1 • 125

—

1420 „

Warm bath.

„ 20

990

1025

1 *248

iq mgrm.

1420 „

,, 21

840

1020

0819

—

1420 „

» 22

—

1420 „

.. 23

«:

1015

0755

—

1420 „

850

1020

o-688

—

1-420 „

.. 25

690

1025

0833

—

1-420 „

Last bath.

„ 26

530

1025

0734

16 mgrm.

1 704 >.

—

„ 27

1270

1017

0749

1420 „

E. M—. Acute mania. Patient took food well. (Amounts
of constituents as in Table I). It will be noted that the
excretion of urine does not correspond with the volume of
actual fluid consumed daily. The excretion of creatinine was
increased as a result of the warm bath treatment, but the
effects were only temporary. This sharp rise is in accordance
with the observations of Hoogenhuyze and Verploegh (patient
No. 12). In all probability the baths when first given gave
rise to considerable mental excitement, and this may possibly
account for the increased excretion.

Table IX.

Warm baths, ioo° F.—M. E. W—, female, aet. 28. Adolescent
dementia. Weight on commencing baths, 45^ kg.; weight on
ceasing baths, 46'3 kg. Height, 1*65 metres.

Google

Original from

PRINCETON UNIVERSITY

1910.] BY R. L. MACKENZIE WALLIS, B.A. 21 5

Diet .—Ordinary female diet. (Amounts of constituents as
in Table I.)

Twenty-four hours' sample.

* 9 ° 9 -

Vo!.

Sp. gr.

Creati-

nine.

Creatinine
per kilo.

Water.

Remarks.

May 19

850

1020

° 73 I

1-136

lit.

)(

850

1015

0603

•3'9 mgrm.

1420

900

1015

0592

—

1*420

—

IOOO

1020

—

1420

—

1260

1015

0642

—

1*420

—

1 •*

820

1020

0 844

—

1420

Bath.

700

1015

0-544

—

1-420

»>

720

1020

0613

14-5 mgrm.

1740

'»

1 ”

450

1015

0-554

—

1-420

| „

1120

1015

056.S

1-420

600

1025

0-354

—

1420

850

1015

0550

—

1420

Last bath.

♦ 1

3 '

800

1020

0526

13* I mgrm.

1420

—

June 1

1040

1020

0787

—

1-420

—

! ..

1120

1015

05 « 5

—

1*420

—

i ”

1340

1015

1-420

M. E. W—. Adolescent dementia. Patient took food well.
The creatinine excretion remained fairly constant throughout,
and was not influenced by the warm bath treatment to any
great extent. The maximum figure was 0*844 and the minimum
figure 0*354 grammes. The creatinine co-efficient is low.

Table X.

Warm baths, ioo° F.—R. C—, male, at. 25. Hypochon¬
driacal delusions about gastric region ; secondary depression.
Weight on commencing baths, 57*3 kg.; weight on ceasing
baths, 58 kg. Height, 1*67 metres.

Diet .—Ordinary male diet. (Amounts of constituents of
diet as in Table VII.)

R. C—. This patient showed an increase in weight as a
result of the treatment, but no mental change. The incon¬
sistency in the volume of urine excreted is well marked, and
if an average value be taken extending over three days, the
excretion is found to be within the normal variations of excretion
in the insane.

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PRINCETON UNIVERSITY

Digitized by

2l6 ELECTRIC BATH TREATMENT, [April,

Twenty-four hours' sample.

1909

Vol.

Sp. gr.

Reaction.

Appear¬

ance.

Creati¬

nine.

Creatinine
per kilo.

Remarks.

! Nov. 22

840

1025

Acid

0924

I4'0 mgrm.

„ 23

650

1020

—

0605

—

| .. 24

740

1030

0886

—

1 .. 25

710

1030

0946

—

1. 26

680

1030

*»

0999

17*0 mgrm.

Warm bath 27th.

>• 28

570

1028

0914

—

.. 29

—

3 °

320

1030

Acid

0^640

—

Dec. 1

470

1030

0813

13 2 mgrm.

—

.. 2

400

1030

082

—

ti 3

430

1037

098

167 mgrm.

—

.. 4

590

1035

II 9

—

.. 5

8to

1016

—

°'737

— —

—

,, 6

960

1025

—

x ‘228

i6'0 mgrm.

Last bath.

.. 7

720

1025

—

0856

—

890

1020

—

0901

—

.. 9

IOOO

1020

092

—

„ 10

670

1030

I'XO

Table XI.

Warm baths, ioo° F., January i6th-27th, 1910.—J. R—, male,
ast. 32. Subacute melancholia. Weight on commencing baths,
55*7 kg.; weight on ceasing baths, 58*1 kg. Height 17 metres.

Twentv-four hours’ sample.

1910

Vol.

Sp. gr.

Reaction.

Appearance.

Creatinine.

Creatinine
per kilo.

j Jan. 14

2500

IOIO

Acid

I’OO

21*3 mgrm.

,, 15

2890

1012

—

1 38

—

11 16

2095

1012

—

0963

.. 17

1400

1020

—

0938

—

>1 18

U30

1012

—

0508

—

2370

1015

—

1 266

—

„ 20

« 57 °

1015

—

0*942

—

„ 21

1620

1015

—

0891

—

.. 22

1470

1015

—

0735

—

» 23

1470

1015

0735

—

1590

1015

0815

I4'0 mgrm.

1490

1015

Allsaline

0745

—

„ 26

1590

1015

0540

—

.. 27

1560

1015

0702

—

n 28

1620

xox8

0729

—

11 29

950

1015

0304

—

» 30

1910

IOXO

Acid

—

o'6x 1

—

.. 3 '

1700

10X3

—

0875

—

Feb. 1

1980

1012

0910

I2’4 mgrm.

Google

Original from

PRINCETON UNIVERSITY

i9io.]

BY R. L. MACKENZIE WALLIS, B.A.

2 17

Diet. — Breakfast: Bread, margarine, coffee. Dinner: Meat
or bacon, fish, vegetables. Tea: Bread, margarine, tea, eggs,
milk. (Amounts of constituents as in Table VII.)

J. R—. Subacute melancholia with ideas of unworthiness.
In addition to the ordinary diet the patient received two pints
of milk, one egg, and milk puddings. During the warm bath
treatment the patient did not take his food well. The warm
baths in this case apparently had no influence on the excretion
of creatinine. The preliminary observations were unfortunately
curtailed, and in consequence the figures given above are not
strictly representative.

Table XII.

Warm baths, ioo° F.—J. L—, male, aet. 37. Melancholia.
Weight before commencing baths, 54^8 kg.; weight on com¬
mencing baths, 54‘8 kg.; weight on ceasing baths, 53'4 kg.
Height, r62 metres.

Diet .—Ordinary male diet, and similar to that when under¬
going treatment with electric baths.

Twenty-four hours' sample.

1909.

Vol.

Sp. gr.

Creati¬

nine.

Creatinine
per kilo.

Water.

Remarks. j

May

350

1025

0707

—

31°

1015

0339

12 mgrm.

—

• 3

350

1025

0567

—

Preliminary

490

IO30

0264

—

observations.

i.S

575

1025

0 788

—

660

1015

0554

—

•9

500

1020

0430

—

1.278 lit.

Warm bath.

660

1015

0567

11 mgrm.

1-278 „

620

1020

0694

—

1-278 „

720

1020

0-813

—

1278 „

1043

1022

0-978

—

1-278 „

410

1025

0623

—

1278 „

Last bath.

940

1030

1269

—

1278 „

—

880

1025

0-963

16 mgrm.

1278 „

—

580

1025

0-730

n 36 „

For comparison with Table VII-

Table XIII.

Warm baths, ioo° F.— H. H—, male, jet. 30. Adolescent

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PRINCETON UNIVERSITY

Digitized by

218 ELECTRIC BATH TREATMENT, [April,

dementia. Weight on commencing baths, 73*6 kg.; .weight
on ceasing baths, 74 kg. Height 176 metres.

Diet. — Breakfast: Bread, 22672 grm.; margarine, 14-17 grm.;
coffee, o' 568 lit. Dinner : Bread, 56-68 grm.; meat or bacon,
I 98'38grm.; peas, 14170 grm., or potatoes, 453’44 grm ; water,
0-568 lit. Tea: Bread, 226-72 grm.: margarine, 14-17 grm;
tea, 0-568 lit.

Twenty-four hours' sample.

iqog.

Vol.

Sp. gr.

Creati¬

nine.

Creatinine
per kilo.

Water.

Remarks;

May

1430

1015

0993 1

1-436 lit.

815

1025

1043

—

•540

10x5

1-540

14 mgrm.

—

890

1015

0679

—

Preliminary

1450

1015

1123

—

observations.

I »

>095

1025

0-678

—

1052

1025

1-209

—

1650

1025

2521

—

1136 lit.

Warm bath.

9>5

1030

1346

20 mgrm.

> >36 „

1160

1025

1-252

—

i-> 3<5 „

920

1025

0783

—

1420 „

1000

1030

1-390

—

1278 „

Last bath.

1250

1025

0822

—

1420 „

1120

1025

1-411

—

1420 „

—

460

1030

0570

12*4 mgrm.

1-420 „

—

I I IO

1025

>•340

—

1-420 „

—

1270

1015

0857

1278 „

“

H. H—. Adolescent dementia of long standing. This patient
took his food well and gained in weight. The marked increase
in the creatinine excretion, especially on May 19th, 20th, and
21st, is very striking, and at the same time difficult to explain.

Table XIV.

Warm baths, ioo° F., January 24th to February nth, 1910.—
B. S—, female, set. 43. Subacute melancholia. Weight on
commencing baths, 55-8 kg.; weight on ceasing baths, 57-3 kg.
Height, 1-54 metres.

Diet .—The same as patient M. A. T— (Table Ila).

B. S—. Subacute melancholia, with ideas of unworthiness
and suicidal impulses. This patient took all her food and
improved somewhat in mind, and certainly in general health.

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Original from

PRINCETON UNIVERSITY

i9io.]

BY R. L. MACKENZIE WALLIS, B.A. 219

Twenty-four hours' sample.

1 QYO.

Vol.

Sp. gr.

Reaction.

Appear¬

ance.

Creati¬

nine.

Creatinine
per kilo.

Remarks.

j Jan.

IOIO

IOI5

Acid

Clear

0555

*»

1220

1015

0-451

—

”

Mis sed

—

qq mgrm.

—

1620

IOIO

Acid

Clear

0-662

—

1250

IOIO

o'S 37

—

Warm bath.

1180

1016

0826

—

1»

1110

1014

0477

10*9 mgrm.

1570

IOIO

0700

—

1780

1012

l»

—

0712

—

1150

1017

—

0 908

—

♦ 1

1820

IOIO

—

0 728

—

3 *

680

1020

0-496 1

—

Feb.

2290

1012

—

1 '374 i

—

920

I0l8

0908

—

1420

1015

—

0-568

—

1050

1017

—

0787

—

1110

IOIO

—

0777

—

1260

IOIO

—

0604

13 8 mgrm.

1190

1015

—

0821

—

2210

IOII

—

0917

—

1500

1012

0750

—

1020

IOIO

0408

—

1390

1014

—

0-695

—

1125

I0l8

—

0711

—

1680

IOIO

—

084

124 mgrm.

—

IOIO

1014

—

0626

—

1018

1016

»»

0606

—

The creatinine excretion is low, and is almost unaffected by the
treatment. The baths were repeated on fifteen consecutive
days so as to be comparable with the electric bath treatment
extending over a similar period. The gradual decrease in
creatinine metabolism is not shown in this table {cf. Table VII).

Summary of Results.

An examination of the tables reveals the lack of uniformity
in the secretion of urine, and for purposes of comparison the
amount of actual fluid taken daily is given.

Folin noted the same variations in the volume of the urine
in the patients he examined at the McClean Hospital for the
insane.(3)

A possible explanation can be offered in the case of J. L—
(Table VII), where this apparent abnormality is very well
marked. The patient suffers from ptyalination, and in

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consequence loses a considerable amount of water in his
saliva. Since creatinine excretion is constant for each indi¬
vidual from day to day, it serves as a valuable means of detect¬
ing any loss of the twenty-four hours’ sample. In all cases
where such a discrepancy has been detected the results have
been discarded. Consequently the occurrence of any loss of
the total quantity excreted cannot account for this feature.
The patient may possibly eliminate large quantities of water
in the expired air and the sweat.

There is also a tendency for some patients to retain urine,
but this error is obviated by taking the average excretion of
creatinine over three successive days. The creatinine values
show the normal variations as regards weight, age, and sex.
The question of age hardly affects these results, as the ages of
the patients are mainly between twenty-four and thirty-eight
years.

The excretion of creatinine was observed at least three days
before the baths began, and showed values of from n to 16
mgrm. per kilo, of body-weight in the case of the women
patients, and from 12 to 24 mgrm. per kilo, of body-weight in
the men.

As a result of the electric bath treatment the creatinine
figure was increased with one exception, e.g., J. O’B—
(Table VI). The creatinine co-efficient in the female patients
varied between 13 and 23 mgrm. per kilo, of body-weight, and
in the men from 15 to 21 mgrm. per kilo.

After cessation of the baths the excretion of creatinine showed
a slight diminution, but in only two cases did it fall below its
former value.

The effect of the warm baths, on the other hand, was to
lower or increase the excretion of creatinine to a very slight
extent, and in only two cases did the figure rise much above its
former level.

These observations are in accord with those recorded by
Tuttle (4) on the effects of different kinds of warm baths
installed at the McClean Hospital for the Insane. Folin
investigated the metabolism in nine cases treated in this way,
and found no definite changes. The creatinine figures are,
however, not given.

A comparison cf the values given above with those obtained

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i 9 io.]

BY R. L. MACKENZIE WALLIS, B.A.

22 1

by other observers for the insane reveals the fact that in the
electric bath cases there is a most decided increase in creatinine
during the period of the baths. This increase rapidly reaches
a maximum value and then gradually falls, and this fall is most
marked when the treatment is prolonged (see Tables II, III,
and VII).

A series of electric baths of short duration seems to be more
beneficial than a single series of long duration (compare Table
Ila with Table II).

The difference between the two forms of treatment is most
strongly marked in the case of J. L—. He received warm
baths from May 19th to May 24th inclusive, and during that
time the creatinine co-efficient was 11 mgrm. per kilo. On
October 14th of the same year an electric bath was given, and
repeated daily until November 1st. During the first week the
excretion of creatinine gradually increased, reaching a maximum
during the second week of treatment. Subsequently the value
gradually fell to its former level. Reference to Table VII
will show the co-efficient increased from 12 mgrm. to 17 mgrm.
per kilo, of body-weight.

Now what is the significance of this increase ? The crea¬
tinine in the urine is now recognised to be entirely of endo¬
genous origin, and intimately bound up with the muscular
system. Although there is evidently a rough proportionality
between the body-weight and creatinine excretion, the bulk of
muscle seems to play a prominent role. However, it is difficult
to completely reconcile all the facts with these two views. All
the patients examined showed very little muscular develop¬
ment or muscular efficiency, hence the low figures obtained.

The results seem to support Shaffer’s view that creatinine is
an index of a special process of metabolism taking place in the
muscles, and that the muscular efficiency depends upon it.
Exposure of the muscles to a sinusoidal current probably
intensifies this process, increasing the general tone of the
muscles, and consequently the creatinine metabolism. The
effect of electric baths on these patients affords considerable
support to this view, not only from the aspect of creatinine
metabolism, but also from the clinical observations.

With regard to the origin of creatinine, a valuable and
interesting contribution has been made by Waldemar Koch (7).
He points out the close chemical relationship between lecithin

LVI. 1 5

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22 2 ELECTRIC BATH TREATMENT. [April,

and creatinine, and thinks that the latter is derived from the
disruption of lecithin molecules.

In this connection it is interesting to note that the increase
of creatinine was always accompanied by an increase in
inorganic phosphates in the urine.

The results recorded above, although not definitely conclusive,
seemed to be of sufficient interest to warrant publication. A
much more detailed investigation is, however, necessary, and
we hope at a later date to contribute further observations on
this subject. As far as is possible the same patients will be
examined to obtain the creatinine excretion extending over the
same periods of time, but without adopting any bath treatment.
It also seems necessary to investigate the effects of baths on
the normal healthy individual, and also on other pathological
subjects besides the insane, especially patients with muscular
atrophy.

Conclusions.

(1) The excretion of creatinine in the insane is in general
subnormal.

(2) Electric bath treatment, using the sinusoidal current,
tends to increase the creatinine in the urine.

(3) Treatment with warm baths without the current has
very little, if any, influence on the creatinine excreted.

(4) The variations in volume of the urine excreted and
the great proneness to bacterial decomposition seem to be
characteristic of the insane.

Bibliography.

(1) Neubauer.— Ann. de Chem. u. Phann ., cxxxvii, p. 288.

(2) Folin.— Zeit.f. Physiol. Chem ., xli, 1904, p. 223.

(3) Folin.— Amer. Journ. of Insanity , vol. lx, 1904-5, p. 732; ibid.,
lxi, p. 299.

(4) Tuttle.— Ibid., vol. lxi, p. 179.

(5) Folin.— Atner. Journ. Physiol., vol. xiii, 1905, p. 66.

(6) Folin.— Ibid., vol. xiii, p. 117.

(7) Koch.— Ibid., vol. xv, 1905, p. 15.

(8) Hoogenhuvze and Verploegh.— Zeit.f. Physiol. Chem., vol. xlvi,
1905, p. 415.

(9) Closson.— Amer. Journ. Physiol., vol. xvi, 1906, p. 252

(10) Klercker.— Biochem. Zeit., vol. iii, 1907, p. 45.

(11) Benedict and Myers.— Amer. Journ. Physiol., vol. xviii, 1907,
P- 377 -

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1910 .] ELECTRIC BATH TREATMENT. 223

(12) Hoogenhuyze and Verploegh.— Zeit. f. Physiol. Chem., vol. lvii,
1908, p. 161.

(13) Benedict and Myers.— Ibid. (II), p. 397.

(14) Benedict.— Carnegie Inst, of Washington, 1907, Publ. No. 77.

(15) Benedict and Diefendorf.— Amer. Journ. Physiol., vol. xviii,
1907, p. 362.

(16) Spriggs.— Biochem. Journ., vol. ii, 1907, p. 206; also Quart.
Journ. Med. (Oxford), vol. i, 1907, p. 63.

(17) Leathes.— Journ. of Physiol., vol. xxxv, 1907, p. 205.

(18) Lusk.— Amer. Journ. of Physiol., vol. xix, 1907, p. 464.

(19) Underhill and Kleiner.— journ. of Biol. Chem., vol. iv, 1908,
p. 165.

(20) Richards and Wallace.— Ibid., vol. vii, 1908, p. 179.

(21) Leffmann.— Zeit.f. Physiol. Chem., vol. lvii, 1908, p. 476.

(22) Froschbach.— Arch. f. Pharm. u. Path. Exp., lviii, 1908,
p. 112.

, (23) Mellanby.— Journ. of Physiol., vol. xxxvi, 1908, p. 447.

(24) Wolff and Shaffer.— Journ. Biol. Chem., vol. iv, 1908, p. 439.

(25) Shaffer.— Amer. Journ. Physiol., vol. xxvii, 1908, p. i.

Discussion,

At the Quarterly Meeting at Leicester, February, 1910.

The President said he was sure all present were highly delighted with the most
elaborate paper of Dr. Goodall and Mr. Mackenzie Wallis, which was stamped
with the evidence of a great deal of labour, time, and thought. The authors
seemed to have taken the hydrd-electric treatment of mental diseases entirely out
of the region of pure empiricism, and to have erected it upon a plane of something
like scientific investigation, producing, therefore, accuracy of result. He did not
propose to enter into details, but he desired to ask the gifted authors whether it
was regarded by the latest authorities that the amino-acids, glycosin, creatin,
leucine, and so on, were the necessary precursors of urea formation during the
protein metabolism in the tissues, particularly in the muscles; and if the creatinine
which resulted from such changes in the muscle creatin, which Mr. Wallis found in
the urine, was simply the surplus of those precursors which were eventually con¬
verted into ammonia and carbon dioxide, and so passed the liver and the kidney as
urea. That appeared to be a very important point, and he would be glad to know
whether there was a more simple mode of splitting off, as had been suggested by
Drechsel’s experiments, experiments which were quite classical, in which strong,
alternating currents were passed through solutions containing proteid material.
That was found not to bring those amido-acids into being, but carbon dioxide and
ammonia. And it was suggested that that was the immediate and simple method
which might occur in the human economy. Perhaps this might be too simple to
explain what occurred in the human economy; and he would like to know whether
recent research upheld the possibility of this occurring, because he had never yet
seen a reply to Professor Halliburton’s question, that if those amido-acids were the
precursors to urea formation from proteid metabolism, why did one not find them
more freely escaping into the blood and passing on into the liver in ordinary meta¬
bolism, in the forms of leucine, glycosine, and creatinine in very great abundance ?

Dr. Percy Smith desired to congratulate his late colleague, Dr. Goodall, and
Mr. Mackenzie Wallis on the paper which they had produced. Dr. Goodall would
remember that many years ago tepid baths were used a good deal at Bethlem
Hospital in the treatment of certain excited and maniacal cases, and with the
greatest possible benefit. There was no doubt that, as a result, patients who were
excited became calmer—whether post hoc or propter hoc was another question—
and there was general improvement. They gained weight, their sleep came back,

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and eventually they recovered. Therefore, he was interested in Dr. Goodall's
statement that short baths were preferable to long ones. He was speaking purely
of warm baths, as in those days they had no sinusoidal current, and no means of
obtaining proper electric baths. He believed Dr. Goodall said there were 108
cases treated, and that 62, or 57^4 per cent, recovered or were mentally improved;
so that 46 did not improve. And the author compared those 108 cases which had
been treated by the electric current and bath with 16 others who had the warm-
bath treatment only. He thought it was rather unfortunate, for purposes of com¬
parison, that a larger number—for instance an equal number—were not treated by
pure warm baths. Of the 16 cases treated in the latter way the author said those
who did not improve on that method were the patients who did not gain weight.
One knew that gaining weight was a common accompaniment, if not the cause, of
the improvement in many acute mental cases. And of course the improvement in
the cases which were treated with the electric bath was most marked in those who
were physically weak at first; and no doubt physical improvement was going on—
whether concurrently with it, or because of it, was a matter on which there was
room for doubt. He was very much interested in the question of the increased
excretion of creatinine in the cases treated by the electric bath. It occurred
markedly in one of the sixteen cases treated by mere warm bath, without electricity ;
and the investigation raised the question as to whether the creatinine was the elusive
toxin for which everyone seemed to be looking as the prime cause in mental
disease. Many said that a toxaemia of some form was at the root of insanity. He
would like to hear the views of the authors on that point: whether they thought
the investigation brought the profession nearer to the causal agent in mental
disorder.

Dr. G. Scott Williamson said he would like to congratulate the authors of the
paper on its supreme value, and also remarked on the fact that it was the first
attempt in the annals of British psychology to tackle the functional abilities of the
insane. A number of workers were taking up the question in America, but even
there the workers at the subject were few. A contribution like the present one was
supremely welcome. With regard to creatinine, he would like to mention some
observations which he made some time ago with regard to a condition in which
there was undoubted toxxmia, namely, in tuberculosis, and especially phthisis.
The patients in question were all undergoing sanatorium treatment, and, as a result
of that, some of them were increasing in body-weight. But the creatinine in no
way varied with such increase in body-weight. Every three or four weeks the
amount of creatinine was estimated, and it was found to be that of a practically
normal individual, although some of the patients had pronounced cavitation and
toxaemia, as evidenced by their rise and fall of temperature. The increase in
body-weight owing to the sanatorium treatment presumably meant a pure increase
of fat. With regard to the patients who were undergoing the graduated labour
treatment at the sanatorium—and presumably, from the estimation of their opsonic
indices, they were overcoming their toxaemia and neutralising some of it—in them,
as the weight increased, the creatinine showed signs of rising, but not sufficiently to
enable one to say that the increase was pari passu with the increased body-weight,
i.e., that the muscles were functionally capable of breaking up and giving rise to
more creatinine. In the patients who were subjected to inoculation treatment, one
found that if one induced a very profound negative phase, i.e., a condition of
hypertoxremia—perhaps the toxaemia was very different, and might have differed
from the circulating toxaemia, as it was an endotoxaemia coming from the bacil¬
lary bodies themselves—the creatinine showed a very profound fall. In a patient
who was losing much weight the creatinine remained markedly stationary. Those
observations were not sufficient on which to form any conclusions, but he thought
they were worth relating, and might, perhaps, help to elucidate some of the
problems brought forward by Dr. Goodall and Mr. Mackenzie Wallis.

Dr. Stoddart said that he had been wondering whether, after all, it was a good
thing to get rid of the creatinine. He would like to know whether creatinine was
really a body poison. Could anyone give information who had had experience of
examining the creatinine excretion in normal people ? If so, he would be glad to
know whether the sinusoidal current increased the creatinine excretion of the
average normal person. He did not know whether Dr. Goodall adopted the same
classification as he did himself; but the cases which Dr. Goodall mentioned as

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being treated by sinusoidal current all seemed to him cases which one would have ex¬
pected to recover under the treatment hitherto commonly adopted. With regard
to the treatment by plain warm baths, his experience practically coincided with
that of Dr. Percy Smith, namely, that warm baths certainly had a beneficial effect.

Dr. Robert Jones sent the following communication, which was read by Dr.
Bond: I have tried the electric bath treatment in the case of adolescents mostly.
In these, as also in some adults, the form of insanity was that of melancholia.
Some of the cases presented well-marked melancholia attonita and the so-called
anergic stupor. Most of these cases are characterised generally by gradual deterio¬
ration ; they stand or sit about in a fixed or passive attitude, and have almost
always to be considerably coaxed (if not forcibly fed) in order to get them to take
nourishment. The mental condition is so unsatisfactory that some authorities call
the disease " primary dementia "or “ dementia praecox,” and it is certainly not a very
curable form. After consultation with Dr. Lewis Jones and the encouragement
experienced by using a simple method of electric bath treatment, I tried it upon
eighteen male and five female patients. The five female cases improved greatly in
health; two were phthisical,and whilst undergoing the electric bath treatment both
of them gained several stones in weight. One of them died later of phthisis, but the
other was discharged recovered ; the third recovered, the fourth developed epilepsy,
and the fifth remains at present as a helper in the asylum. In addition to these cases
the electric bath treatment was used for certain cases of puerperal insanity, and it was
considered to be a help towards restoration. Of the eighteen men, nine have left the
asylum (six recovered, two were discharged relieved, and one has improved but not
recovered). All the men gained weight under treatment, being weighed weekly, and
the record has been kept, the average gain of the nine who left the asylum being
seven pounds during the bath treatment, which lasted for an average period of
seven weeks, but some received baths for nine or eleven weeks. The maximum gain
in one case whilst under treatment was twenty-two pounds, the next highest being
seventeen pounds. Of the nine cases remaining under treatment one was phthisical,
one was suffering from progressive muscular atrophy; the others are considerably
improved mentally, the stupor or profound melancholia having quite passed off.
Upon the whole I consider the results to be satisfactory. So little has yet been
done in regard to the systematic treatment of the different forms of insanity by
electro-therapy that it is, perhaps, premature to formulate any definite conclusion,
but I consider that in electric baths we have an excellent and valuable stimulant
to metabolism. The skin in the insane is in an abnormal condition, but whether
the improvement after baths is due to increased elimination, or due to vascular
changes brought about by the bath, or whether it is due to increased nervous
stimulation and metabolism, I am not prepared to say. I should especially recom¬
mend this treatment in the melancholia of adolescent and apathetic cases such as I
have referred to.

Dr. Goodall, in reply, said he was glad to find the paper had aroused so much
interest. He would leave his colleague to answer the points concerning the
creatinine excretion. Dr. Percy Smith commented on the paucity of the controls.
He, Dr. Goodall, agreed that sixteen control baths were few, and he would be
pleased to see the results in a larger number. But, as he had intimated, it was an
arguable point how far it was justifiable to conduct such control experiments,
since merely putting a patient into a bath at a temperature of 99°-ioo° F. for
twenty minutes at a time scarcely constituted treatment. He had asked a friend
at another asylum if he would make similar controls, to assist in getting a larger
number of them, and that gentleman's reply was that he did not feel justified in
doing so. Some of the patients had electric baths and warm baths as well, and
they said the electric bath did them more good than did the plain warm bath. He
thought that repeated warm baths, at increasing temperatures up to, say, 105° F.,
had a sedative effect, but this was an entirely different proceeding; he did not
believe it could be shown that baths at the low temperature employed had a
stimulating effect; certainly not such a tonic, stimulating effect as electric baths
had. Dr. Lewis Jones, an authority on the subject, said that the latter were
invigorating and stimulating in a number of cases. Dr. Lewis Jones had had a
large experience in the matter, both in private and in hospital practice. In reply
to Dr. Bedford Pierce, he would say that the effects of the sinusoidal current were
improved by rhythmic variation. Dr. Stoddart had seemed to suggest that the

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class of cases treated were those which got well if left to Nature and the nurse.
To prove that the results were not due to the electric bath it would be necessary to
ignore wholly the results of sixteen careful controls, and furthermore, to take an
equal number of like cases, adopt no treatment, giving the same diet merely, and
compare the ratio of recoveries and the recovery-period with those obtaining in the
cases treated by current. He believed, as stated, that if he had reckoned the
recovery-period in all cases from the time of commencing the bath treatment, it
would have been found to be considerably shorter than that recorded.

Mr. Mackenzie Wallis, in reply, said he desired to thank his audience for
having listened to such a long and tedious paper. In reply to the President,
creatin was derived originally from amino-acids, because if one took the developing
chick one found that there was no creatin at all, and in the hatched chick there
was only a very small quantity. It was only after the fourteenth day from the
hatching that one found the maximum amount of creatin in the muscles, and only
after that stage was creatinine eliminated. There was practically no creatin given in
the food of those chickens, and so creatin must be derived from the proteins of the
egg. When the muscle had reached its saturation-point, creatinine was excreted—
in other words, creatin was used up in muscle, and the surplus was converted into
creatinine and excreted. The precursors which had been mentioned were possible
ones, but there was no proof at present that those amino-acids were formed and
absorbed as such, or in combination with each other. Possibly a number of
amino-acids were united together, and for utilisation by the organism the nitrogen
was split up and disseminated; and that nitrogen went to the liver and was con¬
verted into urea. The small amount which was required to maintain the wear and
tear of the tissues, and also derived from amino-acids produced in digestion,
represented the endogenous metabolism, and the body creatinine was included
among the substances formed. With regard to the work of Drechsel, the splitting
up of proteids by passing a strong current, it was possible that the result of the
electric baths was to increase the protein-destruction in the body. Unfortunately,
they were unable to investigate the subject owing to lack of apparatus ; but it was
hoped that that would be done in the future, and then they would have some idea
whether the increase in the creatinine under electric bath treatment was con¬
comitant with the increase in the other nitrogenous constituents. He was more
inclined to Koch’s view of the origin of creatinine, i.e., from lecithin, rather than
from amino-acids ; but the lecithin itself was probably derived from amino-acids in
the first place. Creatinine seemed to be indirectly connected with the destruction
of lecithin. Dr. Percy Smith had mentioned the possible toxic origin. The
creatin in the muscles was toxic; but when it was converted into creatinine—and it
was a simple hydrolysis which took place in the liver—this creatin was rendered
non-toxic. The former was a strongly basic chemical body, but it had no toxic
effect. Creatin was constantly being produced in muscle, and the surplus was got
rid of. It was necessary to convert the residue into an innocuous form, and that
conversion was carried out by the liver, and the surplus was excreted. In the
insane there was a very low excretion of creatinine, and it was possible that creatin
in the muscles might be oxidised into some other body, and that other body might
cause the toxic effect. By increasing the creatinine excretion, one eliminated the
danger of conversion into some other, and probably more toxic, body. The origin
from lecithin was suggested by the fact that lecithin was always being broken
down; because even if phosphates were excluded from the food one still found
organic phosphates in the urine. In answer to Dr. Williamson's remarks, there
was always an increase of creatinine with an increase of temperature. If the
oxidation of the tissues was lowered there was a consequent lessened excretion,
and that might account for what Dr. Williamson had observed. It was creatin
which was the poisonous substance, and the body converted that creatin into
creatinine, and after that conversion it became innocuous. With regard to testing
the effect of the electric bath on the normal person, that had not been done by his
colleague and himself. It certainly should be, but possibly it would not show any
effect at all. One might take all kinds of exercises, and increase the diet, but the
creatinine excretion would not be affected in an ordinary individual by such means.
Possibly a more liberal dieting of the patients under observation would have made
a good deal of difference to the creatinine excretion. He did not think the routine
nstitution diet was sufficient.

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I9IO.] MORBID ANATOMY OF MENTAL DISEASE.

2 27

Observations on the Morbid Anatomy of Mental
Disease. By George A. Watson, M.B., Pathologist
to the Lancaster County Asylum, Rainhill.

The following observations are founded upon the records of
301 autopsies performed by myself at Rainhill Asylum. They
are concerned principally with certain abnormal and morbid
manifestations which occur within the crania of the insane. Of
these the chief are, on the one hand, indications of subevolu¬
tion, as shown by macroscopic structural defects of the cerebral
hemispheres, such as deficiency of weight or of convolutional
complexity, and on the other, evidence of dissolution as
exhibited by wasting of the cerebral hemispheres. The
relationship existing between these abnormal and morbid
manifestations and certain other intracranial appearances is
also discussed. No attempt, however, has been made—for
reasons which will afterwards be given—at any close correla¬
tion between these abnormal and morbid manifestations and
the mental states recorded during life. The observations,
therefore, are of a pathological rather than a clinical nature.

The method of recording the intracranial appearances has
been the same as that used by Dr. Bolton at Claybury Asylum
and subsequently there by myself. Adoption of the method at
Claybury led me to conclusions similar to those of Dr. Bolton,
and I thought it desirable to know whether or not a further
and more extended experience of the method in another asylum
would confirm these conclusions^ 1 )

The subject will be dealt with under the following headings :

Part I.

Examination of Material from Rainhill Asylum.

I. Method of recording and grouping the intracranial
appearances (pp. 229, 230).

2(a). The average weight of the cerebral hemispheres in the
different groups (p. 231).

(1 b ) The convolutional pattern of the cerebral hemispheres in
the different groups (p. 235).

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Conclusions (p. 238).

3. Factors which may influence the passage of the cases
from the earlier to the later groups (p. 240).

(a) Age of the patient; ( b ) duration of the attack of insanity ;
(c) degeneration of the cerebral vessels (pp. 241, 242).
Conclusions (p. 245).

Part II.

Comparison of Results Obtained at Clay bury Asylum and at

Rain hill Asylum.

1. The weights of the cerebral hemispheres (p. 246).

2. The percentage of cases in the different groups (p. 249).

3. The comparative amount of degeneration of the cerebral
vessels at Claybury and at Rainhill (p. 250).

General conclusion (p. 251).

Part I.

Examination of Material from Rainhill Asylum.

1. Method of Recording the Intracranial Appearances.

The intracranial appearances to which attention has been
paid are : Conditions of the dura and pia-arachnoid ; the
amount of sub-dural and sub-arachnoid fluid—w'hether natural
or in slight, moderate, large, or great excess ; the manner in
which the cerebral hemispheres strip—whether naturally or
more readily than naturally, readily, very readily, or extremely
readily ; and the amount, if any, of cerebral wasting. The
absence or presence of degeneration of the cerebral vessels, and
the degree of degeneration when present, has also been
recorded, together with notes concerning the general confor¬
mation and convolutional pattern of the cerebral hemispheres.

The cerebral hemispheres are weighed, firstly unstripped,
and then one or other, usually the left, sometimes both, after
being stripped of its membranes. The amount of loss after
stripping is noted, this serving as a useful check upon the other

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i9io.]

BY GEORGE A. WATSON, M.B.

2 29

observations concerning the intracranial appearances^ 1 ) It has
been found convenient for other purposes to confine the strip¬
ping of the cerebrum to that of one hemisphere in the majority
of instances, and the left has usually been chosen for certain
practical reasons. This, however, is of no particular moment
in so far as the following statistics are concerned, because in
cases of gross lesion, general paralysis, and perhaps epilepsy
excepted, it has not been common to find a difference in weight
between the right and left hemispheres of more than a few
grammes. The rare instances in which any marked difference
has occurred have not been included.

For reasons which will appear obvious, all cases of gross
lesion which would be at all likely to appreciably affect the
weight of the cerebral hemispheres have been excluded, as also
have all general paralytics, epileptics, idiots, and imbeciles.
Many of the cases, and certainly all the doubtful ones, have
been examined microscopically. The cases from which the
data used in compiling the statistics have been derived are,
therefore, examples of the ordinary asylum population—cases
of confusional insanity, mania, melancholia, paranoia, and the
dementias, excepting, as before stated, those affections asso¬
ciated with gross lesion, general paralysis, or epilepsy. The
tables are thus founded upon observations in 301 consecutive
cases of insanity, in no way selected, with exception of the
above mentioned necessary omissions, and of a very few cases
which, for some special reason or other, could not be included.

A grouping of the intracranial appearances found in these
cases has been made in the following manner :

Group I : No morbid appearances. No, or very slight,
excess of fluid ; membranes appear normal, and strip about
naturally ; no obvious wasting of the cerebral hemispheres.

Group II : Slight morbid appearances. Slight to moderate
excess of fluid ; membranes strip a little more readily than
naturally ; slight cerebral wasting.

Group III : Moderate morbid appearances. Moderate to
considerable excess of fluid ; membranes strip readily ; moderate
to fairly marked cerebral wasting.

(') The actual amount lost after stripping will probably vary a little with
different observers according to the extent to which the hemisphere is drained
of fluid before the preliminary weighing, but the relative amount of loss, in the
different groups to be presently described, should remain fairly constant in a
given series of cases examined by an individual observer.

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Group IV: Marked morbid appearances. Large excess of fluid ;
membranes strip very readily ; well-marked cerebral wasting.

Group V: Gross morbid appearances. Great excess of
fluid ; membranes strip extremely readily; very marked
cerebral wasting.

The above will serve as a guide to the method of placing
the individual cases in the different groups. It is not pretended
that all the particulars associated with a certain group will
apply absolutely and in every detail to some isolated cases,
although in the majority they will do so. At times instances
occur in which, owing to certain bodily conditions or modes of
death, the amount of intracranial fluid is increased above that
which one is accustomed to find when these conditions are
absent, or the membranes separate either with unwonted facility
or with unusual difficulty, or in which it is difficult to estimate
the degree of cerebral wasting, if any, owing to this being
obscured by oedema of the brain substance. Hence, sometimes
some little judgment may be required before a given case can
be placed in what appears to be its appropriate group, and
occasionally the intracranial morbid appearances taken together
are so anomalous as to necessitate the actual omission of the
case ; but such instances as the latter are rare, and are in¬
variably explicable on the grounds of the bodily conditions
present.

The most important of these bodily conditions which may,
but do not always do, modify the ordinary intracranial appear¬
ances, is tuberculosis—the most important because of its fre¬
quency. Certain other bodily diseases which tend towards a
general water-logging of the system may have the same dele¬
terious effect. With regard to tuberculosis, this was the actual
cause of death in 3 1 per cent, of the total cases, viz., of those
in Group I 37 per cent., in Group II 40 per cent., in Group III
31 per cent., in Group IV 19 per cent., and in Group V 20 per
cent. Thus tuberculosis was most frequently found in the
cases in Groups I and II and least frequently in those in Groups
IV and V.

Naturally also, as the grouping is an entirely artificial one, the
groups tend to shade into one another to some extent. Whilst
Group III stands out fairly clearly by itself, it is not always
quite easy to decide whether a given case should be allotted to
Group I or to Group II, which groups somewhat resemble each

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231

other, or similarly to Group IV or to Group V. Still, it is
quite unlikely, for example, that any case which properly
should have been placed in Group II has been included in
Group IV, and as regards the smaller differences, which might
be put down to the personal equation of individual workers,
these would be greatly discounted by the large number of
instances involved. In an investigation of this description
great exactitude of detail is almost an impossibility ; all that
can be hoped for as the outcome is a generalisation. The
method, however, in spite of these strictures, is one that can be
readily applied by any close observer of intracranial appear¬
ances, and, indeed, substantially accurate results should be
obtained by all but the most inexperienced.

2. The groups may now be considered from the following
aspects :

(a) The average weight of the cerebral hemispheres.

(b) The convolutional pattern of the hemispheres.

(r) The mental state of the patients.

2 (a). The Average Weight of the Cerebral Hemispheres.

This is shown in the following table.

Table I.— Weights of the Stripped Hemispheres in Grammes.

Males.

Females.

Average loss of weight
after stripping the
hemispheres.

Number
of cases.

Average
weight of
hemi.
spheres.

Number
of cases.

Average
weight of
hemi¬
spheres.

Males.

Females.

Group I.—No morbid

appearances

540

510

22 S

Group II.—Slight mor-

bid appearances

569

494

25 '5

Group III.—Moderate

morbid appearances .

561

503

Group IV. — Marked

morbid appearances .

557

506

Group V.—Gross mor-

bid appearances

545

482

405

General

Total

average

Total

average

number

weight of

number

weight of

of cases.

hemi-

of cases

hemi-

spheres

spheres.

149

554

152

501

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The most outstanding feature shown by the table is the
small difference in the weights of the hemispheres in the
different groups, considering that the hemispheres placed in
Group I and II presented no or little wasting, and those in
Groups III, IV, and V either moderate, marked, or gross wasting.
In the case of the males, indeed, the average weight of the
hemispheres with gross wasting in Group V slightly exceeds
that of the hemispheres with no wasting placed in Group I.
In the case of the females the average weight of the hemi¬
spheres in Group V only falls short of those in Group I by
28 grm.

The weight of any given hemisphere in Groups I and II
must be either that of, or nearly that of, its original weight. It
is, of course, impossible to say what was the original weight of
any individual hemisphere in the Groups III to V, but those in
Group III must have lost a not inconsiderable amount of their
original weight—may be 30 to 50 grm.—whilst those in Groups
IV and V may have lost anything from 50 to 80 grm., and in
some instances, particularly in the case of the larger hemispheres,
probably much more. Therefore the hemispheres in Groups
III to V must have originally weighed decidedly more than
those in Groups I and II, and it is thus evident that the cerebra
which have undergone most wasting are, on the whole, those
which were originally the heavier ones.

The relationship of the weights of the hemispheres in the
different groups to one another is naturally the significant
feature rather than the relationship of these to a supposed
normal average. It would, however, be of interest, if not of
advantage, to compare these weights with that of the average
weight of the cerebral hemispheres of the sane population of
the district from which the inmates of this asylum are derived.
Unfortunately such average weight is not known, and the
mean brain weight appears to differ to some extent in different
localities.

The most recent and comprehensive statistics bearing upon
the question of the normal average brain weight, at all ages
from fifteen to eighty years, are those of Marchand.( 2 )
According to this observer the average weight of the unstripped
encephalon in 1,234 cases was 1,400 grm. for the male and
1,275 g rm - f° r the female. By using Huschke’s ratio of 13 to
87 for the conjoined cerebellum and pons to the cerebrum, and

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233

by allowing 20 grm. as being approximately the amount which
the normal hemisphere loses on stripping, it may be readily
calculated that the average weight of the normal stripped
hemisphere is about 589 grm. for the male, and about 534
grm. for the female. Marchand, however, derived his data
entirely from Hessians. From the statistics of the older
investigators it is not easy to arrive at a correct idea of the
average weight of the brain at all ages. In the tables com¬
piled by Marshall, from extensive data collected by Boyd, the
number of cases in each of the columns is not stated, so that
the exact average of the whole cannot be calculated, but it
would appear from these tables that the general average weight
of the brain for both sexes is lower than that given by Mar¬
chand. Boyd found the mean weight of the brain at from
twenty to forty years to be 1,360 grm. for the male and 1,230
grm. for the female, or calculated as above about 572 and 5 1 5
grm. respectively for the stripped male and female hemispheres.
Between the ages of thirty and thirty-five years Broca gives
an average weight of 1,421 grm. for the male and 1,269 grm.
for the female brain, or about 61 8 grm. and 532 grm. for the
stripped hemispheres of the males and females^ 3 ;

So far as can be judged, it would appear that the mean
weights of the normal male and female cerebral hemispheres, as
calculated from Marchand’s figures, are probably approximately
applicable to the average hemisphere weights of the general
sane population of this district, and at least there is every
reason for believing that these weights so applied are not
excessive. Although the matter is of very secondary import¬
ance, these average weights for the stripped male and female
hemispheres, viz., 589 and 534 grm. respectively, may there¬
fore for the moment be compared with the average hemisphere
weights of the cases in the different groups in Table I. The
following facts will then be noticed. Firstly, that the average
weights of the hemispheres in Groups I and II are appreciably
below the above figures; especially is this noteworthy in Group I,
which includes hemispheres showing no wasting. Secondly, if a
reasonable number is added to the average weights of the
hemispheres in each of the Groups III, IV, and V, in order
to compensate for the amount lost owing to wasting, it is
plain that the majority of the hemispheres in these groups
cannot originally have weighed less than the presumed normal

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234 MORBID ANATOMY OF MENTAL DISEASE, [April,

average, and the probability is that they weighed considerably
more.

It is obvious that the defect of weight of the hemispheres in
Group I, taken as a group, is the consequence of subevolution,
seeing that these hemispheres presented no evidence of wasting ;
and it is equally clear that most of the deficiency of those in
Group II is similarly the result of subevolution, as the loss due
to wasting in these cases was slight. Also, it is evident that
the lack of weight of the hemispheres in the Groups III to V,
taken as groups, is largely, and in some instances probably
entirely, the result of a loss due to dissolution, for all these
hemispheres showed wasting in various degrees from moderate
to gross.

A point worthy of special mention when dealing with the
weights of the cerebral hemispheres in this connection, is that
a given deficiency of weight which is the consequence of sub¬
evolution is probably of more significance than is the same
loss of weight the result of dissolution. In the first place, in
subevolution microscopical examination shows that the actual
defect may lie not so much in gross diminution in the number
and size of the cortical neurones as in deficiency of the finer
connections of the latter, and the weight of these finer con¬
nections must be comparatively small, whereas in dissolution
not only are the more delicate neuronic connections affected,
but the bodies of the neurones themselves are actually more or
less destroyed. Also in definite cerebral dissolution, naked-eye
demonstration of marked destruction of the whole neurone is
given by such manifestations as thinning of the white matter
and dilatation of the ventricles ; in cerebral subevolution uncom¬
plicated by gross lesions such manifestations are absent or
slight. Further, in subevolution deficiency of weight is gene¬
rally the equivalent of almost purely neuronic defect, and is,
therefore, the actual deficiency. Loss of weight which is the
result of dissolution does not usually represent the total neuronic
loss, this being greater than appears, because such loss may
be, and so often is, compensated for to some extent by vascular
and neuroglial proliferation, particularly in the outer layers
of the cortex. Hence, from these considerations it seems cer¬
tain that more importance may be attached to the defect in
weight of the hemispheres placed in Groups I and II n which
the signs of dissolution were absent or slight, than to the actual

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loss of weight of the hemispheres in Groups IV and V, in
which these signs were marked.

2 (b). The Convolutional Pattern of the Cerebral Hemispheres.

Some notes have been made concerning the convolutional
pattern in all the cases, and in many instances a very detailed
account of the general formation and fissuration of the hemi¬
spheres is on record. In fact, because of its obvious import¬
ance, much time and attention have been devoted to this matter.
For present purposes, however, it will be sufficient to reduce
the description of the convolutional pattern to such terms as
“very complex,” “above average,” “average,” “simple,” and
“very simple.” In the following table will be found the
number of hemispheres in each group which have been judged
to answer to one or other of these descriptions. The numbers
in one or two of the groups are rather small for reduction to
percentages, but for easy appreciation of the results it is con¬
venient to adopt this method.

A glance at the table shows that in Group I, both male and

female, the majority of the hemispheres are below the line-,

being either simple or very simple in pattern. In Group II a
greater proportion are above the line—in the case of the males
the majority being so. Groups III, IV, and V agree in that a
large proportion of the hemispheres (87 to 91 per cent, in the
case of the males and 77 to 80 per cent, in that of the females)
are above the line, being either very complex, above average, or
average in pattern. In fact there is a rather striking similarity
in the percentage of hemispheres in each of the Groups III, IV,
and V, male and female respectively, which are either of average
or above average complexity of pattern. The hemispheres in
Groups I and II are therefore on the whole decidedly more
simple in convolutional pattern than are those in Groups III to
V. Moreover, it may be stated in general terms that local
areas of under-development, gross anomalies of fissuration, and
other defects which may be classed as cerebral stigmata, although
found to a certain extent in some of the hemispheres in all the
groups, are more frequently met with in those hemispheres
placed in the earlier than in those belonging to the later groups.
It must be admitted, however, that these stigmata are not
uncommon even in large and complex hemispheres, but their

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236 MORBID ANATOMY OF MENTAL DISEASE, [April,

number in such instances is almost always more limited and
their prominence much less than it is in the smaller and simpler
hemispheres.

Table II. — The Convolutional Pattern of the Cerebral Hemi¬
spheres.

Males.

Pattern.

Group I.
No. of Per
cases, cent.

Group 11,
No. of Per
cases, cent .

Group III.
No. of Per
cases, cent.

Group IV.
No. of Per
cases, cent.

Group V.
No. of Per
cases, cent.

Very complex.

Above average
Average .

Simple .

Very simple .

o} 3S

3 [67

21 j

7U7

30 J

ib s

16 J

o } I2 '5

Total cases

TABLE II — continued.

Females.

Pattern.

Group I.
No. of Per
cases, cent.

Group II.
No. of Per
cases, cent.

Group III.
No. of Per
cases, cent.

Group IV.
No. of Per
cases, cent.

Group V.
No. of Per
cases, cent.

Very complex.

Above average
Average .

Simple .

Very simple .

0I38

12 J

si*

20 j

I ]. 8 o

23 J

2I78

19 J

8 }62

13 J

5 } 2 °

o } 2 3

Total cases

2 {c). Mental State of the Patients.

Bolton was able to show, from personal investigation into the
mental state of the patients included in his series, that the
groups grade very closely with the degree of dementia present
at the time of death. Unfortunately no data are available

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237

which will enable me to make a pathological and clinical correla¬
tion of the cases in this series with any degree of accuracy. The
form of insanity from which the patient was supposed to have
suffered at the time of death is stated in the return supplied to
me as a matter of routine practice by the medical officer in
charge of the case, the return being made out in accordance
with the schedule of the Commissoners in Lunacy. According to
this schedule of forms of insanity the medical officer is under
no obligation to state in connection with certain of the chronic
cases whether he considers that any dementia existed or not.
Consequently in the majority of such instances he has expressed
no opinion on this matter, and the returns, therefore, do not
always supply information in the form which is necessary for
the present purpose. At times such a statement as “ mania
with mild dementia ” occurs ; this case should clinically, accord¬
ing to Bolton, come under Group II. Another return may
simply state “ chronic melancholia.” Inquiry as to this case
may elicit the reply that a moderate degree of dementia existed,
but as the symptoms of melancholia apparently predominated
no mention was made of dementia in the return ; such a case
should clinically be placed in Group III. As personal inquiries
have not been made in every instance, the returns, if any use
were to be made of them, would have to remain as they stand.
This being so, even if the cases were arranged under two head¬
ings only— viz., (1) insanity other than dementia, including all
those in which no mention of dementia occurs, and (2) all the
dementias—for the reason just stated a number of cases would
inevitably be classed as insanity other than dementia, which
properly should have been placed under dementia. On the
other hand, some cases would probably be included under
dementia in which no dementia existed at all if by this term is
to be understood “ a permanent psychic disability,” for there is
no knowing at the present time in what sense the term may
have been employed by a junior medical officer of perhaps only
very limited clinical experience. Apart from this there are the
difficulties of diagnosis to be considered—difficulties which no
doubt diminish as experience increases. Attention has already-
been directed to certain bodily conditions, the most important
being tuberculosis, which may modify the ordinary intracranial
appearances, although they do not necessarily do so. The same
bodily conditions may complicate the diagnosis from the
LVI. 16

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MORBID ANATOMY OF MENTAL DISEASE, [April,

clinical aspect; indeed, difficulties of this nature are likely to
be much greater ante-mortem than post-mortem. The mental
lethargy and confusion exhibited by some patients who suffer
from a more or less long-standing illness may be readily mis¬
taken for a permanent psychic disability. It has previously
been shown that the percentage of deaths from tuberculosis is
highest in Groups I and II and considerably lower in Groups
IV and V ; it is presumably, therefore, in connection with cases
in the first two groups that mistakes in diagnosis—if such
mistakes have been made—are the more likely to have occurred.
This may explain why such a large proportion of cases included
under Group I {vis., 20 per cent, of the males and 41 per cent.
of the females) were considered to have suffered from dementia,
although all, post-mortem , showed no cerebral wasting nor any
other intracranial morbid appearance.

Owing to these various considerations the returns relating to
the mental state of the patients are of little or no value for the
purpose in view. If, however, the cases are roughly divided
into the two classes before indicated, viz., according to the
absence or presence of dementia as stated in the returns, it is
found that in the majority of the cases in Groups I and II (70
per cent, and 5 4 per cent, respectively) no mention is made of
dementia, whilst the larger proportion of the cases in Groups
III, IV, and V (67 per cent., 77 per cent., and 81 per cent.
respectively) were regarded as having shown symptoms of
dementia. Thus, although the data concerning the mental
state of the patients in this series are by no means satisfactory,
such general conclusion as can be drawn from them agrees, to
some extent, with our previous impressions regarding the close
association existing between the intracranial morbid appear¬
ances and the presence of dementia.

Conclusions.

The different groups have now been considered from the
aspects of the average weight of the cerebral hemispheres, of
their convolutional pattern, and, in so far as the data available
will allow, of the mental states of the patients included in the
series. It has been shown that the hemispheres in Groups III
to V—those which had undergone the most wasting, and which,
therefore, presumably should have belonged to the patients

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239

who exhibited the most dementia—were, taken as groups,
originally the heavier ones as compared with those in Groups
I and II. It has also been shown that the hemispheres in
Groups III to V possess,on the whole, the better convolutional
pattern, and are relatively the more free from cerebral stigmata.
If developmental deficiency in weight of the cerebrum, sim¬
plicity of convolutional pattern, and the frequent presence of
cerebral stigmata—not necessarily any one of these features
by themselves, nor in individual instances, but considered as a
general average of a large total—are to be looked upon as
criteria of amentia, then the majority of the hemispheres
included in Groups I and II were derived from cases of
amentia. This is as far as a generalisation made from statistics
gathered from macroscopic sources will enable us to go. Such
a generalisation will not, of course, apply in certain individual
instances, for two additional factors of the utmost importance
require to be taken into consideration, viz., the depth of the
cerebral cortical layers and the degree of development of the
neuronic elements in these layers. For example, a compara¬
tively large cerebrum may be found, on microscopic examination
and measurement, to possess a poorly developed and relatively
shallow cortex, and vice-versA. This, however, does not imply
that a generalisation such as the above is without value.

In going over the details from which Table I was compiled,
it was found that hemispheres of almost all weights within the
ordinary limits occurred in all the groups. The following
table shows the number of instances in each group (with the
percentages) in which the hemisphere weight was above, and the
number in which it was below, that of the average weight of
the series of cases. This average weight is, of course, con¬
siderably below that of the normal.

Whilst the general result shown by Table III is somewhat
similar to that exhibited by Table I, it will be seen that in a
large number of instances the hemispheres in Groups I and 11
weighed more than the average of the series. These groups
also, as has been previously shown, contain a fair percentage of
cases with hemispheres of at least average convolutional pattern.

It might be argued that the above conclusions are not valid
because a certain proportion of cases with hemispheres of good
weight and well-developed pattern are to be found in the earlier
groups. Groups I and II, however, it may be pointed out,

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morbid anatomy of MENTAL DISEASE, [April,

contain the hemispheres of a number of recent or comparatively
recent cases, some of which doubtless would have been dis¬
charged recovered had the patients not died of some inter¬
current illness, whilst others, it is reasonable to suppose, would
in the course of time have passed on to one or other of the
later groups. In some instances these cases possessed hemi¬
spheres of a weight considerably above that of the average of
the series, and the inclusion of these in Groups I and II natu¬
rally increases the average weight of the hemispheres in these
groups. Conversely, many hemispheres which were originally
small (and of poor convolutional pattern) have passed out of
the earlier groups into the later, and these reduce the average
weight of the hemispheres in the later groups.

Table III. — The Number of Cases in each Group in which the
Hemisphere Weight was above , and the Number in which it
was below , that of the General Average Weight of the Series.
General Average Weight of the Series : Males , 554 grammes ;
Females , 5 00 grammes.

Males.

Females.

No.

cases.

No.

above

general

average

weight.

Per

cent.

No.

below

general

average

weight.

Per

cent.

No.

cases.

No.

above

general

average

weight.

Per

cent.

No.

below

general

average

weight.

Ptr

cent.

Group I .

«3

„ II • •

„ HI • •

6 3

„ IV . .

I I

•3

46;

1 ” v ■ ■

3 i

Total cases .

149

152

3. Factors which may Influence the Passage of the Cases from
the Earlier to the Later Groups.

Some consideration may now be given to the chief of these
factors, viz., (a) the age of the patient, ( b ) the duration of the
attack of insanity, ( c ) the presence or absence of degeneration
of the cerebral vessels.

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24 I

In the following tables the average age at death of the
patients in the different groups and the average duration in the
asylum are placed side by side.

Table IV.— Average Age at Table V.— Average Duration

Death. in Years.

Males.

Females.

Males.

Females.

Group I .

„ 11 • •

„ II • •

„ III . .

„ HI ■ •

IV . .

„ IV . .

. V . .

„ V . .

General average

age .

52 |

duration •

{a) Age of the patients. —Although the average age at death
together with the average duration in the asylum increases as one
passes from Groups I and II to the later groups, yet included
in Groups I and II are to be found patients of almost all ages.
Thus, in Group I, male, 4 out of 20 patients (20 per cent.) were
above the general average age of 49, the oldest being 66
years of age ; in Group I, female, 3 out of 34 (9 per cent.) were
above the general average age of 52 years, the oldest being 59.
In Group II, male, 11 out of 37 (30 per cent.) were above
the general average age, the oldest being 63 ; Group II, female,
contains patients of all ages up to 72 years, and 19 out of 47
(40 per cent.) were above the general average age of 5 2 years.

( 6 ) Duration of the attack of insanity. —A large proportion of
the cases in Group I, both males and females, were recent or
fairly recent ones, yet one male was in the asylum for twenty
years, one female for eleven years, and many others for periods
varying from four to nine years. The patients included under
Group II, although only slight wasting of the cerebral hemi¬
spheres existed, had been in the asylum for varying periods up
to thirty-one years in the case of the males and eighteen years
in that of the females, in fact, 25 out of the total 84 cases in
this group (i.e., 30 per cent.) had been in the asylum for over the
general average duration period of seven years.

Thus it would appear that neither the age of the patient nor
the duration of the attack of insanity is in itself an im-

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242 MORBID ANATOMY OF MENTAL DISEASE, [April,

portant factor determining the passage of any given case from
one of the earlier groups to one of the later.

(c) Degeneration of the cerebral vessels .—The following tables
(VIrt and VI/;) show the total amount and the degree of
cerebral vascular degeneration found in all the cases, also (VI£)
the number of patients with vascular degeneration in each group
who were below, and the number of those who were above the
general average age for the males and females respectively.

Table VI a.—Number of Cases of Cerebral Vascular Degenera¬
tion in each Group *

Males.

No. of
canes in

A rerage
age of

Number of cases with vascular
degeneration.

Group

percentage

vascular

Group per¬
centage of
moderate
and severe

Slight.

Moderate.

Severe.

degene¬

ration.

degene¬

ration.

Group I

—

„ II •

4 2

„ HI ■

„ iv .

„ V .

148

Table VI«— continued.

Females.

No. of
cases in
group.

Average
age of
group.

Number of cases wit!

degeneration

Slight. Moderate

vascular

Severe.

Group

percentage

vascular

degene¬

ration.

Group per¬
centage of
moderate
and severe
vascular
degene¬
ration.

j Group I

—

! „ 11 .

10'6

: „ hi .

1 „ iv .

I V .

I I

151

l 6

* One male and one female omitted as insufficient data were recorded in these
cases.

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243

TABLE VI b.—Number of Cases with Cerebral Vascular Degene¬
ration above and below the General Average Ages of 49
years {Males') and 52 years {Females).

Males.

Number of cases with vascular degeneration.

No. of cases
in group.

Slight.

Moderate.

Severe.

Below

49 years.

c a

* t*
< ft

S St

■a £
< ?

Average

age.

> ft

I?.

< ft

J £
< s

Average

age.

tfj

i 5

0 g.
« »
as ▼

« I «

B . g§

< ft | < *r

Average

age.

Group I

5 '

—

„ II .

—

6.1

—

- 1

„ III .

»3

5 «

36 3

„ IV .

—

— 1 6

„ V .

- 14

Total

148

—

Table VI b — continued.

Females.

No. of cases
in group.

Number of cases with vascular degeneration.

Slight.

Moderate.

Severe.

Below

52 years.

bfi

I-

< ct

£ «

0 V

Average

age.

Above

5 j years.

I . 5
Lgg.
< « i ce S.

Average

age.

Above

52 years.

Average

afire.

Group I

- .

» II

—

70 | —

—

» HI

—

65 —

—

iv .

—

6l -

—

„ V .

■

69 —

Total

151

—

When attempting to make any correlation between degenera¬
tion of the cerebral vessels and cerebral wasting, it is no doubt
advisable to exclude instances of slight vascular degeneration,
as it is probable that, even if vascular degeneration is able to
initiate or to hasten the progress of cerebral dissolution, it is

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only the moderate and severe forms of atheroma which would
have any very appreciable effect. As the number of examples
in the above tables of moderate and severe degeneration of the
cerebral vessels is rather small in any of the groups, the male
and female cases may be considered together. It will then be
seen that no instance of moderate or severe atheroma occurred
in Group I. In Group II there were 7 examples out of 84
cases, or 8 per cent.; in Group III 27 out of 76, or 35*5 per
cent .; in Group IV 37 out of 52, or 71 per cent. ; and in Group
V 29 out of 35, or 83 per cent. Thus decided degeneration
of the cerebral vessels and definite cerebral dissolution appear
to be associated features.

This correlation can also be shown in another way. It has
been stated that whilst the greater number of the hemispheres
in Groups I and II are of less weight than the majority of those
in Groups IV and V (and certainly were originally so if the
loss of weight due to wasting of those in the two latter groups
is considered), yet hemispheres of almost all weights within the
usual limits occur in all the groups. Table III shows the
number of hemispheres in each group having a weight above,
and the number with a weight below that of the general average
of the series of cases. The 71 cases in Groups I and II, male
and female, with either no or only slight cerebral wasting, which
possessed a hemisphere weight above that of the average of the
series, showed no sort of constancy either as regards the age of
the patients, which varied from nineteen to seventy years, or
in respect to the period of duration in the asylum, which
ranged from a few days to twenty years. All these cases, how¬
ever, agreed in being free from severe degeneration of the
cerebral vessels, and only 4 instances of moderate atheroma
(5*6 per cent.) occurred in the whole 71 cases. In Groups IV
and V, male and female, there are 46 cases in which the hemi¬
sphere weight was below that of the average of the series.
Whilst the ages of these patients was generally higher, and the
duration period usually longer than that of the cases in Groups
I and II, the most striking feature exhibited by these cases in
Groups IV and V, with marked or severe cerebral wasting, was
the prevalence amongst them of moderate or severe degenera¬
tion of the cerebral vessels, this being found in 38 cases (6
moderate and 32 severe) or 82 per cent, of the whole.

Group III occupies an intermediate position between Groups

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245

II and IV with regard to the prevalence of cerebral vascular
degeneration as it does in respect to the degree of cerebral
wasting. There is a wide gap between the percentage amount
of moderate and severe atheroma in Group III and in Groups
IV and V, taken together, particularly with regard to the
amount of severe atheroma. This gap—represented in the
matter of severe atheroma by 17 per cent, on the one hand and
56 per cent, on the other—suggests that in the majority of
instances cerebral dissolution only reaches a moderate stage in
the absence of gross degeneration of the cerebral vessels. In
a number of the rarer cases in which cerebral dissolution was
marked, although there was no gross naked-eye degeneration
of the cerebral vessels, microscopical examination has shown a
special affection of the smaller vessels and considerable neuro¬
glial proliferation. These cases, it is of interest to note, have
not infrequently been regarded clinically as probably being
examples of general paralysis.

Conclusions.

The apparent effect upon cerebral dissolution of age, of
duration of the attack of insanity, and of degeneration of the
cerebral vessels, may be summarised as follows :

(1) Neither the age of the patient nor the duration of the
attack of insanity is in itself an important factor concerned in
the production of, or in hastening the progress of, cerebral
dissolution.

(2) Atheroma and age may be independent of one another.

(3) It is a matter of general experience that simple senility
is not necessarily associated with gross degeneration of the
cerebral vessels ; also that cerebral vascular degeneration, even
if gross, does not necessarily lead to or hasten the progress of
cerebral dissolution, for although no instance happens to be
included in this series, very occasionally a case is met with
showing severe atheroma but little or no cerebral wasting.

(4) Whilst propositions 2 and 3 are admittedly true, it is
evident that cerebral vascular degeneration and cerebral dis¬
solution are commonly concurrent phenomena, and that “ the
percentage amount and also the severity of naked-eye degene¬
ration of the cerebral vessels vary directly with the degree of”
cerebral wasting present.

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246 MORBID ANATOMY OF MENTAL DISEASE, [April,

(5) In the majority of cases cerebral dissolution only reaches
a moderate stage in the absence of gross degeneration of the
cerebral vessels.

Although the above line of argument in the treatment of this
subject is somewhat different to that adopted by Bolton, the
general conclusions arrived at are very similar.

Part II.

Comparison of Results Obtained at Claybury Asylum

AND AT RAINHILL ASYLUM.

I. The Weights of the Cerebral Hemispheres.

It has already been stated that there are grounds for believing
that the mean weight of the normal brain varies to some extent
in different localities. It is therefore of interest, for this and
for other reasons, to compare the table of weights of the
cerebral hemispheres obtained from Rainhill Asylum with that
already published by Bolton concerning the weights of the
hemispheres at Claybury Asylum. Although Bolton did not
expressly exclude all idiots and imbeciles from his statistics, yet
on going through his data it will be found that there are in his
series of non-epileptic cases only eight male and female idiots
and imbeciles altogether—all in Group I.( 4 ) Reference to the
brain weights of these shows that their inclusion makes no
appreciable difference to average weight of the whole series of
hemispheres in this group, so that the data contained in the
subjoined table are for all practical purposes quite comparable.

The sets of figures derived from Claybury and from Rainhill
both point to the similar conclusion that the weights of the
cerebra in Groups III to V must have been originally greater
than that of those in Groups I and II. The Rainhill figures
are, however, the more striking of the two, because of the
greater weight of the hemispheres—as compared with those
from Claybury—in Groups III, IV, and V, particularly of those
in the two latter groups.

The general average weight of the hemispheres in all the
groups is : for Claybury, males, 538 grm. ; females, 471 grm. ;
and for Rainhill, males, 554 grm. ; females, 500 grm. It will
be noticed that the Rainhill hemispheres are heavier than the

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1910.] BY GEORGE A. WATSON, M.B.

Table VII. —Comparison of the Weights of the Cerebral Hemi¬
spheres from Clay bury and Rainhill Asylums.

Males.

Claybury.

Rainhill.

No. of
cases.

PtT ant.
of total
cases.

Average
weight
of hemi¬
spheres.

No. of
cases.

Ptr am.
of total
cases.

A rerage
weight
of hemi¬
spheres.

Group I. —No morbid
appearances

553

540

Group 11. —Slight mor-

bid appearances

5C5

569

Group III.—Moderate

morbid appearances .

551

561

Group IV. — Marked

| morbid appearances.

509

2 4

lC>

557

| Group V. — Gross mor-

bid appearances

513

545

_ i

Total
number
of cases.

log

General
average
weight
of hemi¬
spheres.

538

Total
number
of cases.

149

General
average
weight
of hemi¬
spheres.

554

Table VII— continued.

Females.

Claybury.

Rainhill.

No. of
cases.

Per cent.
of total
cases.

Average
weight
of hemi¬
spheres.

No. of
cases.

Per cent.
of total
cases.

Average
weight
of hemi¬
spheres.

Group I—No morbid

1 appearances

499

510

! GroupII. — Slightmor-
1 bid appearances

480

494

Group III. — Moderate
morbid appearances.

482

508

Group IV. — Marked
morbid appearances .

455

506

Group V. — Gross mor¬
bid appearances

437

482

Total
number
of cases.

255

General
average
weight
of hemi¬
spheres.

471

Total
number
of cases.

152

General
average
weight
of hemi¬
spheres.

500

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248 MORBID ANATOMY OF MENTAL DISEASE, [April,

Table VIII. —Average Ages at Death.

Claybury.

Rainhill.

Males.

Females.

Males.

Females.

Group I .

» 11 .

..HI.

5 «

IV.

,, v.

7 °_

General average age .

Claybury ones in all the groups excepting male Group I, in
which the Claybury hemispheres exceed those from Rainhill
by 13 grm. ; there is, however, a difference of only 4 grm. in
the hemispheres in male Group II derived from the two places.
In all the other groups, male and female, there is a more or less
decided difference in the weight of the hemispheres obtained
from the two institutions—a difference in favour of Rainhill.
This difference in Group III is 10 grm. in the case of the males
and 26 grm. in that of the females ; in Group IV it amounts to
as much as 48 grm. in the males and 49 grm. in the females ;
and in Group V to 32 grm. in the males and 45 grm. in the
females. It is particularly significant that the difference is
greatest, on the whole, in Groups III to V, which groups have
been shown to contain, as groups, not only the cerebra which
were originally the heavier ones, but also those which possessed
the better convolutional pattern. These also are, of course, the
cerebra which have suffered most from dissolutive changes^ 1 )

It might be suggested that the greater mean weight of the
Rainhill cerebra can be partly accounted for by the supposed
taller stature of the northern people. Marchand {loc. cit.), how¬
ever, states that there is no constant relationship between body-
weight and brain-weight, although the mean weight of the brain
in males and females of short stature is rather less than that
of those of average height. Also, that the smaller size of the

(*) I also have the impression, derived from my own experience at the two
asylums, that the Claybury cerebra were of a generally simpler pattern—although
naturally with many exceptions—than those at Rainhill, but an impression of
this kind is not of any great value, and may indeed be fallacious.

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249

female brain is not dependent on the lower stature of the female,
for the mean weight of the brain in women is less than is that
of men of equal height. Judging from the older statistics of
Marshall {loc. cit.) the influence of stature upon brain-weight
appears to be rather more marked. If, however, the conjoined
cerebellum and pons is allowed for according to Huscke’s ratio,
the greater weight of each cerebral hemisphere in the taller
people is not very considerable, and it is greater in the males
than in the females. The matter in any case is of little impor¬
tance in so far as the present statistics are concerned, for, owing
to the kindness of Dr. Robert Jones, I have been able to make
a comparison between the average heights of the patients
admitted to Claybury and to Rainhill Asylums. Dr. Jones
states that the average height of all the admissions to Claybury
Asylum during 1909—at least of all the adults whom it was
possible to measure—was, for 203 males 66 T V in., and for 219
females 61 i in. The average height of the adult patients
admitted to Rainhill Asylum during the years 1908 and 1909
was, for 316 males 65 in., and for 264 females 60J- in. These
figures are sufficient to indicate that there is no difference in
stature between the two asylum populations such as would be
likely to appreciably affect the weight of the cerebral hemi¬
spheres.

2. The Percentage of Cases in the Different Groups. (See
Table VII [p. 247].)

With regard to the percentage of cases which have been
placed in the respective groups at Claybury and at Rainhill, if
the males and females are taken together it will be seen that a
greater proportion of cases belonging to Groups I and 11 occurred
at Rainhill than at Claybury, and a lesser proportion belonging
to Groups IV and V, especially to the two latter Groups (II and
V) in each instance. The former fact may perhaps be accounted
for by the non-existence in the County of Lancaster of a body
similar to the Metropolitan Asylums’ Board. The latter fact is
somewhat difficult of explanation excepting on the grounds that,
apparently for local administrative reasons, fewer recent, or
fairly recent, senile cases were admitted to Rainhill than to
Claybury. It will be seen from Table VIII (p. 248) that the
average age at death is less in all the groups except one (female

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Group I) at Rainhill than at Claybury, and that in Groups IV
and V the difference amounts to as much as ten years in each
group in the case of the males and to three years in each group
in that of the females. Had there been a greater proportion of
elderly people with the commonly concomitant vascular degenera¬
tion amongst the Rainhill cases, it is probable that the percentage
of cases allotted to Groups IV and V would have been higher.
Whatever the explanation may be, I was surprised, some little
time after taking up my duties at Rainhill, to find few instances
of gross cerebral wasting (exclusive of cases of general paralysis)
compared with the number I had been accustomed to see at
Claybury, and it is interesting to have this impression confirmed
by further experience and by the evidence of statistics.

3. The Comparative Amount of Degeneration of the Cerebral

Vessels.

Bolton’s tables dealing with the question of vascular degene¬
ration in his Claybury cases are compiled somewhat differently
to mine, but the two sets of statistics can be readily contrasted.
It would appear that not only is degeneration of the cerebral
vessels more prevalent at Rainhill that at Claybury, but that
it is found at an earlier age in the former institution. Possibly
this can be accounted for by differences in the habits of the
general population of the two districts. With regard to the
matter of “ drunkenness ” and “ the comparative prevalence of
insanity ascribed to intemperance,” the county of Lancaster is,
or was, according to the Fifty-ninth Report (1905) of the Com¬
missioners in Lunacy, one of the blackest patches on the map
of England.

As it has been stated that vascular degeneration appears to
be the chief factor in hastening the progress of cerebral dissolu¬
tion, it may be thought difficult to reconcile the fact of the
relatively greater prevalence of drunkenness in the county of
Lancaster with that of the lesser proportion of cases belonging
to Groups IV and V at Rainhill as compared with Claybury.
It is, however, only reasonable to suppose that vascular degene¬
ration, incited by such an extraneous cause as alcoholic excess,
and occurring at a comparatively early age, would have less
influence in hastening the progress of cerebral dissolution than
would the gross vascular degeneration which is so commonly

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BY GEORGE A. WATSON, M.B.

251

associated with senility, and which is only one of the many
evidences of wearing out of the whole bodily tissues, including
the brain. As has been shown, it is the class of case with the
atheroma of senility which appears to have been admitted with
less frequency at Rainhill than at Claybury.

General Conclusion.

Many of the points which have been touched upon in this
paper have previously been dealt with by Bolton, from both
clinical and pathological aspects, and any reader interested in
the subject may be referred to his published work for further
details.

Consideration of the weights of the cerebral hemispheres in
their respective groups, whether derived from Claybury or from
Rainhill, have led to the same conclusion—a conclusion which
has been strengthened by the investigation of the convolutional
pattern of the Rainhill cerebra. I wish to especially emphasise
the fact that this inference can be drawn very largely from a
consideration of intracranial appearances alone.

A general conclusion, the result of a study of the cases in this
series—a series from which, it should be remembered, all cases of
idiocy, imbecility, epilepsy, general paralysis, and gross cerebral
lesion are excluded—is, that all cases of “mental disease” may,
on the data furnished by intracranial appearances, be divided
into two main classes. Cases with cerebra which are develop-
mentally deficient in weight and in convolutional complexity,
and which are frequently characterised by the presence of an
unusual number of other stigmata, but which exhibit no, or only
slight, intracranial morbid appearances, and are hence not
prone to cerebral dissolution. These manifestations of cerebral
subevolution, therefore, suggest that such cases should be
regarded clinically as examples of amentia in contra-distinction
to the second class of case, which possessed cerebra of origin¬
ally greater weight and more highly evolved convolutional
pattern ; in the latter class of case the cerebrum has undergone
dissolution to a more or less extent, and such cases should
presumably therefore be looked upon clinically as cases of
dementia.

Lest it should be objected that there is a certain recovery
rate amongst the insane, and that cases of recovery do not come

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252 MORBID ANATOMY OF MENTAL DISEASE. [April,

under either of the above described classes, it may be remarked
that cases of mental disease which recover may be roughly
divided into two clinical types: (1) Cases suffering from a first
attack, and liable at any period to a second attack, and cases
of relapsing insanity ; (2) cases of obvious cerebral toxaemia—
from whatever cause, but often primarily at least, incited by
alcoholic excess—in which affection of the cortical neurons has
not been sufficiently intense to prevent recovery from taking
place. Clinical evidence indicates that numbers of the first
type of case, which died from some intercurrent illness, are
included in Groups I and II, and to a less extent in the later
groups ; and as regards the second type of case, a certain
number of recent confusional cases exist in the earlier groups,
and numerous examples of a more severe, but otherwise similar
type, in which recovery has not taken place, occur in the later
groups. The present series of cases may therefore be regarded
as being typical of “ mental disease ” as a whole.

My main object in undertaking this investigation was to
determine whether the conclusions arrived at concerning the
Claybury Asylum series of cases w r ould find their counterpart
in the series obtained from Rainhill. Whilst the conclusions
drawn from a study of the material derived from these two
institutions are generally identical, it has been found that
certain local differences exist, particularly with regard to the
weight of the brain, to the proportion of cases which should be
assigned to the respective groups and to the prevalence of
degeneration of the cerebral vessels. In view of these local
differences it is, perhaps, not too much to suggest that statistics
similar to those which have just been under consideration, and
prepared by independent workers in different asylums, would
lead to the acquisition of interesting and valuable information.
By some, also, the whole matter may seem in need of further
inquiry, for a survey of the text-books and monographs which
have been published in recent years on the subject of mental
disease would almost lead one to suppose that relatively little
importance can be attached to intracranial appearances, and
that no special relationship exists between the clinical pheno¬
mena of mental disease and the subevolutory manifestations
or dissolutory changes found inside the cranium after death.

(') The references to Bolton’s papers dealing with the subject are: (i) Arch, of
Neurol., vol. ii, 1503; (2) Brain, part cii, 1903; (3) Journ. of Mcnt. Sci., April,

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1910.] CARE AND TRAINING OF FEEBLE-MINDED.

253

1905, and April, 1906.—(*) Journ, of the Scientific Soc. of Saxony, vol. xxvii,
p. 380: abstract in Ctntralb. f. die Physiol., 1902. p. 294.—( 3 ) The above data
are quoted in Quoin’s Anatomy, vol. iii. part i.—(■*) See Arch, of Neurol., vol. ii,
p. 438, and Journ. of Ment. Sci., April, 1905, p. 20.

The Care and Training of the Feeble-minded. ( 1 ) By

Archibald R. Douglas, L.R.C.P., L.R.C.S.Ed., Medical
Superintendent, Royal Albert Institution, Lancaster.

From the earliest ages in the history of man, we find evidences
of the existence of beings stunted in body and defective in mind,
whose relations with their fellows varied through the centuries.
At one epoch they were exalted almost to the level of a deity,
and their symptoms were interpreted as manifestations of Divine
will. At another they were looked upon with loathing and dis¬
gust, not unmingled with fear. Still later, they were either the
playthings of kings or the victims of cruel jibe and blow, and
their existence at the present day, and the associated conditions
of insanity, crime and intemperance, constitute one of the most
serious, if not the most serious problem which a civilised com¬
munity is called upon to solve.

To Itard, of the Bicetre, belongs the honour for all time of
being the first to recognise the condition of the imbecile and to
take steps for his amelioration. The first idiot to be scientifically
treated was the so-called “Savage of Aveyron ” in 1B01 ; this
story is too familiar to need repetition here. Guggenbuhl, in
Switzerland, began to study cretinism in 1839, and opened a
school on the Abendberg in 1842 simultaneously with Saegert,
who did the same in Berlin. In 1846, Kern established a
school at Leipzig. In 1842, the Eastern Counties’ Asylum at
Colchester was opened. Scotland followed with her first institu¬
tion in 1852, and in 1853, the foundation stone of the Earlswood
Asylum was laid. The first American institution for the idiot
was opened in 1846. It is worthy of note that the movement
for the amelioration of the condition of the imbecile was solely
the result of private charitable enterprise, absolutely unaided by
the legislature. The untiring efforts and the able advocacy
of the elder Seguin, first in Paris, and afterwards in America, of
Conolly, Andrew Reed, and our own Dr. de Vitr£ in this country,
gave the movement a tremendous impetus. Institutions at

LVi. 17

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Bath, Earlswood, Colchester, and later on at Exeter, Birming¬
ham and Lancaster opened their doors, and money was sub¬
scribed lavishly to enable this good work to go on. Thus
commenced the mighty undertaking which has since undergone
such vast development throughout the United Kingdom, and
particularly in America. The primary object aimed at in the
early days of the work was the education of these children, in
fact to fit them as far as possible for the duties and enjoyments
of life. With the boundless enthusiasm of workers in new
fields, those pioneers obtained brilliant results in many cases,
and the possibilities of the education of the idiot were somewhat
over-estimated. Whilst a few boys and girls were educated to
such a degree as to enable them to read and write, the majority,
alas, were found to be incapable of learning, chiefly because of
their lack of the faculty of attention. Again, those who had
been educated were found to be severely handicapped by the
lack of sufficient mental balance to carry them along in the
absence of control. As long as individuals of this kind remained
within the walls of the institution, all went well, but when their
term of training was completed, and as soon as they attempted to
take their places in the outside world, very few became useful
members of society. Those who did succeed were invariably
possessed of relatives or friends, under whose aegis they were
protected and encouraged. Nowadays it is the care and protec¬
tion of these children which ought to be our premier considera¬
tion ; without this, attempts at education are little better than
waste of time. In the first place, such custody provides them
with the proper hygienic surroundings, which are practically
only found in our public institutions. Few indeed of these
children possess a perfectly normal physique, their faulty
organisation is easily thrown out of gear, and when this occurs,
it is at once reflected in the mental state of the individual.
Thus before the boy or girl can be expected to benefit from
efforts made to educate them, it is absolutely necessary that
they should be maintained in a condition of health as near to
the normal as their defective constitutions v/ill permit, and with
this object, constant and careful medical supervision is of the
utmost importance. How many are the physical shortcomings
in the patient which escape all eyes but those of the educated
physician is only known to those who have experience in institu¬
tions of the kind. Occasional stupidity, which is too often

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255

attributed to their mental state alone, may be the result of
temporary depression of the general health, or of defects of
vision and hearing, by which the sensorium is deprived
of normal educational stimuli. Along with efficient medical
care, there is another factor which operates powerfully
in the well-being of the feeble-minded, and that is the
general environment provided by residence in a well-regulated
institution. Isolation is characteristic of the imbecile, and
is brought about by his inability to be a partaker in the
ordinary daily routine of persons of normal intellect. This
deficiency is, beyond doubt, acutely felt by the individuals of
the higher grades of defectives ; it causes them to shrink into
themselves, and to avoid the intercourse of their fellows, for the
simple reason that they are acutely conscious of the depressing
influence of their own lack of capacity, which is being con¬
tinually demonstrated to them by unfavourable comparison.
The remedy for this is obviously the removal of the individual
into the society of his peers, which immediately provides to the
minds of those who are not quite impervious to impressions,
the healthy stimulus of rivalry existing among the members of
a community endowed with more or less equal gifts. The
stimulus to the moral senses afforded by the commendation
elicited by correct behaviour, the increased diligence resulting
from judicious rewards and encouragement, all create a higher
form of morality, the attributes of which are industry, honesty,
and self-respect, and it is to the attainment of this object that
the Royal Albert Institution has for over forty years striven with
constant earnestness of purpose to accomplish. But what are
the advantages to be gained by the residence of one of these
feeble-minded children in a special institution ? These are to
be found in the application of the simpler amenities, obliga¬
tions, and observances which ordinarily hold in a normal com¬
munity ; this tends to transform the institution into a little
world of its own for the less afflicted inmates, where the usual
sombre panoply and insignia of detention do not exist, but
where loss of prestige overtakes the individual who offends
against his fellows, or commits an infraction of the “ law,” and
it is surprising to see how great a part the desire to stand well
in the eyes of others plays, even in a colony of the mentally
defective. Here, beyond the deprivation of an entertainment
or a religious service, there are no punishments ; a constant

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gentle, yet firm system of discipline, together with the example
of obedience shown by others, is sufficient to ensure amena¬
bility, and in time even the most disorderly child is sure to be
subjugated. It is when away from this influence that deteriora¬
tion commences, and is often noticed by parents who have
their boy or girl home for a holiday—indeed, it is not uncommon
for some of them to ask for the child to return to the institu¬
tion after ten days or a fortnight’s absence, as they are quite
unable to exercise proper control. Contact with the outside
world we find does not tend to improve those of our patients
who are without relatives or friends to guide them ; they are
unfortunately readily responsive to evil influences, and less
likely to adhere to a strictly moral line of conduct. Although
surprisingly few get into actual trouble, under stress of circum¬
stances they find it difficult to steer an absolutely straight
course. Dealing with the subject of training and education, I
am of opinion that to expect systematic improvement from any
but the highest grade imbeciles, merely from three or four
hours a day in a school, apart from care out of school hours, is
somewhat unreasonable. The patient housed in a properly ,
managed institution is learning a very great deal out of school
—his faulty habits are corrected, his manners improved, he is
being taught to eat his food decently, and in a great number of
cases some rudiments at least of personal cleanliness are being
instilled into him. Even in the matter of play hours, his
recreation is so directed that he derives the maximum amount
of benefit from it. I am afraid this is where the special schools
will be found wanting, as the children are only under the eye
of the teachers for a limited time, and at home the amount of
supervision necessary is often lacking. Many of them come
from poor, squalid, and often dirty homes, where the defects of
the parents themselves preclude the possibility of adequate
oversight. It is therefore obvious that the risk of losing any'
benefit they may have gained in school is very' great. Again,
this imperfect system of instruction is only' operative up to the
age of sixteen, a time which is undoubtedly the most critical
in their life history, both for themselves and particularly in the
case of the girls for the next and succeeding generations. It is
the child who, only slightly' defective, may, as the result of
education, acquire a superficial veneer allowing of a return
to the community, and who constitutes thereto a very grave

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danger. The feeble-minded child is rarely an accident, and in
the great majority of cases the causes at work can be traced in
the parents themselves. Unfortunately, in the existing state
of the law, should we segregate all those who at present are
generally returned as possessing some grade of mental defect, we
have practically left untouched the whole breeding-ground in
which defectiveness has its origin. With reference to the
education of the patients here, and in similar institutions, let
us first consider the teachers. A few years ago, the schools
were conducted by some half dozen highly certificated, and
at the same time, highly paid teachers. After considerable
experience of these ladies, we came to the conclusion that
the work could be more efficiently performed by intelligent
nurses, with, of course, an experienced school-mistress at
their head, and we have since found that our conclusions
were well founded, namely, that the men and the women
who had experience of the patients in the wards of the
Institution were the most successful instructors. As atten¬
dants and nurses they gained information as to the physical
condition of the imbecile, his idiosyncrasies as to food, pecu¬
liarities of temper, his varying moods, sympathies and anti¬
pathies, and have learned tact and patience, without which
their efforts would be of but little avail. Next, what is the
best system to adopt ? Surely that having for its end some
really material object, which ought to be the provision of a
simple elementary education, which not only can be easily
assimilated, but also used to practical advantage. The time
is wasted which is spent on the cultivation of one faculty
alone, and it is a matter of common knowledge that this
abnormal development is constantly associated with other
defective intellectual and moral senses—the brilliant performer
of difficult classical music who is deficient in other respects,
mentally and morally, is no longer hailed as a desirable.
Sometimes we find that certain patients can never make
appreciable progress in school, and time spent there in the
listless contemplation of a blackboard is lost ; some of those
who fail in ordinary book-learning may do fairly well in the
workshops. Industrial training may with advantage go hand
in hand with scholastic instruction, but in no case should an
inmate continue in school, however young, who is able to read
and write ; his place is on the industrial list learning a trade.

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The elements of several of the industrial occupations could
well be taught in school, as is done here, leaving the corres¬
ponding workshops available for the more advanced pupils.
Nothing is better suited for the lower grade patients than
simple outdoor work in the gardens and grounds. With the
limited time at our disposal to-day, perhaps the best way of
describing the mode of education and training would be to begin
by giving a brief account of the career of the patient from the
time of his admission to the Institution. His first experience
is a fourteen days’ sojourn in the reception house, apart from the
main building and the other patients. This is necessary for
two reasons, one being that a most important safeguard is thus
provided by an isolation department in the event of infectious
disease occurring among the newcomers. The other object
fulfilled by this short term of segregation is the facility it
offers for observation and diagnosis. This is extremely
valuable, and enables a tolerably correct classification to be
made, and the proper department selected for each particular
case. “ Home sickness,” which is never very severe, is soon
vanquished by the attention and kindliness of experienced *
nurses before the boy or girl enters (to them) the greater world
of the Institution. Next come interviews with the heads of the
school staff, who, in the course of a short examination, soon
find out the capabilities of each, after which they are admitted
to classes suited to their attainments. Here the course first
pursued is a system having for its object the cultivation of the
senses, the perfecting of muscular co-ordination in movement,
and the establishment of the normal relation between the brain
and hand. To secure this end, exercises are useful, and of these
the “bean bag” and simple musical drill are examples ; by their
help progress, more or less, is made with the dull and apathetic.
For others who are possessed of superfluous and misdirected
nervous energy, as evinced by irregular and involuntary move¬
ments, the use of the “ peg board ” or kindergarten “ picture
perforating ” is beneficial, and the stereognostic sense is
developed and strengthened by the employment of “ size ” and
“ form ” boards. Taste and smell are not, as a rule, deficient,
and may be tested by interrogating the patient on substances
similar in appearance but differing in taste and odour. A
child may be congenitally deaf as part of his developmental
failure, or the apparent defect in hearing may result from mere

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inattentiveness ; an attempt may be made to deal with the
latter by the aid of musical sounds varying in tone and pitch.
Defects in speech, when profound or dependent on certain
causes, are seldom eradicated ; special speaking lessons often
benefit those in whom the defect is but slightly marked. These
form a somewhat necessary introduction to the more serious
problems, the learning to read and write, but many patients are
of course never able to get so far. For the lower grade cases,
all that can be effected is to provide them with comfortable
home-like surroundings and medical care, for they all labour
under more or less constitutional weakness. Reading and
writing are best approached in the first instance by means
of the “ word method ” and the “ letter box.” Arithmetic
is invariably a difficult matter to the feeble-minded ; many
special aids are employed, and it is altogether the excep¬
tion to come across a feeble-minded child who has any
idea of number in the abstract. The “ shop lesson ” is
most valuable in conveying simple impressions of counting,
value of money, etc. Perhaps the most interesting part
of the Institution to the ordinary visitor is the Herbert
Storey Industrial School and Workshops. Here is carried
on a system of manual training which tends to secure the best
results from the boys. It is not proposed to give a detailed
account of the methods employed in the limited compass of
this paper, and a short description of the trades taught must
suffice. In the first place comes carpentry. In it, new pupils
commence their instruction by learning to make ordinary
boxes, ascending by gradual stages to more ambitious efforts.
Quite a considerable number of articles of furniture used in the
Institution are made here by patients who, under supervision,
are fairly competent joiners. Another interesting craft is that
of wood-carving, and in this some patients are quite skilful.
The instructor in this department is himself an old patient,
who was admitted at an early age. As he showed a distinct
aptitude for carpentry, he passed through its different grades
with considerable credit. A few years ago he turned his
attention to woodcarving in which he has been singularly
successful; handicapped as he is by athetosis, he has executed
some beautiful work, notably one panel which was presented
to the late Bishop of Carlisle. When the last wood-carver
instructor left to better his position, this lad begged to be

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allowed to take his place. After some consideration it was
decided to give him a trial, which proved so satisfactory that
he was over two years ago confirmed in his appointment.
The boys under him have made good progress, and in addi¬
tion to wood-carving, he teaches a class in elementary
joinery. In the shoe-maker’s shop, are to be found boys
who have commenced from learning to stitch, and who are now
able to make boots and shoes throughout. Some of these
have gained prizes at exhibitions where there have been
separate divisions for the work of the inmates of this and other
kindred institutions. Basket-making is peculiarly adapted as
an industry for many feeble-minded patients, and here its
adoption has been attended by surprisingly good results.
Book-binding is also taught ; magazines are bound, and
repairs effected when necessary to the volumes composing
the Staff Library. In the printer’s shop patients are
employed in setting up the type in connection with work
of this kind for the offices of the administrative and secre¬
tarial departments, and all programmes of the entertainments
are printed here. In the tailor’s shop much good work is
done, and a boy was recently discharged at the request of
his mother, who had found work for him ; he had improved
to such an extent as to be able to make unaided a suit
of clothes throughout. I wish I could say that he is doing
well, but I cannot—shortly after leaving us he threw up his
work, assaulted his mother, and went on tramp. In addition to
the above are two other shops, one of which is devoted to the
teaching of mat and brush-making, and many of the articles
made there by the patients are used throughout the Establish¬
ment ; in the other is taught sash-cord making, and simple
upholstery. The Institution possesses an estate of 185 acres,
on which are two farms. At the home farm-house, there is
accommodation for twelve sturdy lads, who assist in general
work, tending the stock, and are useful helpers in the fields.
Much interest is shown during the hay harvest, when the boys
are quite as keen on getting in the crop as the ordinary farm
hands. It is impossible to conclude this paper without a brief
glance at the aetiological factors in operation. These are many
and various, and it is extremely difficult to obtain a family
history which is at all reliable. As is well known, the majority
of people regard the existence of insanity or other mental

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abnormality, epilepsy, alcoholism, etc., in the family as a stigma
and disgrace, and will deliberately lie in order to conceal it.
Yet, when one does get at the real state of affairs, as one
frequently can by persistence and much asking, it is surprising
to find the number of cases which can be clearly traced to
hereditary predisposition. As I have already hinted, from the
most superficial observation of many of the parents and rela¬
tives of the feeble-minded, the source of the defect cannot
escape notice—it literally stares one in the face. Finally, we
are confronted with a momentous question which is impossible
to evade—besides training and educating these obviously
defective children, are we doing anything for future generations?
We are not. Speaking for the voluntary institutions, who are
the pioneers in the work, we are accomplishing the task which
was begun a century ago, and if we have not gone further, it is
because this is beyond our strength and resources. Segregation
for life of those bearing the obvious stigmata of defectiveness
will do something to limit the number of these children in
future, and restriction of marriage to those of healthy inherit¬
ance would quickly do away with its occurrence. Unfortu¬
nately, public opinion must advance greatly before this is
possible ; something, perhaps, may be done in our continuation
schools towards the teaching of the principles of eugenics. At
any rate, I live in hope that, in the words of the founder of
this science, “ it is quite conceivable that a non-eugenic marriage
should hereafter excite no less loathing than that of a brother
and sister would do now.”

(*) A paper read at the meeting of the Northern and Midland Division, held at
the Royal Albert Institution, Lancaster, on October 21st, 1909.

Lunacy Administration in Cape Colony. (*) By T. Duncan
Greenlees, M.D.Edin.

The subject of lunacy administration in our Colonies, and in
other countries, is one not so well known as it should be to
those of us who are specially interested in these matters in this
country, and I was pleased to see recently articles in our
Journal by Drs. Eric Sinclair and Beattie Smith treating of
this subject as found in Australia. If our Editors published a

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LUNACY ADMINISTRATION IN CAPE COLONY, [April,

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series of articles referring to lunacy administration, as met with in
our Colonies and foreign countries, these might prove useful
when our own Lunacy Act undergoes amendment.

Having spent seventeen years as medical officer to a
Colonial asylum, I have thought myself competent to submit
the following brief resume of what has been done in Cape
Colony to improve the condition of the insane, and the adminis¬
tration of the asylums, during the last twenty years.

General historical facts .—Most of you are aware that in 1872
the Colony, which previously had been directly governed by the
Crown, was given responsible government. The granting of
responsible government has enabled its legislators to enact laws
which, while suited to local requirements, are in many respects
well abreast of the times. Many of the Acts, for example,
which form the Statute Book of Cape Colony, are founded upon
the legislation which other countries and colonies have proved
useful in their experience, and thus our younger Colonies are
beginning, as it were, where older countries with their conserva¬
tive habits leave off.

In 1872 the only asylum for the insane in Cape Colony was
on Robben Island—a desert isle eight miles from the mainland—
and which also provided accommodation for lepers, paupers,
and criminals. There was no Act dealing specially with the
insane, and the ultimate detention of any case depended upon
the decision of a medical board which occasionally met in Cape
Town.

In 1875 an Act was passed, but under its provisions it was
necessary that the person of unsound mind should first be
indicted as a criminal before he could be treated as a lunatic !
Of course the law was made very elastic, and there was seldom
found difficulty in finding some act of the lunatic which could
be interpreted as “ criminal,” and thereby justify the detention
of the person.

But even in these early days it was recognised that in some
cases it was not deemed prudent that patients should be first
criminals before they became legally lunatics, and the Govern¬
ment, with no legal powers whatever, enacted that in certain
cases the Colonial Secretary might issue authority for deten¬
tion in an asylum for treatment. Fortunately for the cause of
lunacy in the Colony, this ruling was questioned ; a lady,
detained in one of the asylums by order of the Colonial

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263

Secretary, prosecuted the Government for illegal detention, and
the judge, in ordering her immediate discharge, made some
very severe remarks about any department of the Government
taking upon itself such powers as were not conferred upon
them by Act of Parliament.

This was in 1890, and the Government, threatened with
innumerable law suits for illegal detention, was forced to
introduce a Lunacy Bill, which was passed and became law in
1891.

Shortly prior to this, viz., in 1889, an agitation was made to
house the better class of the insane on Robben Island on the
mainland, and monetary provision was made by Parliament for
the erection of a new asylum in the immediate vicinity of
Cape Town, on property already belonging to the Government.
At the same time the necessity for technical advice in lunacy
matters made itself keenly felt by a country awakening to the
sense of its State responsibility in the care of the insane, and
Dr. W. J. Dodds, of Montrose Asylum, was appointed the
Government adviser and inspector of their asylums.

Dr. Dodds, on his arrival in July, 1889, immediately set
about effecting improvements, both structural and adminis¬
trative, in the asylums under his care ; new rules and regula¬
tions were drafted and adopted, and soon he saw a modern
asylum erected in the neighbourhood of Cape Town, designed
by a distinguished architect from his own ideas, and thence a
number of the quieter cases from Robben Island were transferred
and cared for in accordance with modern methods.

The Lunacy Act of 1891 was an immense advance on what
had previously existed, but experience in its working proved
it had many defects, especially in a country where the distances
are so great that it sometimes happened certificates, signed at
a patient’s house, became invalid before the patient could reach
the asylum.

Accordingly, in 1897 an amendment to this Act was passed
by Parliament, in which many of the defects of the previous
enactment were removed, with the result that for its simplicity
and ease of working—for I presume the doctors had had more
to do with its drafting than lawyers—I have little hesitation
in saying it will compare favourably with any Lunacy Act in
existence. So near perfection is it that, at a meeting of medical
superintendents of Colonial asylums, held in Grahamstown

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several years ago, with a Government instruction to “ consider
lunacy legislation with the view to further amendments of the
Act,” they expressed themselves as unable to offer any such
criticism as would justify their advising the Government to
amend it.

Briefly, it may be stated that lunatics in Cape Colony before
1891 were simply legally “ criminal or dangerous persons”;
after the passing of the Act of 1891 they were classified into
“criminal, dangerous, and other cases”—the “other cases”
being those who could not be dealt with under the criminal
law, but for whom treatment in an asylum was deemed advis¬
able ; and finally, under the Act of 1897 the insane were
simply divided into “ criminal and others.”

The Act of 1897, which was promulgated on May 25th,
1897, is divided into five parts, comprising seventy-eight sec¬
tions, and it may be of interest to refer briefly to its various
provisions.

Part I.

Part I of the Act deals with lunatics who are not criminal,
and is that portion most used in dealing with the insane in
the Colonial asylums. Under its provisions a magistrate—and
a Colonial magistrate is a paid Government official—after
satisfying himself as to the insanity of a person from evidence
on oath, and two medical certificates, may order the detention
of an alleged lunatic for a period not exceeding one month.
Thereafter the further detention can only be granted, after sub¬
mission of all documents and a medical certificate by the
medical man in charge of the patient, on the order of a
judge.

A judge has great discretionary powers, for, under Section
15, he may either—

(1) Make a further order for the detention of the alleged
lunatic sine die , or for such period as he deems necessary.

(2) Order a summons to be issued on the alleged lunatic to
appear before him.

(3) Appoint a curator bonis for the care of the lunatic’s
property, authorising him to disburse necessary monies out of
the lunatic’s estate, and to submit a financial statement to the
Court from time to time.

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(4) Direct that the alleged lunatic be discharged forthwith.

(5) In cases where the lunatic is a poor man the judge may
order that the legal expenses be free of cost to the lunatic’s
estate.

(6) Generally give such directions as may appear to him
necessary and proper.

Under Section 13 the Crown solicitor, whether he is the
Attorney-General, with jurisdiction over the Western Province,
the Solicitor-General, over the Eastern Province, or the Crown
Prosecutor, over West Griqualand, acts ex officio as the
curator ad litem of all lunatics within their respective districts,
and exercises a general judicial supervision over the interests
of their clients.

It will thus be seen that, under Part I of this Act, the
authority of the magistrate for the detention of a lunatic lasts
only for one month, while the final disposal of the patient and
his estate rests entirely with the judge, who has practically
unlimited powers to “ do anything he may consider necessary
and proper ” in the interests of the patient, ordering him to an
asylum from “ single care ” or vice-versA ; ordering periodical
reports as to his mental or physical condition ; making perma¬
nent or temporary orders for his detention ; ordering the
disposal of his property ; or he may declare null and void the
existing certificates, and order the lunatic to be re-certified.

Further, under Section 17, any person detained under the
provisions of this Act may apply to the Court for an inquiry
into the cause and grounds of his detention, and the official
curator ad litem is compelled to undertake the duty of sub¬
mitting such application to the Court, gratuitously in the case
of paupers.

Section 18 provides for the issue of a warrant of transfer by
the Colonial Secretary of any lunatic committed by a summary
reception order of a magistrate or by an order of a judge from
an asylum, hospital, or gaol to another “ safe place of confine¬
ment.”

* Tart II.

Part II of the Act provides for the disposal of Governor’s
pleasure and criminal lunatics. Governor’s pleasure cases are
those criminals found insane prior to arraignment, and these

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cases may be detained in custody during the pleasure of the
Governor of the Colony. At the trial, in certain cases, the
magistrate or judge, as the case may be, may abandon the
criminal charge, and then the lunatic may be dealt with under
Part I of the Act as “ an ordinary case ” ; and when the charge
is a trivial one this procedure is usually carried out.

When a prisoner becomes insane he has to be “ certified ”
by two medical men, and thereafter he is dealt with as a
criminal lunatic, and detained either in the only criminal
asylum in the Colony, Robben Island, or failing room there, in
the prison. Should such a person recover his reason, formerly
he was sent back to the prison to complete his sentence, but
now the time of his detention counts in the period of his
punishment; should he not be fit for discharge at the termina¬
tion of his sentence he may be discharged pro forma as a
criminal, and thereafter be considered an ordinary lunatic as if
admitted under Part I of the Act.

The Governor of the Colony reserves to himself the right to
discharge, conditionally or unconditionally, any Governor’s
pleasure or criminal lunatic; such power, it need hardly be
said, is never used unless on the advice of his Ministers.

Part III.

This part of the Act provides for the care and administra¬
tion of the lunatic’s property ; under it the Court may appoint
a curator of the estate ; it may also appoint a curator of the
person of the lunatic. Both posts may be given to one
person, but this is rare ; as a rule the medical attendant is
appointed curator of the person, and an attorney, or other
business man, curator of the estate. In certain cases it is
advisable to make only one appointment, and then it is generally
the estate that is supervised, the lunatic being at liberty.

Further, the Court may dissolve a partnership, one member
of which is declared of unsound mind.

The appointment of a curator to a lunatic’s property is most
carefully safeguarded in the interests of the lunatic ; the curator
is subject to the master of the Supreme Court, to whom he files
an inventory of the estate, reports details of his disbursements
from time to time, and submits to his decision as regards his
own remuneration for his services, such being usually 5 per cent.

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of all monies expended out of the estate. His powers of
expenditure are limited and confined to the instructions of the
Court.

It will thus be seen that the financial interests of any person
declared of unsound mind are most carefully supervised, and I
have personal knowledge of the great care that is exercised in
the administration of the estates of patients under my care in
Grahamstown Asylum.

Part IV.

Part IV deals with offences and penalties under the Act,
and I may here say the provisions are as stringent as they are
under the English Lunacy Act.

For the illegal detention of an alleged lunatic the penalty
must not exceed £ 50, and for wilfully making any mis-state¬
ment the limit is £100. The same penalty is meted out for
obstructing anyone, under Government authority, in the
exercise of such powers as are given them under this Act.

Contravening the provisions of the Act or any of its regula¬
tions involves a fine not exceeding £20 ; the same fine maybe
inflicted—or, failing a fine, imprisonment not exceeding three
months—for ill-treating a lunatic, or conniving at his escape, by
an asylum official.

Carnal knowledge of a female lunatic by any person in
charge entails, upon conviction, imprisonment, with or without
hard labour, for a period not exceeding five years.

Part V.

This part of the Act deals more especially with matters
arising out of the other sections. In it provision is made for
dealing with lunatics from other States or from across the seas,
to prevent dumping; and Sections 52, 53 and 54 refer to the
regulations of licenced houses and “ single care ’’ cases. There
is only one licenced house in Cape Colony at the present
time.

Section 58 treats of voluntary boarders, who can be
admitted to an asylum voluntarily on application to the
medical superintendent, such admission being duly reported
to the Colonial Secretary. There is no need there, as exists
here, for official consent to be previously granted before a

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person can voluntarily place himself under treatment. Other¬
wise the regulations, pertaining to voluntary boarders in the
Colony, are similar to those met with under the English
Lunacy Act.

Section 75 provides for the Governor reserving to himself
the right to issue rules and regulations for the better working
of the Act; such rules deal with the procedure in the
admission, discharge, or transfer of lunatics, the guidance of
asylum visitors, the necessary books to be kept, financial and
other reports, paying patients, etc.

Perhaps the most interesting portion of this part of the
Act is Sections 76 and 77, which refer, all too briefly, to the
legal custody of imbecile and idiot children, for whom, on
my representation, separate accommodation was provided in
connection with Grahamstown Asylum, and the Institute for
Imbecile Children is the only institution specially devoted to
the care and education of such cases in Africa at the present
time. I understand, however, that Natal is urging the pro¬
vision of similar accommodation in connection with one of its
hospitals.

Such, then, is the Act under which the insane of Cape
Colony are cared for, and their estates superv ised ; its analysis
shows it to be better in many respects than our own Lunacy
Act, the final disposal of a person, whereby he is deprived of •
his personal liberty, being an extremely important point.

It would seem to me that if any person requires to be
deprived of his liberty, whether on account of some crime he
has committed, or on account of mental disease, the proper
tribunal before which he should appear, whether in person or
by representative, is a court of justice, and the proper person
to deprive him of his liberty is a judge. The exception is
made of the lunatic who is unfortunately situated, for his
sentence is pronounced by admittedly incompetent authorities,
for so the “ great unpaid ” justices of this country are said to be.

Then, again, how is it that restraint and seclusion can be
carried out to an unlimited extent in a general hospital on a
“ borderland case,” without the legal formalities necessary
when the case is a certified one ? Does “ certification ” imply
insanity, and is the strict line of separation between “ border¬
land ” and “ insanity ” bridged over by the mere act of filling
up certain legal documents?

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Surely if insanity is a disease, and if it is considered that an
Act of Parliament is required for its treatment, then the Act
should be made as simple as possible, its sole object being
the early treatment of the insane, and if detention is necessary,
the same justice as is meted out to the ordinary criminal
should be given the lunatic, and a judge, and a judge alone,
should have the power to deprive even an insane man of his
liberty.

But I digress; I merely submit these thoughts for your
consideration.

The Asylum Service of Cape Colony .—The public asylums
in Cape Colony, like similar institutions in all the British
Colonies, and some foreign countries, are State institutions,
supported out of public funds, and the officials are civil
servants, subjected to all the rules and regulations that govern
public servants.

A civil servant so soon as he joins the service is compelled
to contribute to two pension funds, a general fund for his own
pension, and a widows’ fund; and he may retire at sixty years
of age, drawing, as a retiring allowance, one-sixtieth of his
annual salary and allowances for each year of service, the
amount being calculated on the average emoluments of the
last three years of his service.

This scale is, upon the whole, a liberal one for the ordinary
civil servant, who joins when he is seventeen years of age, and
whose office hours are from nine until four ; but it is different
with asylum officials, such as medical officers, who are
appointed only after having had their training. These men
are rarely appointed before the age of thirty, and accordingly
have already lost thirteen years’ service for pension purposes.

In view of this anomaly, and to bring the question of pen¬
sions, as they affect asylum employees, directly under the
notice of the Government, a meeting of asylum medical officers
was held, and a scheme drafted enabling asylum officials to
retire at fifty, after fifteen years’ service, and at fifty-five for
certain others of the staff, with ten years added to their
service.

Fortunately, just at that time a Commission was sitting to
consider generally the Civil Service, for there were many
injustices requiring amendment, and Dr. Dodds and I were
enabled to lay before them the claims of asylum officers for

L VI. IS

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more liberal terms as regards pensions, etc., than were already
provided for by the Civil Service Act.

As a result the Commission recommended that officials in
the asylum service should be allowed to retire on pension after
fifteen years’ service, being fifty years of age, such pension not
to exceed one-half of the salary, if the usual calculation on the
Civil Service scale did not amount to this ; otherwise the pen¬
sion would be in accordance with the ordinary scale of the
service. These terms were on a more liberal scale than those
submitted by us.

A Bill was drafted to give effect to the Commissioners’
recommendations, but it never got so far as Parliament, owing
to a political crisis occurring at the psychological moment!
There is no doubt, however, that the next amendment of the
Civil Service Act will embody most, if not all, of the recom¬
mendations of the Commissioners, and, in the meantime, an
assurance was given us that their recommendations would have
effect in any case submitted.

Mental Nursing in Cape Colony .—Previous to 1 S90 nothing
in the way of training was even thought of in the asylums of
Cape Colony, although before this date the hospital nurse was
thoroughly trained, and a register was kept of all hospital-
trained nurses. But with respect to the asylums, nurses and
attendants were simply pitchforked into their respective wards
without any previous knowledge of their duties. And even in
England the training of asylum nurses was only taken up
seriously three years before this, although in many individual
cases training was, for long before this time, carried out. So
recently as in 1887 I heard a distinguished asylum super¬
intendent deprecate educating asylum nurses lest they should
get to know too much, and thus undertake duties that rightly
belonged to the medical officer ! I am glad to say this gentle¬
man has long since seen the error of his ways, and has become
a powerful advocate in promoting this good work.

All praise to our Association for inaugurating the systematic
training of mental nurses, and for putting it on a firm basis.

There was much pioneer work to be done in this direction
when I first went out to the Colony in 1890. That year I
established a course of training, and became associated with
the Medico-Psychological Association in its training and
examinations, and, in time, a number of my nursing staff were

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1910.] BY T. DUNCAN GREENLEES, M.D. 27 I

awarded the coveted honour of the medal and certificate of the
Association.

The other Colonial asylums took up this work with
enthusiasm, and ever since candidates are regularly presented
for this examination.

The Government, recognising the importance of improving the
education, and hence the nursing, of its asylum employees, was
pleased to grant increased emoluments to those who had been
successful in these examinations, and thus an increased incentive
was given to us all, and the general tone and esprit de corps
were materially improved thereby.

Not satisfied with this, and noting the agitation in England
for the registration of nurses, and especially the registration of
mental nurses as carried on by this Association for many years
now, Dr. Dodds and I consulted together, and submitted a
memorandum to the Colonial Medical Council, who control the
register for hospital nurses. On our recommendation the
Council established a register for mental nurses ; candidates
for inclusion in this register have to pass either the Medico-
Psychological examination in mental nursing, or an examina¬
tion, held by the Council itself, on similar lines. Thus the
Colonial mental nurse is now on the same legal level as her
sister in the general hospitals of the Colony, a state of affairs
not yet attained to in this country.

Before this system of self-help was inaugurated great diffi¬
culty was experienced in getting vacancies filled up, and we
were glad enough to import our nurses from time to time.
Now all this is changed, and the colony, in this respect, is
practically self-supporting.

All the credit of these improvements, and I could mention
many more did time permit, carried out within the past twenty
years, is due chiefly to Dr. Dodds, the Inspector of Asylums,
who, by his indefatigable energy, enthusiasm in his work, and
powerful influence has advanced everything that pertains to the
increased comfort and happiness of the insane and those having
charge of them. Indeed, under him the Colony has done more
in this short space of time for the insane than England in the
last generation. England, with her conservative habits, no
doubt “ hastens slowly ”—which, by the way, is our Colonial
motto ; but she should take care lest, in the race of civilisation,
she is left behind by her own children—her colonies. Already

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in asylum administration and lunacy legislation she would do
well to take a lesson.

The future of lunacy in South Africa .—What the history of
lunacy administration will be under the new Union of the States
of South Africa it is difficult to say, but I would prophesy, if
she is left alone to work out her own salvation, progress in every
direction on the lines carried out in recent years in Cape
Colony.

The central asylum administration will have under its con¬
trol eight asylums and two hospitals where lunatics are received,
and from 3,000 to 4,000 certified patients, together with a staff
of about 400 individuals, an annual expenditure for maintenance
of .£200,000, and possibly £100,000 for additions and repairs.
This is a heavy burden for a country to support whose popula¬
tion is well under 1,000,000 white persons—the coloured people
rarely count for taxation purposes.

The retention of an asylum inspector, untrammelled by other
duties, is absolutely necessary. Such an officer should have
the ear of his political chief, and be the adviser of the Union
Government in all matters pertaining to the asylums under his
jurisdiction.

He should be empowered to authorise the expenditure of any
monies required to carry out his recommendations, otherwise
he is the mere shuttle-cock between the Government and the
various asylums.

If the two white races unite on these lines there is a bright
future for lunacy in South Africa. It will be watched by those
of us interested in the care of the insane throughout the world,
and the time may come when this country, at present tied down
by its conservative habits and laws, will not be ashamed to
imitate, in this direction, this, its youngest of her dominions
beyond the seas.

( l ) A paper read at the Autumn Meeting of the South-Eastern Division, held
at Brooke House, October, 1909.

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I9IO.] HEREDITY AND NEURO-INSANE CONSTITUTION, 273

The Significance of Heredity and the Neuro-insane
Constitution as Important Factors in the Pro¬
duction of Mental Disease , with an Examination
into the History of 100 Consecutive Cases. By
G. Rutherford Jeffrey, M.D.GIasg., M.R.C.P.Edin.,
Senior Assistant Physician, Crichton Royal Institution,
Dumfries ; late Senior Assistant Physician, District
Asylum, Ayr.

From the earliest times in the history of medicine probably
no subject has been more thought about, no subject more
frequently attacked, than that of heredity, and it is therefore
not without a certain amount of hesitation that that all-impor¬
tant subject is brought into consideration in such an article as
this.

At the very commencement of the study of medicine the
attention of the student is soon directed towards heredity,
although it is not to the student of medicine alone that this
subject is of interest. To the every-day individual, layman
and professional man alike, it is a subject that is constantly
demanding attention. In the animal kingdom its importance
seems never for a moment to be doubted, whilst in the breeding
of animals its significance stands unchallenged, l'or example,
by careful selection and mating of animals, special breeds are
procured—in horses, speed, endurance, and strength can be
obtained, in cattle the size and dairy qualities of the animal,
in sheep the quality of the wool, these being only a few
examples of what can be attained by taking into consideration
the parentage, or, in other words, recognising the importance of
heredity.

Among the ancients the principles of heredity must have
been recognised, and undoubtedly gave rise to certain family
names among the Romans, as,e.g., the Nasones, Capitones, etc.,
whilst, coming to more recent times, such an expression as the
“ Bourbon nose ” is sufficient to show that it is a characteristic
which has been handed down from one generation to another.

In the diseases to which the human frame is subjected the
problem of heredity is never neglected. By some its significance
is accepted, and is held to explain a condition that is quite
beyond ordinary understanding.

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As years have advanced the importance of heredity in the
production of certain diseases has received more special atten¬
tion ; facts have been established, and by some accepted, and
when one comes to the study of psychological medicine—pro¬
bably the most intricate of all medical subjects—its significance
has been accepted without, perhaps, sufficient grounds.

To a disease like insanity, which at every corner is beset
with appalling difficulties, heredity is by some held to be the
omnipotent factor in its production, whilst by others it is con¬
sidered and set aside without sufficient thought. During the
present time, when the “ toxic theory ” of insanity is so much
in the ascendant, the importance of heredity is apt, by the
younger generation at least, to be overlooked, and, indeed, any¬
one who tries to unravel its mystery and give to it its proper
place is by some said to be behind the times, is accused of
being unscientific, and is thought thereby to have drifted back
to the position of our ancestors, who not only did not know of
such a thing as “ microbic infection,” but who firmly believed
that many obscure diseases were directly transmitted from
parent to offspring.

When one comes to consider the question of insanity there
are facts about heredity that cannot be passed unnoticed, there
are facts which cannot be disputed, and yet no one would go
the length of saying definitely that insanity is a disease which
is transmitted directly from parent to offspring. That in a
large percentage of cases of insanity occurring in an offspring
the disease can be traced in the family history is beyond doubt,
and, as the tubercular parent may beget a child predisposed to
the tubercular virus, so also the insane parent begets a child
predisposed to insanity—the most calamitous of all diseases.
To say, however, that the parental germ-cell is infected—a
condition at one time believed in—is making a statement which,
in the present state of our knowledge, is scarcely justifiable.
Notwithstanding even this assumption requires reservation, for
one is at once confronted with a condition like hereditary
syphilis. In this the morbid poison is transmitted, but can it
be proved that the infection took place through the actual
parental germ-cell ?

No matter what statements are made, or what examples are
given, for or against the inheritance of disease, we are bound in
the first place to believe and accept as a fact that what we are

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1910.] BY G. RUTHERFORD JEFFREY, M.D. 275

as human beings is largely, if not solely, the result of our
inheritance. Is it not by inheritance that we human beings
belong to that marvellous genus—man ?

No one doubts the fact that one animal begets its like—and
its like only. Not only this, but the offspring bears in many
cases a striking resemblance to the parent. Individual bodily
conditions are reproduced, and more—individuality of character,
both good and bad, appear in successive generations. The ovum
enters upon its life, so to speak, charged with inheritance, and
more—charged with an inheritance which in many cases cannot
be passed over. In the face of facts such as these, one cannot
for a moment doubt that an “ unstable ” parent is more likely
to produce an unstable than a stable child. Fortunately,
however, this is not always so. We have always to consider
the opposing factor, and remember that it may be the stronger ;
were it not for this the world would rapidly become filled with
weaklings. The offspring charged with unstable germ - cells
from, say, the father, is equally charged in the reverse way
through the mother, and the sum total of those two individuals
is in all probability an individual with the good and bad of
both parents, but with those qualities probably much exagge¬
rated, minimised, or equalised. If this be so in the ordinary
individual why not in the “ afflicted ” one ? Are we not bound
to believe and accept the fact that in certain diseases—chief of
which is insanity—the unhealthy parent must beget a child at
all events predisposed to that disease ?

We are led, therefore, to consider the “ predisposition,” and it
is to this point that I wish to draw special attention in this
paper. I do not wish to theorise on a subject like heredity—
far be it from me to even attempt without an apology to touch
the fringes of such a subject, a subject which has occupied the
attention of scientists for generations, and which, moreover, has
baffled most ; but I wish to draw attention to the importance
of certain points as being of paramount interest and significance
in the production of mental disease. For some knowledge of
such a difficult and interesting subject as heredity, the able
works of such men as Darwin and Weismann must be consulted.
Darwin, in his book on the Origin of Species, seems to indicate
that, while the qualities and characters of the ancestors are
transmitted to the offspring, there are circumstances, as, e.g.,
environment and example, which tend to modify or alter those

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qualities, and more—that those qualities or characters are gradu¬
ally altered, inasmuch as their alteration is necessary for the
preservation of the species ; in other words, qualities which will
be useful in the struggle for existence and in order that the
fittest may survive. According to Weismann’s conception,
living matter has no ending. He believes in a “ continuity of
the germ-plasm.” “ A part of the germ-plasm contained in
the parent egg-cell is not used up in the construction of the
body of the offspring, but is reserved unchanged for the forma¬
tion of the germ-cells of the following generation. Thus the
parent is rather the trustee of the germ-plasm than the producer
of the child ; and in a new sense the child is a chip of the old
block. Similar material to start with, similar conditions in
which to develop, therefore like tends to beget like.”(i)

I shall at once commence to draw attention to certain points
in the production of mental disease—points which are of impor¬
tance because their position has been established by facts, and
by facts which have been carefully and accurately elucidated.

The points which I propose to consider are :

ist. The importance of, and the position held by, heredity
in mental diseases.

2nd. The importance and significance of the so-called
neuro-insane constitution in people, the subjects of mental
disease: And—

3rd. The presence of a direct cause which is held to be the
actual cause of a special attack of mental disease.

Before commencing to discuss and dwell upon these three
points in detail, I may briefly state the basis upon which I
venture to express my ideas and conclusions.

The facts elucidated have been obtained from an examina¬
tion into the personal and hereditary history of 100 consecu¬
tive cases. For convenience, fifty of each sex have been taken,
and it so happens that for that number of each sex there has
been covered almost the same period of time, and they com¬
prise the admissions into the higher rate department of the
Crichton Royal Institution for a period extending to well over
two years. In nearly all the cases the history has been
obtained by myself, and by personal interviews with relatives
when possible. If an interview was impossible, my information
was obtained in answer to written questions, bearing directly
on the points upon which I desired information.

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1910.] BY G. RUTHERFORD JEFFREY, M.D. 277

Passing now to the first point which I wish to consider
in detail, viz., “The importance of, and the position held by,
heredity in mental diseases,” I would at once preface my
remarks with the statement that one animal begets its like and
its like only. From this quite unmistakable and incontestable
physiological law we are forced to believe that individuals or
animals transmit to posterity all the traits that characterise the
species to which they belong. Although in this paper I am
trying to bring out the importance of heredity in disease, I
feel certain that its significance can only be realised if the
ordinary physiological law of inheritance be accepted and
believed in. If it were not through heredity where would
we, for example, obtain our instinct—the most remarkable and
obscure faculty underlying all animal life, and probably the
basis upon which character, such as we observe it in the full-
grown individual, is built? Apart from instinct, we find that
certain families possess or present certain qualities or aptitudes.
For example, through some families we find running, perhaps
for several generations, a mathematical, scientific, musical, or
artistic temperament, to say nothing of business integrities,
truthfulness, and temperance, whilst, on the other hand, one
finds in the same way such conditions as drunkenness, dis¬
honesty, untruthfulness, and even bad spelling passing from
one generation to another. At every corner, however, we are
beset with difficulties, for, although most people would be ready
to recognise the occurrence of such qualities and characteristics
as I have mentioned, they would be equally ready to explain
their presence as being for the most part due to environment
and example.

Be this as it may, what I wish first of all to lay stress upon is,
that if any given person can transmit his like to an offspring—
which is a physiological fact beyond dispute—surely he must also
transmit his like in some form, even when that like is an
unstable nervous system. What form that like will take must,
of course, be greatly modified by environment and by all the
numerous unfavourable and antagonistic external circumstances
and agents to which we as human beings are subjected.

This being so it is at once apparent that my first two
headings, viz., (1) the part played by heredity, and (2) the
significance of the so-called neuro-insane constitution, are
scarcely capable of distinct differentiation, for in my last para-

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graph I indirectly laid stress upon the inheritance of a pre¬
disposition, the significance of which I shall discuss more fully
later on.

Coming now, without further theorising, to the facts which I
have elicited from the examination of 100 consecutive cases,
I find that in 55 per cent., 27 males and 28 females, there was
a history of insanity or well-marked neurosis in the direct
ancestors, i.e., father, mother, and grandparents. Although this is
certainly not a large number, still, it comprises more than half
of the cases, and one has to consider, of course, the few cases
in which reliable imformation was impossible, and also those
about which no information at all could be obtained. No
attempt has been made to accurately classify or diagnose the
exact nature of the mental illness in those near parents, for in
a considerable number all the information granted was, e.g.,
that a father or mother “ had been insane.” Moreover, I do
not think that it is of such infinite importance to try and prove
that a parent and child suffered from identically the same form
of mental disease ; sufficient be it to prove that there was
handed down to the offspring such an intensely unstable
nervous system that it had at one time culminated in an attack
of insanity—an actual attack of insanity being presumably the
acme of nerve-cell unstability. In more than half of the cases
examined, then, there was a hereditary history of mental disease,
and surely even this percentage should be sufficient to make
one stagger and dread with fear the begetting of an offspring
by those who have at some time in their life been affected
mentally.

Having seen, then, that in 55 per cent, of the cases there was
in the father, mother, or grandparents distinct evidence of
insanity, or of a marked neurosis—which I think is almost of
equal importance if it be specially pronounced—the next point
that would occur to one is, which parent exerts the stronger
influence ? Is inheritance stronger from the mother or from
the father ? Most people believe that the maternal heredity' is
the stronger, but I must say I do not think that this is at all
certain. I am inclined to believe that the maternal heredity is
stronger in the case of the female offspring, and the paternal in
the case of the male. I am not aware, however, that there are
on this point any convincing statistics one way or the other.
Certainly one does get terrible and numerous mental “ flaws ”

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2 79

occurring in a family whose mother was apparently the only
weak spot in the genealogical tree, but one gets the same bad
histories in families where presumably the father alone was the
weak member mentally. Both sides can furnish examples in my
own series of cases, and many cases could be quoted from other
authorities. Dr. Bruce (2), in his work on Clinical Psychiatry ,
quotes a striking case of parental heredity, viz., “ The father
became insane at seventy ; the eldest daughter became melan¬
cholic at the climacteric ; the second daughter suffered from
puerperal mania at thirty-eight ; the third daughter developed
adolescent mania at eighteen ; and the fourth child, a boy,
was born an imbecile ; the mother appeared to be a healthy
woman.”

In my own series of cases, No. 18 (female) furnishes a good
example. An extremely neurotic melancholic and rather hypo¬
chondriacal father had a family of five, all of whom had had at
one time in their life an attack of insanity. Three of the
family were sons, and as well as having been at least on one
occasion insane, they were all alcoholics, whilst the mother,
although she died when young, was apparently quite healthy
mentally. Equally striking cases can be quoted as coming from
the mother, e.g., No. 14 (male): The mother was an epileptic,
and had five children. Three daughters had had attacks of
melancholia, one son was inclined to be depressed, and the
youngest of the family—a son—was an epileptic. It may also
be mentioned that one of the mother’s sisters had had at least
two attacks of melancholia. Numerous other instances could
be quoted from my own series of cases. The hereditary tables
in Dr. Macpherson’s book (3) (after Mobius and D^jerine) are,
indeed, striking as well as most interesting, and show mental
defects in whole families, originating in some cases from appa¬
rently only one mentally unsound parent.

Coming to my own statistics dealing with the maternal and
paternal inheritance, I find that in 34 per cent. (19 males and
1 5 females) there was a bad heredity through the mother, and
if one takes into account maternal grandparents the percentage
is 42. On the paternal side the number is also 34 per cent.
(17 males and 17 females), whilst taking into account paternal
grandparents, it is 42 per cent., the total numbers being identi¬
cally the same in both cases. As far as my statistics go
(although they are certainly limited), there is no proof to show

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whether the maternal or paternal factor is the more potent.
In 22 (or 44 per cent.) of the males the morbid heredity was
through the father or paternal grandparents, whilst in 19 (or 38
per cent?) it was through the mother. In the females, 23 (or
46 per cent.) showed the morbid heredity through the mother
or maternal grandparents, whilst in 20 (or 40 per cent.) it was
through the father or paternal grandparents. The difference,
therefore, is slight, but what difference there is seems to suggest,
as I have already done, that apparently the males seem to take
more strongly the heredity through the father, and the females
through the mother.

It is interesting to note that Darwin, when discussing this
point in his book on the Origin of Species , says : “It is a
fact of some importance to us that peculiarities appearing in
the males of our domestic breeds are often transmitted either
exclusively or in a much greater degree to the males alone ” (4).
Whether or not this is a point of importance I am not prepared
to say, but I feel certain that an offspring seldom escapes
untouched when both parents are mentally unstable. A
mentally healthy father may counteract the unstable qualities
of the mother, and may beget mentally healthy children, or a
healthy mother may counteract unstable qualities in the father
with the same good result in the offspring ; but I think it is
almost impossible for the offspring to escape where there is a
bad heredity from both parents. It is almost bound to tell in
the offspring—although in many ways far short of actual
mental disease—to make them neurotic subjects, and even if
they themselves escape from that appalling disease, insanity,
they are so slenderly formed from a mental point of view, they
enter the world charged with a mental inheritance so far from
stable and perfect, that the subsequent generations stand a poor
chance. As a result of this bad inheritance, they in their turn
are apt “ to go to the wall,” to break down mentally, to become
alcoholics, degenerates—moral or otherwise—neurotics or neur¬
asthenics, and to be apparent to us as the results of Nature’s
efforts to exterminate a bad stock, and to show us in a truly
ironical way that the fittest survive, whilst the weaklings
perish.

Looking more widely into the hereditary history in my
cases, I find 71 per cent, of them came from “bad stock.” I
mean by this that somewhere in the genealogical tree there

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was a mental flaw, a flaw which, even if it occurred in collateral
or distant relatives, was sufficient to strengthen the opinion
that one of the progenitors of the person in question had been
the unstable thread, that this unstable thread had continued to
run into some of the successive generations, and had stealthily
asserted itself somewhere in the genealogical tree.

In examining only ioo cases one must be careful to avoid
“jumping to conclusions”; dogmatic statements are quite
unjustifiable in expressing opinions from facts collected from
such a limited field of inquiry. I think, however, that such a
percentage as has been obtained is not only striking, but
should be a stimulus for further inquiry. The mere fact that
in 71 per cent, of people who had been affected mentally
there was proved to be somewhere a hereditary flaw is, indeed,
a statement that must give rise to careful thought—a statement
which cannot be thrown aside lightly, and which must have
some bearing upon the production of mental disease.

Having in the preceding remarks tried to point out that a
person’s parentage is of such importance that it influences to a
great extent the character of the individual, I now wish to pass
on to the consideration of my second heading, vis., “ the
importance of the neuro-insane constitution in people the
subjects of mental disease.” I do not think the importance of
such a “constitution ” can be over-estimated, and, in my opinion,
it is the “ foundation-stone ” of practically all insanities. One
can hardly conceive of a healthy, stable-minded individual,
born of equally stable-minded parents, being the subject of
mental disease ; such cases may occur, but I feel certain that
they are few. No matter what may be cited as being the true
cause of any special form of insanity, be it micro-organism,
syphilis or alcohol, there must be, I think, a special “ receptive
medium ” upon which those factors exert their influence, or
bring about their characteristic changes, and this special
medium is undoubtedly the neurotic constitution. Many
factors, individually or collectively, go to the formation of such
a constitution, but, even if one single factor is of out-standing
prominence, I think it is sufficient to go a long way in establish¬
ing the presence in the individual of an unstable brain, and to
make him in one sense a neurotic subject.

The further one gets away from stability of mind, the nearer
does one approach the neurotic constitution. Take, for example,

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a person who exhibits undue nervousness. If that person
naturally is always in a state of nervous tension, is that person
not more liable to a mental breakdown than the stable-minded
individual ? Is this undue nervousness not the outward ex¬
pression of unstable brain-cells, and do not unstable brain-
cells make themselves manifest to us in every form of mental
disease ?

From our knowledge of the cerebral cortex—slight in reality
though it may be—we recognise the clinical manifestations of
“ storms,” presumably among its cells. Are these manifesta¬
tions confined only to the mentally unsound mind ? In the
patient suffering from acute mania they reach their climax, but
does the person who exhibits a fit of violent passion not remind
us of the person suffering from acute mania inasmuch as for
the time being all self-control is gone, all actions are out of
gear, the whole brain, in fact, is in a condition of uncontrollable
turmoil ? So also in the persons who are unduly nervous or
unduly excitable, any slight occurrence may cause, like a match
to gunpowder, a sharp explosion ; their brain-cells are normally
in a state of tension—a tension which is far from safe, and
which is constantly altering—the results of which are well
known to all of us. Nervousness, excitability, and extreme
passion, then, are signs of a neurotic constitution, but these are
far from all ; these are deviations in the “ upward ” direction, so
to speak, from the normal stable line. So also do we get the
“ downward ” deviations, as evidenced by unnatural gloominess,
morbidness, and the tendency to depression.

By some my remarks so far could, I have no doubt, be mis¬
interpreted and misunderstood. I do not wish,noram I trying,
to prove that the person who at a time becomes excitable and
depressed, who becomes morbid or loses his temper, is a
neurotic. Far from that ; all those are conditions which pro¬
bably every human being exhibits from time to time ; but what
I do wish to point out is, that the person who exhibits one or
more of those characteristics constantly is a neurotic, inasmuch
as he is removed from the normal line of mental stability.
Many people assert that one has no right to call a person
“ neurotic ” without being able to demonstrate in him the
physical evidences of such a condition. With this assertion I
am inclined to disagree. Undoubtedly one recognises clinically
such a condition, based often solely upon the general appear-

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ance. For example, the thin-lipped, delicate, flushed, nervous,
and rather apprehensive-looking female is a type of neurotic
which is, to the thoughful physician, quite apparent. It does
not need for its confirmation the presence, in that patient, of the
highly arched palate or some other defect in development,
although the presence of some such defect would undoubtedly
be supporting evidence of the condition.

I consider, then, that any person who constantly exhibits,
when in his normal self, any deviation from stability, is a
neurotic, is a person of neuro-insane constitution, and it is that
person who is apt to become, at some period during his life,
affected mentally, usually through some adverse external cir¬
cumstance, no matter whether that circumstance be worry or
anxiety, fright or shock, or the “ fail-me-never ” microbe.

The day has yet to come when special forms of insanity
shall be definitely proved to be due to particular micro¬
organisms. They may be demonstrated in certain kinds of
cases, but would that special organism cause the same disease
if “ inj'ected ” into the person with a thoroughly stable brain ?
Is one to regard mania, for example, as a disease like diph¬
theria, cholera, or plague ? Surely not! No matter how
many organisms are asserted to cause it, one has to remember,
I think, that that organism grows only upon a suitable soil.

Many authorities would consider my remarks most un¬
scientific, would accuse me of accepting the causation of
insanity without sufficient thought, and would think that my
remarks were only relevant had they been expressed several
centuries ago. I do not wish, therefore, to be misunderstood ;
I only wish to lay stress on the neurotic constitution as an
important factor, if not an omnipotent one, in the production
of mental disease. I have no doubt the time will come when
a special organism will be isolated in nearly all kinds of mental
disease, but I think the time will never come when the presence
of the neuro-insane constitution will be overlooked. To do so
would, in my opinion, not only be most unscientific, but would
be quarrelling with Nature, and putting at defiance her appal¬
ling mysteries. Any person who, in a true way, is trying to
solve the hidden mysteries of the causation of mental disease,
must first of all believe that there is a Nature, that she must be
considered along with the wonderful contrivances, suggestions,
and discoveries of man, in order to unravel the hidden depths.

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Turning again to this so-called neuro-insane constitution, I
would feel inclined to approach the subject in three ways:
Firstly, What exactly does one mean by the term “ neuro-
insane ” ? Secondly, Is a person born a neurotic, or can the
condition be acquired ? Thirdly, What direct bearing has the
condition on actual mental disease? With reference to the
first question, what exactly does one mean by the term ? This
has been already alluded to, and any person is, I think, a
neurotic, or of a neuro-insane constitution, who shows in any
form pronounced instability or perversity of character. Thus
we have the man who is easily upset, easily excited, who is
sometimes in the “ seventh heaven,” and at times in the depths
of despair ; the man who is “ puffed up ” with conceit, so much
so that his arrogance almost amounts to a delusion of grandeur ;
the man who is easily swayed from one course to another, who
doubts and hesitates, and has little mind of his own ; the man
who is solitary and taciturn, who shuns society, who is uncom¬
fortable in the presence of others, who is naturally of a gloomy,
retiring, foreboding, and ultra-religious disposition. Such are
but a few examples of what, when carried to extreme or when
persistently present, must be regarded as unnatural qualities,
and which betoken anything but a sound and equally balanced
nervous system. In a great number of my cases, one or other
of these points were outstanding features of the patient’s natural
disposition. Moreover, I include as well, and consider also of
the strongest evidence of this neurotic temperament, any person
who has had a previous attack of insanity. Is not this the
acme of instability ?

Again, is not the alcoholic to be ranked in the same
category ? Doubtless a few cases of alcoholism can be
attributed solely to force of example, but even in those one
must consider the brain-cells of the person upon whom the
example exerts its influence. Several people may be thrown
open to the same examples and temptations, and yet it is
probably only the minority that succumb, and is this not on
account of the different susceptibility or instability of those
brains in question ? As Ferd very aptly puts it, “ to become
an alcoholic one must be alcoholisable.” (5)

With reference to the second point—Is one born a neurotic
or can the condition be acquired ?—there is little doubt, I
think, but that both conditions may occur. A person may be

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born neurotic and remain so throughout his life, and there is
also, I think, little doubt that it is in this respect that heredity
is of such importance. Actual kinds of mental disease are not
as a rule transmitted in the same form from the parent to the
offspring, although such cases, of course, do very frequently
occur. Thus a mother who has had an attack of melancholia
may beget a child who also may suffer from melancholia, but
it is much more likely that that melancholic mother passes on
to her offspring an intensely unstable nervous system—a
nervous system which at some future period is apt to give
way, and its owner thus to become the subject of a definite
attack of insanity. Such a person, then, is undoubtedly one
who has been born with a neuro-insane constitution, the
sequela of a bad heredity. It is in this way, therefore, I think,
that a bad heredity is apt to tell. Although it does not
follow that the offspring of a mentally affected parent will
become insane, there is every likelihood that that offspring will
be unfortunate enough to be possessed of the neuro-insane
constitution.

As well as being born in the individual, this constitution
can, I think, be acquired. A person may be born and may
appear to all intents and purposes quite stable mentally, and,
further, may be descended from parents who in no way were
affected mentally—nor did they show any marked instability
of mind—and yet that person becomes insane. How does
this occur ? Where is the suitable soil to be found in this case ?
The hereditary history is carefully investigated and yet no trace
of even nervousness can be found. It is such cases that are
apt to overthrow the importance of heredity, and make one feel
inclined to think that after all too much importance is attached
to it. Still, I hold that this special individual must be of the
neuro-insane constitution in order to allow of his mental
breakdown, and, as a matter of fact, one finds if one inquires
carefully enough, that the condition has been acquired. The
person starts life like his neighbour, with a sound, evenly
balanced brain ; he is, perhaps, in later years exposed to severe
strain, his work—business or profession—demands excessive
care and thought, and he is subjected to an undue amount of
wear and tear. Through stress of business he neglects Nature’s
laws, he becomes careless about his mode of living, neglects to
care sufficiently for his body, is careless about his meals, shuns

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exercise and recreation, “ burns the candle at both ends,” all for
the sake of his work. His only thought is for his work, and
finally he breaks down in health. He is now no longer the
same person ; what would not have worried him before does
so now ; what before was natural manly anxiety becomes rest¬
less uneasiness, perhaps even actual depression ; he commences
to lose interest in things, becomes easily annoyed, apprehen¬
sive, and perhaps irritable ; he has, in fact, acquired the neuro*
insane temperament, and is now on the level with the person
who has that temperament naturally—the gift of a bad heredity.
He in his turn is apt to completely break down and to
become affected mentally.

In this way, therefore, we can often account for the sporadic
cases of mental disease springing up in an isolated member of
a family, much to the surprise of his relatives, who firmly and
possibly quite truthfully assert that such a thing as insanity or
even nervousness was “ never known of in their family.”

The recognition of this method of becoming the subject of a
neurotic temperament is not, I think, sufficiently realised. It
behoves us as doctors to thoroughly recognise and appreciate
it; it behoves us to keep it constantly in view, and to be ready
at any moment to step in and check its growth before it is too
late, and thereby, from our knowledge, to bestow a blessing not
only to an individual who may be rapidly drifting towards an
asylum, but also to the yet unborn, who, without being asked
and quite unconsciously, are thrust into the world with a
heredity over which they have had no control, who are therefore
forced to begin the cruel race of the “ survival of the fittest ” at
a great disadvantage and probably much crippled mentally.

I have, then, briefly discussed the meaning of the term
“ neuro-insane constitution ” ; we have seen, secondly, that such
a condition maybe the gift of heredity ; that it is an important,
if not an almost natural, sequela of a bad inheritance ; more¬
over, I have tried to show that as well as this it may be an
acquired condition, a normal person becoming through stress,
strain, or adverse circumstances, a person of neurotic tempera¬
ment.

We are left, therefore, with the third question, “ What direct
bearing has the condition on actual mental disease”? In
answering this point there is, I think, little to add to what
I have already said in discussing the foregoing points. Its

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bearing on actual mental disease is an important one ; so impor¬
tant is it, indeed, that I question very much if the healthy
stable-minded person ever becomes insane. Even if the exciting
cause of any definite kind of insanity be ultimately proved to
be in that particular case microbic, or if it be definitely proved
to be the result of the ravages of syphilis or alcohol or some
such poisons, I think we must still look to the original tem¬
perament, representing as it must the nidus for suitable growth,
destruction, or development. The favourable soil for the
occurrence of growth of mental disease is undoubtedly an
unstable brain, and this, I think, is a fact of such importance
that it can never possibly be overlooked or ignored. To
repeat myself, a melancholic mother may beget a melancholic
child, but she is much more likely to beget one who has inherited
not the same kind of mental disease, but her intensely unstable
nervous system, and who as a result of this “hereditary gift ” is
apt to become in time affected mentally through some adverse
external or internal exciting cause.

The results of my statistics dealing with this point, viz., the
presence of the neuro-insane constitution in the individual, are,

I think, most striking and even convincing. Out of 100 cases
I found evidence of this constitution in 93 instances. It was
present in 49 out of the 50 males, and in 44 out of the 50
female. When one takes into account that in at least three
cases no information on this point could be obtained, and also
that in several cases the information granted was extremely
scanty and superficial, these results are indeed striking, and
allow one, I think, to express with a certain amount of legitimate
dogmatism the belief that the neuro-insane constitution is an
important—if not an omnipotent—factor in the production of
mental disease.

I wish now to consider briefly my last heading, namely,
“ The presence of a direct cause of a special attack of mental
disease.”

I would at once state that eighty-four cases out of the hundred
which I investigated showed the presence of a distinct cause.
What, then, is the significance of such a result ? A rapid glance
through the “ causation ” column of my hundred cases would
not fail to at once strike one most forcibly that such “ causes ”
as are mentioned are only circumstances which are daily occur¬
rences in the life of almost every adult man or woman. Why

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should business worry, overwork, stress and strain, love affairs,
etc., be accused of making a person insane ? Why should such
occurrences affect people so very differently ? I must say I
am not inclined to believe that the adult man who has been
endowed with a strong, evenly balanced mind becomes insane,
nor do I think that he becomes the subject of a so-called “ nerve
breakdown ” through overwork. A man who is living an
ordinary healthy life, who is taking care of himself, and who,
of course, is thoroughly well physically, does not succumb when
subjected to strain or hard work ; he does not as a rule
become nervous or neurasthenic after an attack of “ influenza ” ;
he does not become melancholic because he is a “ martyr ” or a
“ rejected lover.” No! A man who has a mental breakdown
resulting from one or other of those occurrences is pre-eminently
the man with the neuro-insane constitution. Given a man with
this highly strung neurotic temperament, such as I have pre¬
viously alluded to and described, subject him to severe business
worry or strain, place him in financial difficulties, expose him
to the worry of an unhappy domestic life, and he will break
down almost certainly. One must never forget, however, that
if anyone be subjected to such adverse circumstances for any
length of time, he, so to speak, “ moves one down.” What was
before a strong, stable, healthy-minded man is that no longer ;
he passes into the second grade and becomes the man of
neurotic temperament, and it is he who is apt to break down
mentally.

In dealing with the history of mental illnesses, relations and
friends are, of course, most eager to ascribe a cause to the attack
—“ influenza ” or a “ fall when a child ” being most frequently
suggested at some time during our interview. Although one
knows, however, how much importance to attach to statements
like those, there can be very little doubt that careful inquiry
and sifting of facts will almost invariably detect a direct excit¬
ing cause. The man’s illness, for example, will date from his
subjection to severe business worry. It may follow the sudden
loss of money, or it may follow a severe fright. Is it not,
perhaps, natural that overwork, worry, or shock should act in
this way on a very nervous brain ? Take the man who is
strenuously and eagerly working to support his family, who is
having a struggle “ to make ends meet.” Would not the
receipt of bad news or some financial loss affect him ? Would

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it be unnatural if he became “ down in his luck ” ? Would he
be called dull and morbid if, for the time being, he shunned
society and sought instead the privacy of his own home ?
Surely not! but if that man be strong mentally, his worry and
anxiety will show themselves in a manly way ; he will through
time throw them off and gradually rise above his temporary
misery. If, on the other hand, he has little reserve stability, is
naturally gloomy, and of a nervous and morbid nature, his
anxiety, which was at first quite legitimate, will slowly drift into
a condition of anxiousness and fear ; he next becomes de¬
pressed, and finally passes into a condition of true melancholia.
His suspicious anxiety and fears remain, he has now lost all
sense of proportion, cannot control himself, and from this it is
easy to picture almost any kind of mental disease. Such is,
indeed, a common story, and one of everyday experience in
asylum life.

I maintain, therefore, that in almost every case of insanity
occurring in a person of neurotic temperament one can trace a
definite cause as the exciting cause of the mental breakdown.
In such a category also one would place the alcoholics. The
neurotic man gives way to drinking. Does he drink because
he is a neurotic, or has the alcohol caused that special constitu¬
tion ? For both sides something can be said, and certainly
there is little doubt but that alcohol may exert and even cause
terrible havoc on a so-called neurotic constitution, so much so
that in some cases it must almost of necessity be ascribed as
the probable cause of a certain mental attack.

Take, again, the neurotic girl; is it not, perhaps, natural that
the “ pangs of unrequited love ” may quite unhinge her, but
would it unhinge the strong-minded woman, who, free from
cares and worries, spends her life working in the fields ? I
think not! Again, does the act of child-bearing—severe though
it may be—unhinge completely the strong-minded mother ? I
question if it ever does, unless she be naturally a nervous, in
other words, a neurotic woman. Many examples could be
quoted in dealing with this point, but the conclusion drawn
from them all is the same, namely, that in almost every neurotic
who has become insane there can be traced a definite exciting
cause. My own statistics support this statement, for it was
present in 84 per cent, of the cases, leaving only 16 per cent, to
be accounted for, and amongst whom one has to remember

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those most interesting and obscure forms of mental disease
which begin gradually, progress slowly, and are in reality a slow
evolutionary change in the person’s character. With a per¬
centage like 84 one is, I think, justified in drawing reserved
conclusions, and, although I maintain that there is an exciting
cause in the majority of cases, I fail to see why, for example,
adolescence is supposed to cause insanity. Why should a
physiological process be accused of such actions ? Surely
Nature is not so ironical. On the other hand, there can be no
doubt that during the period of adolescence there is naturally
so much extra strain thrown upon the brain—which at best is
a strange as well as a marvellous structure—that if that extra
strain occurs in a person of the neurotic temperament, he will
at that period break down, probably through some adverse
circumstances.

Take, again, a disease like general paralysis. No matter
what its true cause may be—be it syphilis or microbe—there
can be no doubt that even it is more liable to occur in the
person the subject of a neurotic temperament, and more, it not
infrequently follows some occurrence which one must at all
events consider as being a possible exciting cause.

Turning again to my cases, I find that in 84 per cent. (46
males and 38 females) there occurred some circumstance which
was said to be an exciting cause. In 43 per cent, of the cases
(28 males and 25 females) that cause was overwork and
worry—domestic and financial. In 14 per cent. (7 males and
7 females) it was fright or shock. In 16 per cent. (12 males
and 4 females) it was alcohol, whilst in 11 per cent, other cir¬
cumstances, eg ., marriage and physical illnesses, were stated to
be causal. In my statistics the small number of those whose
mental illness is said to have been attributable to alcohol is
rather striking, but as only one hundred cases have been
examined, the small proportion may be simply a coincidence.
Another point worthy of note is that out of the fifty females
there did not occur one case of so-called puerperal insanity, an
occurrence certainly pointing to the fact that such a disease is
more a disease of the lower classes, occurring mostly in those
who have neither the care nor the attention during a period
which is fraught with so much danger, anxiety, and suffering.

Without further comment I will leave my last heading. It
has been, I know, dealt with very superficially, but it is a

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question that is open to so many speculative assumptions that
further reference to it is unnecessary. To deal with it at all
thoroughly one would be bound to consider the presence or
absence of an exciting cause in all of the numerous and
obscure forms of mental disease, and in this paper that is
almost impossible. In making the assumptions and sug¬
gestions that I have done, my remarks have behind them a
basis of fact, without which, of course, all statements are in the
true sense most unscientific.

Before summarising my results, and expressing more con¬
cisely my conclusions, there is yet one point that I would wish
very briefly to refer to, namely, What exactly is the importance
of, or what is the significance of, the presence of well-marked
physical disease in the ancestry ?

In examining my own cases I found that in 40 per cent, of
them (20 males and 20 females) there was a record of pro¬
nounced physical disease in the hereditary history ; I say
“ pronounced,” for I included only the graver maladies. Con¬
sidering that I did not go so carefully into the physical
hereditary history, a percentage of 40 is a fairly large one, and
would probably have been greater had a more accurate investi¬
gation been made.

At present a great deal of attention is being paid to the
simultaneous occurrence of mental and physical symptoms in
the insane, but what is the significance of marked physical
disease in the parents or ancestors of an insane person ? That
it has some significance there can be no doubt, and one
frequently sees quoted as occurring side by side among
the members of a family several cases of physical disease
and insanity. As an example of this I may mention the
following case (No. 29 of my own series) : Patient was the
second son of a family of nine; his father died of “ senile
decay,” and his mother died at the age of seventy of “jaundice.”
The nine consisted of seven brothers (including patient) and
two sisters. Five of the seven brothers and one sister died of
phthisis. One sister is intensely nervous and eccentric. One
brother (the youngest), who had been delicate all his life, died
of “ disease of the liver.” Three of the brothers at least, as
well as dying of phthisis, were alcoholics. The remaining
brother—the patient in question—became insane at the age of
fifty-eight.

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Again, there is not the slightest doubt that such diseases as
phthisis, gout, rheumatism, diabetes, etc., are of very frequent
occurrence amongst the ancestors of the insane. It is also an
acknowledged fact that parents the subjects of those diseases
seem to transmit to their offspring a certain predisposition to
one or other of these affections. Does not the presence of,
say, e.g., phthisis, if it be pronounced in the ancestry, point to
a certain physical degeneracy, and if this degeneracy be handed
on to the offspring, as it almost certainly is, may it not appear
in that offspring in a different as well as in the same form, and
is not that different form very frequently a mental instead of a
physical illness—a mental illness being in this case the gift of
a weak or degenerate inheritance ? Is not this, however, one
of Nature’s ways of exterminating a weak stock, ironical though
it may seem ? As I am not dealing with the inheritance of
physical diseases in this paper, I shall not dwell upon it, but I
wish to point out that, whilst there is frequently seen in the
ancestors or relatives of insane persons grave physical diseases
—diseases the hereditary predisposition to which is undoubted
—it is equally common to find that the predisposition to the
special disease in question has been passed over, and its place
has been taken by a general predisposition to one of the
neuroses, or, perhaps, even to actual insanity. As de Fursac
says, “ All possible evidences of degeneration are observed
among the ascendants and collateral relatives of the insane :
neuroses, psychoses, organic nervous diseases, defects of
character and morals (criminality), arthritic manifestations,
gout, diabetes,” etc. (6). We are bound, therefore, I think, to
believe that such a thing as the transformation of a neurosis
may occur.

Conclusions.

Having discussed the various points of my subject in detail,
it only remains now in conclusion to briefly recapitulate and
summarise the facts which have been elucidated.

(i) In the first place I think we are bound to accept as a
fact the physiological law of inheritance, namely, that like tends
to beget like ; no matter what are the theories of heredity this
law, I think, stands unchallenged. If it be a physiological law
of inheritance why should not its importance be of almost equal

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significance when dealing with an unsound, or “ pathological ”
heredity ? Upon the belief in such a possibility all the problems
of this most intricate subject—heredity—are hinged, and hence
I wish to lay some stress upon it. Like tends to beget like,
even when that like is an unstable, nervous system. It is also
acknowledged, I think, that although one animal begets its like,
and its like only, the qualities or characters of the offspring—
originally those of the parent—are gradually altered or trans¬
formed by various circumstances usually to the benefit of that
offspring, or in order that that they may be fitted for “ the
struggle for existence.” Hence, also, the person born of un¬
stable or even insane parents, even although he starts life with
a bad heredity and therefore at a disadvantage, has a chance
that circumstances may be favourable and helpful, and therefore
instead of succumbing and “ going to the w r all ” he may be
assisted to a higher level. Were it not for this, were it not that
Nature after all tends to protect and help the weak, the world
would assuredly soon come to a standstill.

(2) From an examination of one hundred consecutive cases,
I found that there was a hereditary history of insanity or
well-marked neurosis in 55 per cent, of the direct ancestors
(father, mother, and grandparents). Besides actual mental
disease I included those who showed a well-marked neurotic
tendency, for I think the importance of such a condition can
hardly be exaggerated, and is, in my opinion, if well pronounced,
of almost equal significance as an insane heredity.

(3) Further, when one includes as well as the direct ancestors
the more distant relatives (aunts, uncles, cousins, etc.), I found
that out of the hundred cases 71 per cent, had an insane or
neurotic heredity. It is extremely difficult to obtain accurate
statements as to the percentage of insanity in the ancestors of
the mentally unsound. The percentage varies very largely,
probably because some observers include as well, when dealing
with this point, the presence of a neuropathic heredity ; and
with this I quite agree, for, as previously mentioned, it is of
almost equal significance. Dr. Urquhart, in the Morison
Lecture for 1907, records the results of various observers, and
he says that “the total neuropathic heredity reaches 72 per
cent!' Dr. Hack Tuke calculated the percentage as 20'5 out
of 136,478 admissions into English asylums. Dr. H. Grainger
Stewart reported 49 per cent, out of 901 cases at Dumfries, but

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he included eccentricity and recognised this particular form of
want of mental balance as definitely important. Dr. Savage
recorded 34 per cent, in Bethlem Hospital out of 1,072 persons.
Dr. W. F. Farquharson recorded 30 per cent, out of 3,907
admissions to the Cumberland and Westmoreland Asylum. In
Dr. Urquhart’s experience the percentage of insanity alone rose
to 48 per cent. (7)

(4) When dealing with heredity it is perhaps worthy of note
that there seems to be a tendency for the males to take more
strongly the heredity through the father and the females
through the mother, but as only fifty cases of each were
examined I do not feel justified in making any dogmatic
statement upon this point ; it is an interesting point, however,
accurate facts about which would repay a careful and thorough
investigation.

(5) The next point that I wish to lay stress upon, and that
very strongly, is the presence of the neuro-insane constitution
in the individual the subject of mental disease, and in my
hundred cases I found evidence of it in ninety-three instances.
What exactly constituted this so-called neuro-insane constitu¬
tion I fully described elsewhere.

(6) I pointed out also that this neuro-insane constitution,
besides being in most cases the gift of a bad heredity, was a
condition which could be acquired through adverse circum¬
stances, etc. The fact that the condition can be an acquired
one is, in my opinion, not sufficiently realised, especially as I
think there can be little doubt that the presence of this neuro-
insane constitution is the basis upon which nearly all mental
illnesses develop.

(7) Given a person with a bad heredity, the result in all
likelihood is that that person has been born a neurotic, or the
neurotic temperament has been acquired. In either case I think
that in order to bring about or precipitate a mental attack there
must be some special cause or causes. What those are it is
difficult to accurately state, but usually adverse circumstances,
business or domestic worry, love affairs, alcohol, syphilis, or even
microbic infection are sufficient, individually or collectively, to
precipitate a mental attack in the person with an unsound brain.
I found that in 84 per cent, of my cases there was a distinct
cause attributable to their mental attack. In 43 per cent, it
was overwork and worry, domestic and financial. In 14 pet

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cent . it was fright or shock. In 11 per cent, it was such circum¬
stances as marriage, physical illnesses, etc., whilst in 16 per cent.
it was alcohol. If alcohol be stated to be the cause of the
mental attack, then the case would be called by many alcoholic
insanity. The percentage of such cases varies enormously,
probably because no two observers classify alike, and it is in
many cases difficult to know whether the alcohol causes the
insanity or whether it is only a symptom of the insanity. Dr.
Clouston says : “ From 1 5 to 20 per cent, of the cases of mental
disease in both sexes, and about 25 per cent, in the male sex
among the wage-earning classes in the cities may, taking the
country through, be put down to alcohol as a cause ‘ wholly or
in part.’ ”(8) At the Perth Royal Asylum Dr. Urquhart obtained
a percentage of 9'2 out of 520 total admissions, and he also
observed that out of 110 alcoholics nearly 43 per cent, were
hereditarily predisposed to insanity and nearly 2 2 per cent, to
alcoholism.(9) Out of my 100 cases I obtained a percentage
of 16, and which I think might be regarded as a fairly true
average.

(8) It is worthy of note that amongst my fifty female cases
there was not one case of puerperal insanity ; however, the
majority of the female admissions were unmarried. Although
Clouston says, “ It occurs in ladies with every comfort and
attendance as well as among the poor,” he also states, “ Poverty
and want of proper attendance during childbirth, and having
to get out of bed and to work too soon, 1 have seen bring it
on” (10). Judging from what I have seen both in the higher
and lower classes, I have no hesitation in saying that it is
more frequent among the latter.

(9) In 40 per cent, of my cases I found in the ancestry
evidences of grave physical disease. The significance of this
must be looked upon with great reservation, although that it
is of some significance there can be no doubt. It may at all
events mean that the parents were in a sense physical degene¬
rates, and that their degeneracy appeared in the offspring as a
mental rather than a physical flaw, and it supports de Fursac’s
statement that—“All possible evidences of degeneration are
observed among the antecedents and collateral relatives of the
insane.”

In dealing with any subject which involves a discussion
upon heredity, I am well aware of the numerous pitfalls which

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one has to encounter. It is easy to theorise about, but almost
impossible to prove, the many obscure laws which govern our
inheritance. It is only by a careful recognition of facts which
have been accurately obtained from a large field of inquiry
that one can hope to strengthen any one theory. The moment
we depart from facts we at once embark on dangerous ground,
and only too readily do we drift into the field of speculative
assumption, making thereby any theorising, to say the least of
it, most unscientific.

References.

(1) Green’s Encyclopedia of Medicine, vol. iv, p. 173.

(2) Bruce.— Clinical Psychiatry , p. 39.

(3) Macpherson.— Mental Affections, pp. 35-39.

(4) Darwin.— Origin of Species, p. 10.

(5) De Fursac.— Manual of Psychiatry, p. 147.

(6) De Fursac.— Ibid., p. 9.

(7) Dr. Urquhart.—“ Morison Lecture,” Journal of Mental Science,
April, 1907.

(8) Clouston.— Mental Diseases, p. 483.

(9) Dr. Urquhart.—“ Morison Lecture,” Journal of Menial Science,
April, 1907.

(10) Clouston.— Mental Diseases , p. 551.

The Causes and Treatment of Asylum Dysentery. By
Sidney J. Steward, M.D.Cantab., M.R.C.S., etc., (late
Second Assistant Medical Officer Devon County Asylum,
and Government Surgeon in Trinidad, B.W.I.).

Until the specific causes of the various types of colitis are
ascertained dysentery may be regarded as a group of symptoms
which are presumably the result of microbic action, although
it does not follow that the organisms which have been isolated
from the intestines are invariably the specific cause of the
symptoms, or that their presence will necessarily produce the
symptoms ; even the Shiga (or Flexner) bacillus, which is
looked upon by many as the origin of non-amcebic tropical
dysentery, has been found in the faeces of healthy persons
( v . Allchin) (1). It is probable that the specific organisms are
some of the various bacilli and micrococci which are commonly
to be found in the intestines, and which are normally benign

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in character, but through certain influences within and around
the subject, become pathogenic.

This is particularly likely in the case of so-called asylum
dysentery, as this ailment is almost entirely confined to a
class of patients who are under the same peculiar conditions,
either in public lunatic asylums, or (much more rarely) in poor-
law infirmaries. The symptoms of this form of colitis may be
described by Manson’s (2) definition of dysentery : “ A group
of diseases of which the principal pathological feature is in¬
flammation of the mucous membrane of the colon, and of
which the leading symptoms are pain in the abdomen, tenesmus,
and the passage of frequent small stools containing slime, or
slime and blood.” The only point in which asylum dysentery
does not conform to this definition is in the not infrequent
absence or slightness of tenesmus and tormina ; this may be
due to the decreased sensitiveness of the nervous system or to
the patient’s inability or unwillingness to give expression to
his sensations because of his mental condition ; for instance,
only five out of thirty-six patients complained of typical
tormina and tenesmus (one, H. T. R—, ascribed the latter
symptom to attempts to cut him with knives), and less than
half of them gave any indication of pain. The occurrence of
tenesmus is also dependent upon the position of the ulceration.

It has been recently stated (v. Hawkins) (3) that “the
evidence as regards the ulcerative colitis of asylums is almost
conclusive of the identity of the British and the tropical
disease.” This view is to some extent supported by Goodliffe,
McWeeney, and Eyre, each of whom in separate epidemics
isolated bacilli having similar characteristics ( v . W. B.
Knobel) (4) ; these may have been different types of the
Shiga or Flexner bacillus, especially as Eyre (5) in one
instance obtained a positive agglutinative action against the
tropical Bacillus dysenterice ; on the other hand, the Claybury
epidemic was attributed by Durham to a small micrococcus,
and the Derby County epidemic by Legge to the Bacillus
enteritidis sporogenes , while in other epidemics large numbers
of the Bacillus coli communis and of pyogenic cocci have been
isolated. From this evidence one can only presume that
different varieties of bacteria are concerned in different out¬
breaks of the disease, and that these organisms are often
present in health, but are innocuous, except under certain

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conditions, when they are rendered virulent and obtain access
to the digestive tract in abnormal numbers.

There are certain conditions obtaining among lunatics in
asylums, and peculiar to them, which might well foster this
virulence and this increase of ingestion, and thereby lead to
the frequent occurrence of the disease in such institutions.
The frequency is proved by the statistics of the Commissioners
in Lunacy. In 1903 there were 1,225 cases, with 257 deaths,
while the deaths from dysentery throughout the Kingdom,
outside asylums, were only 53 ; in 1908, among 94,888
asylum inmates there were 1,068 cases and 235 deaths.

From the notes of one hundred cases which occurred during
seven years in Devon County Asylum, I have arrived at the
opinion that the two main causes of asylum dysentery are,
first, exposure to air which has been vitiated by pollution
with faecal gases and dust, combined with the contact with
particles of excremental matter which is inseparable from such
exposure; and, secondly, a diseased state of the gastro¬
intestinal tract which is common in lunatics, who mostly
suffer from chronic constipation and often from stomatitis ;
excessive ingestion of organisms is provided by the first
condition, and a culture-bed where the organisms may multiply
and acquire virulence is provided by the second, especially as
the bacteria may have already passed through unhealthy
digestive systems; by both conditions the normal physical
tone of the patient is considerably lowered.

The first condition applies chiefly to those who have
incontinence of urine and feces with defective habits, and who
are generally known as “ wet and dirty ” patients ; the air
around them is polluted with fecal gas and floating particles,
and by this means, aided by actual contact with their hands
and linen, which must remain to some extent soiled even
when a careful watch is kept over the patients, their food
and feeding utensils become polluted by excremental matter,
and large numbers of intestinal organisms are ingested ; this
pollution is increased by gnats and flies during the summer
months ; out of 100 patients 47 were wet and dirty in
their habits, and 19 others were in wards amongst wet and
dirty patients ; thus 66 per cent . of them were exposed to
fecal contamination to a marked degree. It is because of
their defective habits and not because of any pathological

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condition of the nervous system that dements of all kinds are
the most frequent victims of dysentery; 38 of these patients
were either senile or secondary dements, and 2 others had
dementia paralytica, 40 per cent, in all.

“ Diarrhoea and dysentery are . . . sometimes caused by

breathing air contaminated with excretal emanations
the long-continued inhalation or ingestion of tainted air may be
considered to confer immunity . . . from disease spread by

sewer-air ” ( v . Parkes and Kenwood) (6). This is probably
why many who have been wet and dirty for years escape the
disease, and why many who are exposed to a fecal atmosphere
escape altogether ; it is when they have become particularly
susceptible through ill-health or other cause and perhaps are
exposed to some particularly virulent organisms that they fall
victims. For the same reason newly admitted patients are
extremely susceptible to the disease, even with very slight
exposure to foul air. A certain amount of exposure is bound
to occur, although there are few wet and dirty patients in the
receiving wards ; on the other hand, these rooms often contain
a large number of persons who live in them day and night,
and this prevents complete ventilation and removal of the
polluted atmosphere: 3 5 per cent, of them contracted

dysentery within one year of their admission, and 1 5 per cent.
within two months. There was no evidence to show that any
of them introduced the disease.

The second condition was present in 45 per cent, of the
patients, forty-three of them being habitually constipated and
two of them suffering from recurrent diarrhoea, supposed not
to be dysenteric. Twenty were both costive and wet and dirty;
several of them had stomatitis too. With such a state of
stagnation prevailing in the intestinal tract it is not surprising
that these patients are particularly susceptible to dysentery,
although their exposure to a fecal atmosphere may be com¬
paratively slight ; a certain degree of pollution of the air must
occur even in dormitories in which no wet and dirty persons
sleep, since commodes are placed beside the beds and are used
frequently during the night, with the result that a great deal of
foul gas must escape into the room.

The symptoms to which chronic intestinal stasis gives rise,
are, “ pigmentation of the skin, bad-smelling sweat, headache,
mental and physical lassitude, inability to do ordinary work,

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mental misery and distress” ( v . Arbuthnot Lane) (7). This is
the picture of a melancholic state in which it is difficult to say
how much of the intestinal stasis is due to paresis of the
muscles resulting from the mental condition, or how far the
melancholia is caused and aggravated by the consequent
absorption of toxins ; however it may be, there is a vicious
circle, and the digestive system is in a suitable state to foster
an increase in the numbers and the virulence of any ingested
organisms.

We have seen, then, that a faecal atmosphere and digestive
disturbances may be the chief predisposing causes of the
disease, and that they may account for most of the sporadic
cases. When such cases occur they are liable at any time to
start an epidemic, as the organism is present in its virulent
form, and, unless precautions are taken to isolate the patient
immediately, and to disinfect his excrements in the same way
as is done in the management of enteric fever, the disease is
very liable to spread through the infected ward, and even those
in charge of the patients may acquire it, although themselves
in good bodily and mental health ; however, it is possible that
precautions will not absolutely check an epidemic because the
infecting material may be carried in small dust particles in the
air; for this reason typhoid patients are seldom placed in
general wards nowadays, although a few years ago it was not
considered necessary to isolate them.

One attendant contracted the disease while in charge of a
ward in which ten cases of dysentery occurred during October,
1903 ; from June to October, 1905, there was an epidemic of
eight cases in one ward, and from June to August, 1909, of
thirteen cases in three wards.

Most of the epidemics take place in the summer or the early
autumn, and in this respect there is a resemblance to infantile
epidemic diarrhoea, which is a closely allied disease. This
seasonal influence is probably due to an increase in the amount
of dust and in the number of flies peculiar to this period of the
year. The flies pollute food and feeding utensils with infected
matter which they have picked up from excrements and soiled
linen; in the same way much of the enteric fever was disseminated
during the South African War.

In 1903 there were fifteen cases during September and
October; in 1904 there were five cases from June to Septem-

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ber; in 1905 there were eighteen cases from June to September;
in 1906 there was one in October ; in 1907 there was one in
June; and in 1909 there were twenty-seven from June to
August—that is, 67 per cent, of the cases occurred during the
months from June to October; the remainder were scattered
over the rest of the year.

It is possible that an outbreak is sometimes started by a
patient who has a mild attack of diarrhoea which has been
overlooked or has been wrongly diagnosed as non-dysenteric ;
and again, it is not unlikely that patients who have apparently
recovered from dysentery may for months or even years pass
virulent organisms in their stools, just as do the well-known
“ typhoid carriers.”

Chills, starvation, and indigestible food are predisposing
factors, as they are to many diseases, because they lower the
vitality.

The form of mental disease has no influence except in so
much as it affects the conduct ; thus, dements with wet and
dirty habits formed a large proportion—40 per cent, of all the
cases ; 16 suffered from mania, 18 from melancholia, 6 from
confusional insanity, 7 from epilepsy, 5 from paranoia, 4 from
imbecility, 3 from dementia pra;cox, and 1 was sane.

Age has no influence ; a large proportion were over 60 (38
per cent .), but this is because so many dements exceed that
age; 17 were from 50-60, 13 from 40-50, 20 from 30-40,
and 12 were under 30.

Females preponderate over males in the proportion of 65 to
35, probably because females are more frequently costive and
wet and dirty in their habits ; the asylum population was in
the proportion of 4 females to 3 males, approximately.

The water supply was obtained from a 750 feet bore in
conglomerate sandstone, and was free from animal contamina¬
tion.

The drainage was in good order.

The milk and other food were in good condition.

It has been suggested that nervous degeneration may cause
the lesions in the bowel through trophic changes in the mucous
membrane, but there is no proof of this ; the nervous sluggish¬
ness of melancholiacs and confusionals causes intestinal stasis,
and this predisposes them to the disease.

Preventive measures must be directed mainly towards the

LVI. 20

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avoidance of a faecal atmosphere and the correction of digestive
errors, while the patient is to be kept in the best possible health
by careful feeding and warm clothing.

It is difficult to do away altogether with faecal pollution in
public asylums where economy is a large consideration, as the
staff is necessarily limited (there is usually one attendant for
ten patients), and it is particularly difficult in the older buildings,
where the dormitories sometimes contain as many as fifty or
sixty beds ; but much may be done by segregating wet and
dirty cases in small rooms, under the observation of attendants,
whose duty it is to rouse them at various times during the
night and to see that they deposit their dejecta into bed-pans,
commodes, or closets, which should be covered immediately,
and then deodorised and disinfected by some chemical, such as
Jeyes’ fluid ; all soiled linen should be removed at once in a
covered receptacle in the same way, and should be disinfected.

Even in the wards in which wet and dirty cases are rare it
is impossible to avoid some measure of faecal contamination of
the air, as the patients often use the commodes during the
night, and it is too risky to leave deodorants in the pans in
case any attempt should be made at suicide ; the only practical
remedy is to keep a look-out for those who make a habit of
going to stool during the night and to remove them to an
observation ward ; or else to turn them out of bed at fixed
intervals so that they may visit the closets under the super¬
vision of a patrolling attendant. By this means commodes
might be almost entirely abolished from the dormitories.

It is better to remove bed-ridden patients to a day room in
the morning in order that their dormitories may be thoroughly-
ventilated for a few hours, but space, as a rule, will not allow
this, especially in the case of large receiving wards.

To prevent actual contagion all attendants and patients who
assist in the wards, and especially those who handle the bed¬
clothes and the lavatory utensils, must be made to wash imme¬
diately after completing their work and again before handling
any food or feeding utensils ; and every patient must have his
hands washed before taking food or drink and after a visit to
the closet.

Each case of diarrhoea, even the mildest, should be isolated
in a ward reserved for the purpose, or where this is impracti¬
cable, in a ward where such short-lived incurables as general

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paralytics are kept ; patients who suffer from recurrent dysentery
or diarrhoea should, if possible, be kept in a similar ward
between the attacks, or at least should be kept on a caution card,
as suicidals are, and their stools should be inspected weekly.

Suspected cases of dysentery must be isolated, with their
clothes and bedding, in a single room until the physician has
seen them and until a diagnosis is made ; any commodes or
closets which they may have used recently should be well
scoured with disinfectants.

Other patients in a ward in which dysentery has broken out
should be kept under observation for a week, and their stools
should be examined and their temperatures should be taken
regularly ; the latter proceeding is important because many
cases occur in which pyrexia precedes diarrhoea and blood and
mucus by a day or two ; for example, I. C— (1 day), F. H. H—
(2 days), C. S— (1 day), M. J. J— (1 day), H. L— (1 day).

Dysentery patients must be segregated in a ward kept only
for such cases, and all the precautions must be used which are
employed in the management of enteric fever ; dejecta, linen,
utensils, etc., must be disinfected, and special nurses must be
told off whose work is confined to the dysentery wards.

It is wise to examine occasionally the stools of each person
for a week after his admission, especially if he come from
another asylum or from a Poor Law infirmary.

In order to put the patients in the best possible condition to
resist the disease, in case they should be exposed to infection,
it is necessary to keep them warmly clothed and to regulate
their food carefully. This applies especially to those who are
subject to diarrhoea, and they should have a special light diet
and should always wear a flannel binder round the abdomen.
Each patient’s mouth should be examined from time to time,
and any carious teeth should be stopped or removed ; tooth¬
brushes should be used regularly, and when necessary the
mouth should be thoroughly cleansed with an antiseptic mouth¬
wash, such as liquor hydrogeni peroxidi, one part in ten parts
of water. Above all, the action of the bowels must be regu¬
lated by the use of a mixture containing extractum cascara:
sagradae liquidum, tinctura nucis vomicae, and tinctura bella-
donnae, in doses and at times to suit the degree of constipation
in each patient; to ascertain the latter point notes should be
made from time to time of each individual’s habits in this

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respect. The routine administration of bi-weekly purgatives in
fixed doses to everybody is likely to cause intestinal irritation
in those who are not naturally constipated. A regular action
of the bowels is, however, rarely found in lunatics, as the lack of
exercise, the good feeding, and the want of tone of the intestinal
muscles all tend to constipation.

In the treatment of dysentery some success has attended
the use of anti-dysenteric serum in the early acute stage of the
tropical type, but its effects are uncertain ( v . Flexner) (8),
and it has proved of little benefit, so far, in the treatment of
asylum dysentery, but coli vaccine has been more efficacious
in a few instances ( v . Allchin) (9); specific treatment is
still in the experimental stage, and cannot be used as a routine
in asylums until more certain results are obtained, especially as
it is expensive ; but where vaccines can be prepared from the
patients themselves we may hope for better results.

Many drugs have been employed with effects varying in
different individuals and in different epidemics; MacMillan (10)
uses half- to one-ounce doses of oleum ricini with a few drops
of tinctura opii, or one large dose of magnesii sulphas, or
several small doses at the onset, followed by bismuth and
opium if diarrhoea is excessive ; he advises against the use of
large rectal enemata. Robert Jones (11) gives purgatives at
the onset, followed by salol, resorcin, iodine, carbolic acid, or
chinosol as intestinal antiseptics, and he also condemns enemata.
Stoddart (12) recommends salol or B. naphthol by the mouth,
and rectal lavage with a solution of creasote or lysol ; he also
mentions the treatment with magnesii sulphas. Allchin (13)
gives it as his opinion that ipecacuanha and salines are not so
useful in the treatment of English dysentery as they have
proved to be in the tropics, and advises small doses of calomel
with opium, and large doses of quinine ; he adds that rectal
enemata are uncertain.

Intestinal antiseptics are, in my opinion, of little service,
and may even prove harmful by inhibiting the growth of
benign and protective intestinal organisms—that is, if they can
be used in a strength sufficient to exercise such an action upon
bacteria—in any case, they are irritants to the intestinal walls.
Opium and other astringents are strongly contra-indicated in
the early acute stage, and the same applies to rectal lavage ;
the latter, however, is the best treatment in chronic cases.

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Buchanan obtained splendid results with salines, namely,
nine deaths only in 855 cases ; he gives one or two drachms
of sodii sulphas every one or two hours until the patient is
freely purged, and then one drachm of sodii sulphas in one
ounce of fennel water four, six, or eight times a day, until a
day or two after the cessation of blood and mucus in the
stools ; if the stools become watery he stops the salines at
once ( v . A. Davidson) (14), and (Whitla) (15).

I had the opportunity of seeing the good effects of the
continuous use of salines on a number of people who were
suffering from acute tropical dysentery in its early stages, and
who were under my care in Trinidad, B.W.I., in 1905, and
this led me to use it on a series of cases of asylum dysentery ;
no attempt was made to give ipecacuanha, although this drug
is often very successful in the tropics, because in eleven of the
thirty-six patients it was strongly contra-indicated owing to
their feeble condition ( v ,. A. Davidson) (16); four had
advanced cardio-vascular degeneration, two failing hearts, three
severe chlorosis with poor cardiac action, one was convalescing
from erysipelas, and one was possibly pregnant; moreover, it
would be quite impossible to administer the large doses of
ipecacuanha (half to one drachm of the powder) to a lunatic,
because intelligent co-operation is required in order to prevent
the return of the drug, and the patient must be kept at
absolute rest for four or five hours without speaking, moving,
or taking any food or drink. Small doses are practically
useless, and de-emetinised ipecacuanha has not been very
successful.

The following plan of treatment was used in thirty-six
consecutive cases ; the patient was kept in bed as much at
rest as possible, the bedpan alone being employed :

The diet for twenty-four hours consisted of three pints of
sterilised new milk (preferably pasteurised), which was given
lukewarm in small quantities at short intervals of time (it
may be diluted with soda water or barley water if the thirst is
great, and if there is gastric irritation it may be peptonised ;
if new milk disagrees soured milk can be given, or egg-
albumen). One pint of arrowroot was added to this diet, and
one teaspoonful of brandy diluted was given every hour, that
is, directly after a dose of medicine ; it acts as a bribe to
persuade the patient to take his medicine, it helps him to

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keep it down, and also gives a good deal of relief to tormina,
besides having a stimulating effect. Beef-tea and meat-
extracts should not be given, as they are liable to aggravate
tormina and diarrhoea.

Half an ounce of the following mixture was given every
hour during the day and night : ft. magnesii sulphatis 3j‘,
sodii sulphatis 3j, acidi sulphurici diluti 111.x, tincturae cardamomi
compositae i^x, tincturae camphorae compositae mxx, aquam
cinnamoni to half an ounce, and this was kept up until
pyrexia had subsided and every trace of blood and mucus had
disappeared from the stools ; in the case of very feeble patients,
in whom signs persist for several days, or in whom insomnia
exists, the dose may be given two-hourly during the sleeping
hours. The fact of the motions becoming watery need not
be considered an indication to stop the mixture, so long as
any blood or mucus remains; rather the large bulk of a watery
stool produces the desired effect of thoroughly flushing the
bowel.

In spite of eleven of the patients being in a feeble physical
condition, these large doses of salines did not appear to
produce any symptoms of poisoning or exhaustion. Sodii
sulphas is non-toxic ; the symptoms of poisoning by magnesii
sulphas are paralysis, first of respiration, then of the heart,
with abolition of sensation and paralysis of the motor reflex
areas ( v. Lauder Brunton) (17); but these symptoms occurred
in two only of the small number of recorded cases of
poisoning (18); the remainder died collapsed as a result of
gastric irritation, or with signs of acute obstruction ; they all
took large single doses, undissolved or only partially dissolved.

Given every hour in one drachm doses dissolved in half an
ounce of water, magnesii sulphas (or sodii sulphas) passes
through the lumen of the gut, abstracts fluid from the intestinal
blood-vessels, and very little of it being absorbed, is finally
evacuated from the anus, the dilution having been too great
to allow of any irritating or obstructing action ; the diminution
of the fluids of the blood is made up in a short time by
absorption from the tissues of a nearly equal quantity of the
fluids. Matthew Hay (19) found that the combined use of
the salts produced a gradual but a well-marked increase in the
arterial pressure ; consequently, the patients who undergo this
treatment can for a few days very easily withstand the call on

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their body fluids if they are supplied with a liberal liquid diet,
supplemented by stimulants. Should collapse threaten it may
be combated by cardiac tonics and by intra-venous injections
of normal saline solution.

The drugs were well borne by the feeblest of my patients ;
for instance, H. T. R—, who was an anaemic and emaciated
chronic maniac, with weak cardiac action, took salines in these
doses for nine whole days, and, over a period of twelve con¬
secutive days, he consumed 27 oz. of magnesii sulphas and 27 oz.
of sodii sulphas ; he also took strychnine, digitalis, and sal
volatile as cardiac stimulants every four hours; he had 160
motions, and his temperature rose to 102° F. The blood and
mucus ceased at the end of this time, and after the administra¬
tion of the astringent mixture during twenty-four hours,
recovery was complete ; two or three days later he was up to
the standard of his usual poor health. W. VV—, a:t. 77, suffer¬
ing from advanced arterio-sclerosis with cardiac failure, took
21 oz. of each salt over a period of seven days with no ill-
effects, and his recovery was also quick and complete.

The saline solution accomplishes its work by keeping up a
continuous draining action upon the mucous lining of the
bowel, whereby the latter is somewhat depleted of blood and
its cells are flushed, while all the organisms, toxins, and cUbris
which are accumulated in the intestines are carried away and
evacuated by the frequent purgation ; this irrigation is con¬
tinuous without being excessive in amount, and it is more
thorough in its action and less likely to be harmful than rectal
enemata, with their bulk and intermittence and their disturb¬
ance and discomfort to the patient. The removal of mucus
and other particles relieves the tormina and tenesmus which
are a reflex result of their irritation to the bowel.

The two drachms of salts are dissolved in half an ounce of
water, roughly a 2 5 per cent, solution of each, and this abstracts
sufficient fluid from the body fluids, mostly in the small intes¬
tine, to form a 5 per cent, or 6 per cent, solution, and owing to
the low diffusibility of the salts very little of them is absorbed.
The fluids which are excreted after secretion and osmosis
( v. Starling) (20) accumulate in the canal, reaching their maxi¬
mum bulk in the large intestine, and, partly from ordinary
dynamical laws, partly from a stimulation of the peristaltic
movements (which is only gentle and therefore does not unduly

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disturb the rest of the inflamed surfaces), they are carried
onwards and finally evacuated ( v . Lauder Brunton) (21) ; too
violent peristalsis is also checked to some degree by the other
constituents of the saline mixture.

The earlier this treatment is adopted the sooner will the
pyrexia, blood and mucus cease (provided that the treatment
is not interrupted), and in an asylum where the patients are
under constant observation there is no reason why the disease
should not be detected in a very early stage, and thereby some
of the symptoms may be prevented ; for this reason it is wise
to give salines, as a precautionary measure, hourly for twelve
hours in all cases of diarrhoea, following them by an astringent
mixture ; they may be given also to any patient in an infected
ward who develops a rise of temperature.

The treatment considerably shortens the course of the
disease, and, if given in time, should certainly obviate chroni-
city. Of the 36 patients treated in this way there were mucus
and pyrexia without blood for 24 hours in 1 ; mucus without
blood (four with fever and two without) lasting about 2 days in
6 (these were all cases of simple catarrhal colitis ; probably the
remainder had ulcerative colitis as they all passed blood and
mucus, and all except two had pyrexia) : 14 of them required
less than 2 days of salines ; 7, 3 days ; 2, 4 days (one, E. H—,
died with a fatty heart) ; 2, 7 days (one, A. J. H—, died) ; I,
8 days ; 1,9 days ; 1, 1 1 days ; and I (K. R—) died without
taking any salines, as she vomited everything which was given
to her, and, in spite of gastric sedatives, could only be made to
retain a little nourishment ; she was given rectal enemata con¬
taining 20 grains of quinine sulphate dissolved in dilute sul¬
phuric acid and water; she died after eleven days, having
passed blood and mucus all the time, and the highest fever
being 104° F.

In 2 cases the temperature reached 104° F. ; in 6, 103°;
in 11, 102 0 ; in 6, ioi°; in 6, ioo°; the remainder being
under ioo° ; 3 had no pyrexia at all.

It is supposed that salines have the power of reducing the
temperature in fevers although they have no such action in
health (v. Mathew Hay) (22), and the}''may exert this beneficial
influence in dysentery.

When the saline mixture has effected its object in clearing
up the blood, mucus and pyrexia no other drugs are required,

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except, possibly, cardiac tonics, as diarrhoea usually ceases in a
few hours and constipation often follows. Should the diarrhoea
persist it may be checked by giving one ounce of the following
mixture two-, three-, or four-hourly according to circumstances :
ft bismuthi subnitratis gr. xx, tinctura chloroformi et morphime
compositae my to x, tinctura catechu 3SS, mucilaginis quod
sufficat, et aquam ad 3j-

Any recurrence of blood and mucus should be treated again
with salines.

Post-dysenteric constipation should not be allowed to continue
for more than twenty-four hours, and can be stopped by one
drachm of oleum ricini or by a glycerine suppository.

The patient should remain in bed for at least a fortnight
after the active signs have ceased, and he should be kept in a
diarrhoea ward or general paralytic ward, as suggested before,
for some weeks (or permanently if subject to relapses), and his
stools should be inspected from time to time.

Some symptoms may occur which require special treatment,
for example, tormina may be relieved by hot turpentine stupes
to the abdomen, tenesmus and dysuria by morphine or cocaine
suppositories, or by the rectal injection of half a drachm of
laudanum in two ounces of warm starch solution (these
symptoms are rarely marked in asylum dysentery), insomnia by
one or two drachms of paraldehyde, and vomiting by dilute
hydrocyanic acid and bicarbonate of soda.

Jaundice occurred in one patient (S. H—) about six weeks
after the attack of dysentery, and it was accompanied by slight
intermittent fever for a few days and by considerable hepatic
tenderness. He was treated with salines and bicarbonate of
soda and recovered, but relapsed again in a fortnight and
finally recovered after a few days. Hepatitis is a rare compli¬
cation except of the amoebic form of dysentery, so possibly
this was only a simple catarrhal condition.

If salines produce no good result after a few days’ trial the
following powder may be given : ft pulveris ipecacuanha; gr. j,
hydrargyri 6 creta gr. j, pulveris ipecacuanhae compositi gr. ij,
sodii bicarbonatis gr. iij, bismuthi subnitratis gr. v, given two-,
three-, or four-hourly.

Should the condition become chronic (it did not in this series
of cases and rarely does in asylum dysentery), it may, after a
week, be treated with injections of two or three pints of a 1 in

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4,000 solution of silver nitrate in water after the bowel has been
washed out with a I per cent, solution of sodium carbonate in
water.

There were three deaths among the thirty-six patients ; one
of them, K. R—, was unable to take salines owing to severe
gastric irritability. E. H— was found post-mortem to have
advanced fatty degeneration of the heart muscle, atheromatous
deposits on the aortic valves, and a fatty liver ; the mucous
membrane of the lower portion of the large bowel was swollen
and congested and dotted with small haemorrhages and punctate
ulcers ; the lower part of the ileum was also slightly congested
and the mesenteric glands were enlarged. She had had the
disease for four days only, passing blood and mucus through¬
out. The highest fever was io2‘6° F., and she vomited
frequently. A. J. H— died after seven days’ illness, passing
blood and mucus all the time, the highest fever being io2‘8°F.
She was given salines for the first twenty-four hours; they were
then remitted for one day and continued again for twenty-four
hours, and finally stopped as she was collapsed. Intra-venous
injections of normal saline solution were given twice during the
last day. I think she might have done better if the saline
treatment had been carried on continuously in spite of her
weakness, as subsequent patients, who were quite as weakly,
stood the treatment well.

The remainder of the patients recovered completely, seven¬
teen within four days of the onset, and all except two of the
others (E. H— and H. T. R—) within one week.

The first 64 of the series of 100 cases were given various
drugs, ut seq., 25 quinine and opium enemata, 9 pulvis cretie
aromatics, 10 bismuth and salol, 9 some form of opium, 4
oleum ricini, and 6 catechu (or combinations of these drugs).

There were 2 I deaths among the 64 who were treated by
these various drugs, i.e., 32‘8 per cent, deaths ; the percentage
of deaths amongst the 36 on whom salines were tried was 8 - 3
(3 out of 36).

In all England during 1903 there were 1,225 cases and 257
deaths, and in 1908 there were 1,068 cases and 235 deaths,
that is, a percentage of 21 and 22 respectively.

In conclusion, I am of the opinion that much of the dysentery
in asylums might be prevented by reducing to the smallest
possible amount the faecal pollution of the atmosphere and by

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19*0.] AUTO-SUGGESTION AND DELUSIONAL INSANITY. 3 I I

a longer isolation and more careful observation of those patients
who have had the disease, while the best results in the matter
of treatment of acute cases are to be obtained from the exhibi¬
tion of salines in frequently repeated doses sufficient to produce
purgation, continued without a break so long as active signs of
the disease persist, and followed, if necessary, by a few doses
of an astringent mixture. The sera and vaccines of the present
time are uncertain in their action, but we may hope for a specific
cure when the infecting organisms become known more
accurately and when suitable vaccines and sera can be prepared
from them.

References.

(1) Allchin.— Proc. Roy. Soc. Med., vol. ii, No. 4, Med., p. 72.

(9) . 03 ) Idem, p. 75.

(2) Manson.— Tropical Diseases, p. 375.

(3) Hawkins.— Brit. Med. Journ., 1909, p. 1331.

(4) W. B. Knobel.— Journ. Ment. Sci., April, 1906.

(5) Eyre.— Brit. Med. Journ., 1904, p. 1002.

(6) Parkes and Kenwood.— Hygiene , p. 227.

(7) Arbuthnot Lane.—“Chronic Intestinal Stasis,” Brit. Med. Journ.,
June, 1909.

(8) Flexner.—Allbutt and Rolleston’s System of Medicine, vol. ii,
Part II, p. 523.

(14) , (16) Davidson.— Idem, vol. ii, Part II, p. 520.

(10) MacMillan.— Journ. Ment. Sci., 1902.

(11) Robert Jones.— Idem.

(12) Stoddart.— Mind and its Disorders , p. 427.

(15) Whitla.— Dictionary oj Treatment, p. 225.

(17) Mathew Hay.—Lauder Brunton’s Pharmacology, Therapeutics
and Alateria Medica , p. 391.

(19) , (21), (22) Idem, pp. 391 to 395.

(18) “ Epsom Salts as a Poison,” Lancet, 1909.

(20) Starling.— The Fluids oj the Body.

Auto-suggestion and Delusional Insanity. By David
Thomson, M.B., Ch.B.Edin., formerly Assistant Medical
Officer, Horton Asylum, Epsom.

The presence of delusions, whether arising primarily or follow¬
ing other mental states, is significant of a faulty cerebral action,
yet the co-existence of normal ideas suggests that the morbid
process is limited to certain groups of nerve-cells. It is thus
reasonable to suppose that many of the nerve-cells associated

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with ideation are in such cases working normally. There
would appear to be “ wrong thought centres ” or “ wrong series
of associations ” giving rise to delusions.

Granting this assumption, what curative measures are practic¬
able ? How can we get at these morbid areas or associations ?

We cannot lay hands on the cells, possibly much scattered,
that are the root of the evil to destroy them. But there is
another plan, and that is to train other cells to set up ideas
contradictory to those emanating from the diseased cells, that
is to say, we must try to produce a habit of thought exactly
contradictory to the delusions, and finally, by constant repetition,
cause a group of cells to produce automatically ideas dominating
them. At all ages the brain seems capable of training to a
marvellous extent. It would suggest that there are more nerve-
cells than are ordinarily required. In Italy the re-education of
dements is thought practicable, which means the training of
nerve-cells whose energies have never been tapped.

David Ferrier, in his Lumleian Lecture on “Tabes Dorsalis,”
pointed out that the great improvement in the gait of tabetics
by systematic exercises was evidently due to the opening of new
motor pathways, but that this took considerable time and
perseverance. Reasoning thus, I commenced to try to develop
in several cases of delusional insanity habits of thought directly
contradictory to their delusions. I tried to teach them a process
of auto-suggestion. I carried out this line of treatment in four
cases at Horton Asylum during a period of several months—
from November, 1907, till May, 1908.

Case i. —H. M. H—, admitted June 10th, 1903, a:t. 41,
married. Not the first attack.

Synopsis of notes .—On admission patient has a silly expres¬
sion. Behaves very childishly, laughing and talking constantly
to himself. He states he can take his food here, but at home
it tastes “ queerly,” and he suspects his wife puts something
into it to get rid of him.

History .—Patient has been strange since Christmas last.
He is constantly shouting and laughing and talking to imaginary
people. He dances in the streets to the organs. He refuses
food, does no work, is untidy in his person, and wanders aim¬
lessly about.

May 25th, 1904.—He is weak-minded, irrational, imagines
he is acted upon in some peculiar way, etc.

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313

May 13th, 1907.—He is re-certified as a case of delusional
insanity ; irrational and introspective ; declares he is dead and
has been bleeding to death for the last six months.

September 10th, 1907.—He says he is dead. Writes
gloomy letters to his wife. Says he has no bones, and that his
muscles are torn up.

It was about this time that I got to know the patient. He
was quiet, docile, not excitable, and could reason to some
extent, but he had a strong delusion that his body was in a
state of decline. He was miserable, and said his bones and
muscles were rotting away, and stated so in his letters to his
wife.

On September 20th, 1907, I started him on auto-suggestion
as follows. I wrote distinctly on a sheet of paper the follow¬
ing sentences: “I am strong and happy”; “My body is
strong and healthy” ; “ My bones and muscles are strong and
supple”; “I have a cheerful, happy mind.” I brought him
into a side room, and made him repeat to me aloud these
sentences. After he had repeated them ten times I put a dot
on the paper (.). I kept him till ten dots were on the paper

(.), showing that he had repeated the four sentences

100 times. Thus he had repeated 400 sentences, directing
efforts of thought contradictory to his delusions.

By systematic accumulations of these I hoped finally to pro¬
duce in his mind such a habit of these thoughts that his
delusions would be finally overwhelmed.

I directed him to repeat these sentences to himself thousands
of times a day, and to register the number of times he repeated
them by putting a dot on the paper for every ten times.
Also, to make sure that he did do something, I directed him
further to write down the sentences several times on the paper.

I found the dots and the sentences on his paper at the end
of each day, but whether he repeated the sentences properly to
himself I cannot tell. Anyhow, I made him repeat aloud to
me 400 sentences per day.

By the end of three months he had repeated to himself
150,000 sentences similar to the above, 20,000 sentences
aloud before me, 520 sentences he had written out on paper ;
total, 170,520 single sentences.

The result of all this, as in the other cases, was very slight.
Yet it seemed to me that there was some effect being produced,

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which ought to encourage further efforts. He assumed a more
cheerful aspect, and his letters to his wife became less gloomy.
When I questioned him upon his condition I had him trained
to say that he was strong and happy, and that his bones and
muscles were quite strong and healthy. But his delusions
still remained, though not so intense.

Case 2.— K. R —, admitted April 8th, 1902, set. 54,
painter, married ; not first attack.

Synopsis of notes. —On admission he is violent. His con¬
versation is not coherent. He refuses to answer questions.
Says he is on duty. Has delusions that his arms and legs are
paralysed and broken, etc.

November, 1902.—He is acutely depressed and deluded.

February, 1903.—He declares he is an animal and a dog in
the sight of God, and behaves as such.

I got to know him on October 8th, 1907. His memory
was good, but he was extremely depressed, and sat silent with
his head hanging down all day long. He said he was suffering
judgment for self-abuse, etc. He was very deluded and stated
that he heard God speaking to him through the sounds of the
billiard balls. He was quiet, well behaved, and not excitable
in the least.

On this patient I expended an exceptional amount of
energy and time, and although the results after six months
were very small, yet I think they were hopeful. It required
one month of stubborn perseverance on my part to get him to
finally agree to carry out the instructions I gave him.

The suggestions he got were of the following type : “ I refuse
to have any silly ideas” ; “ I am going to be strong and happy" ;
“ I have a strong and healthy mind ” ; “I have absolute con¬
fidence in myself.” I also got him started to do some useful
work in the wards.

In April, 1908, I finished my endeavours, and in my opinion
he was then more cheerful and his delusions were not so
intensely dominating his mind.

This was the result after he had repeated to himself 296,000
single sentences ; 10,000 repeated aloud to me; 641 written.
Total over 300,000 repetitions.

October, 1908.—The notes describe him as depressed and
self-accusatory. Believes he is a water-rat, etc., and that he is
under God’s judgment. He does a little work and is clean

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and tidy. Health fair. This shows, then, how helpless one
feels in trying to drive away fixed delusions.

About the other two cases I will only say that I devoted
much less time to them, and in them there was very little
result to be observed.

Before concluding I would like to mention a rather interest¬
ing fact about a similar case.

While homeward bound from a voyage to the West Coast of
Africa, a negro, about sixty years of age, came aboard at
Sierra Leone and put himself under my care as ship’s surgeon.
He said he was going to England to get treated by the skilful
physicians there. On careful inquiry I discovered that his
ailments were more or less imaginary and told him so, and
finally I managed to extract from him the whole history of his
case. He was a man with a capable brain and had amassed a
considerable fortune by his cleverness, but he had become the
victim of a delusion which dominated his mind. He had been
brought up in the Christian faith, but had become obsessed by
the idea that the native fetish-men of Sierra Leone were acting
on his brain telepathically and trying to harm him. This
delusion had come suddenly eight years previously, and on
careful inquiry I found that it had originated in a violent night¬
mare. I inquired about sun-stroke, but he declared that his
work at that time was always indoors.

In the hypnotic sleep suggestions have a very powerful
effect, and can produce temporary delusions. Sleep, according
to hypnotists, is identical with the hypnotic sleep, except that
in ordinary sleep the person is en rapport with himself. It
might be possible, then, for a vivid idea to arise during sleep,
as in a nightmare, which might conceivably form the com¬
mencement of a delusion. If, however, it should come to be
proved practicable that new thought-habits can be engrossed
upon the brain to counteract existing wrong thought-habits,
then the practice would be of great use in competent hands in
the mental hygiene and training of children.

In the long-fixed delusions of the insane I have shown that
hundreds of thousands of suggestions have only slight effect,
but they might be of value in very early cases.

I beg to thank Dr. Lord, the medical superintendent of
Horton Asylum, for his kind help and interest.

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Clinical Notes and Cases.

A Case of Acute Mania Relapsing into Unconsciousness
Lasting Seven Months.i 1 ) By Nathan Raw, M.D.,
M.R.C.P., Physician, Mill Road Infirmary, Liverpool.

The following case of a girl is of special interest from the
fact that although she had not spoken a word for over eight
months she suddenly commenced to talk in a most voluble way,
and to quote long passages which she had committed to
memory as a girl.

History .—The mental history of the girl was fairly good; she had
always been bright and active, and fond of reading. An aunt was
insane; no other case of insanity in the family was recorded. The girl
was engaged in domestic service and was performing all her duties well
until three days before admission, when she was observed to be restless
and unsettled, with a loss of appetite. That night she was unable to
sleep, and commenced to sing and laugh without apparent cause. She
rapidly passed into a state of active mania, shouting, gesticulating, and
resisting all efforts to help her. Her temperature now commenced to
rise and was 103° F. ; pulse 126, small and feeble; she was menstruat¬
ing. As it was impossible to manage her at home she was sent into
hospital, when I saw her on admission.

State on admission .—The girl was wildly maniacal and delirious,
throwing herself about and quite oblivious of her surroundings. She
was a strong, well-developed girl of twenty-two years, and before any¬
thing else could be done it was necessary to gently restrain her to
prevent self-injury.

She was placed on a mattress in a single room, and a nasal feed of
milk and egg given, together with 30 gr. of ammonium bromide.

This had a sedative effect for only half an hour, when her maniacal
symptoms reappeared.

Her temperature was now 102° F., pulse 120, and she was extremely
ill. It is not necessary to describe in detail to this meeting the sym¬
ptoms of acute delirious mania, as we are all, unfortunately, too well
acquainted with them. She had retention of urine and afterwards in¬
continence, and the bowels were very constipated, necessitating a strong
purgative.

The bowels afterwards became most difficult to move and were in a
state of paresis.

We were all most anxious to make a diagnosis if possible, but the
most careful and detailed examination of the patient was negative, so
far as any physical cause was concerned.

Lumbar puncture was performed, but the fluid, beyond an excess of
leucocytes, was quite sterile and did not grow on ordinary media.
Microscopically no organisms could be found.

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Widal’s test was negative, and she gave no reaction to tuberculin by
v. Pirquet’s method.

We were thus left with a possible case of general meningitis, probably
confined to the vertex, as there were no localising symptoms and no
signs of paralysis or paresis.

The optic discs were a little congested, but otherwise normal. Kernig’s
sign was not present, nor was Babinsky’s. From this time—that is,
three days after admission—she gradually became less excitable and
restless, and relapsed into a state of stupor, from which she could not
be roused.

For eight months she lay on her back with her eyes wide open, but
apparently seeing nothing. Each day as I passed her bed she was in
the same trance-like condition. Her eyes did not close at night, tem¬
perature and pulse normal, and her limbs were inclined to be flaccid, but
occasionally there was some resistance to movement.

Her reflexes, both motor and sensory, were normal throughout.

It was thought she had some chronic meningitis, which had destroyed
or impaired her mental faculties, but this proved to be erroneous. After
remaining in this helpless condition for eight months she suddenly
turned on her side and said, “ Where am I, nurse.”

She was reassured that all was right, and on being offered a cup of
milk she drank it without a stop and asked for more. I saw her within
half an hour of this time, and although she did not know who I was,
she talked in the most rational and sensible way on subjects relating to
her before her illness. I tested her memory regarding general subjects
of interest in Liverpool, and she remembered all details of many events
I then asked her to write her name and address, which she did correctly,
and then she wrote for me from dictation quite accurately; she could
read from print and writing quite properly, and she could repeat long
passages of poetry.

I can vouch for the fact that she had never spoken or seen print or
writing for eight and a half months, and she was under observation in a
ward both night and day.

She made a complete recovery, and is now engaged in her former
work without the slightest knowledge of what occurred during her long
illness.

(*) A paper prepared for the Quarterly Meeting of the Medico-Psychological
Association held on November 7th, 1909, in London.

A Case of Aggravated Hysteroid Movements .C 1 ) By
Ernest F. Ballard, M.B., B.S.Lond., Second Assistant
Medical Officer, Somerset and Bath Asylum, Wells.

The patient was a strong, healthy young man at the onset of his
illness. There was no family history of mental or nervous disease; the
patient was one of ten children.

He was quite well until his twenty-first year, when he began to have
"jerky” movements of his head, in which it was drawn backward and

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to the left. He is said to have “ strained ” his neck while lifting stones
in competition with his fellow workmen.

Three weeks after the onset of these head-movements, which rapidly
became worse, he attended the Paulton Cottage Hospital at Midsomer
Norton, and was admitted there as an in-patient on October 26th,
1906.

On admission he was a strong, well-nourished young man, over 6 ft.
in height, well-developed and healthy. His head was drawn back and
to the left by strong clonic contractions of the trapezius. These con¬
tractions occurred every few minutes, and only ceased during sleep.
There was no tenderness in the neck. On one occasion he complained
of pain in the left side of his neck, which seemed to be in the region of
the spinal accessory nerve. When the head was prevented from moving
the shoulder was drawn up. The clonic movements were always worse
when the patient was at all excited or fatigued. There was no visceral
disease, fever, or mental symptoms.

He improved slightly under treatment ( i.e ., rest in bed, massage,
bromides, and arsenic), and after four months was discharged.

He then went up to Guy’s Hospital, was admitted, and remained
there for twelve days. His symptoms were the same as when he was in
Paulton, and the diagnosis was spasmodic torticollis. He returned
from Guy’s unchanged, but was able to do some work for about seven
weeks, after which the movements of his head became worse.

He then went to London again and was treated as an out-patient at
St. George’s Hospital from June till October, 1907. When examined
there he had backward jerking movements of his head, without pain,
and absent during sleep. The right sterno-mastoid muscle was found
to be very weak, the right trapezius quite strong, and the left trapezius
weaker than the right. The other muscles were normal, those of the
back on the right side being better developed than on the left. The
movements were clonic, stronger, and rather more frequent than when
the patient was in Paulton Hospital. There was some dorsal curvature
of the spine. The knee-jerks were increased, and a pseudo-clonus was
obtained. The case was diagnosed as spasmodic torticollis. While
under treatment as an out-patient he improved at first, but became
worse towards the end of September, 1907, and was admitted as an
in-patient in October. He continuously lost flesh from about this time,
and there was no improvement in the head-movements. While in the
hospital he developed an attack of mental disorder which lasted for ten
days. In this he became apprehensive, hid himself under the bed¬
clothes, and had delusions that people coming into the ward were going
to shoot him. He gave no trouble during this attack, and did not
attempt to get out of bed. Before this apprehensive state he was taking
potassium bromide, gradually increasing up to fifty grains per diem.

He was discharged from St. George’s on December 27th, 1907,
recovered from his mental symptoms, but without improvement in the
clonic movements of his head. This attack of insanity occurred about
one year after the onset of his illness.

He returned home but was unable to work, though he had a partial
remission of his symptoms for three or four months. Then he became
worse again, spasmodic movements of the trunk began to occur in

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addition to those of the head, and in September, 1908, he could hardly
walk.

The patient was re-admitted into Paulton Hospital on September rath,
1908. He could just walk in a jerky manner with his hand steadying
his head. He could not lie still in bed, but was continually arching
his back, jerking his head backward, and making spasmodic, purpose¬
less movements with his arms and legs. He remained in the hospital
for about one month, and was discharged “not improved.” While
there he was treated by rest in bed, massage, chloral hydrate, and
suggestive treatment, with only very temporary benefit. When partially
anaesthetised the patient would lie quite still when it was suggested to
him that the movements should cease. Finally, after repetition of this
treatment, two or three drops only of chloroform on the mask accom¬
panied by the suggestion would cause him to lie still for half an hour or
so, after which he would often go to sleep. No permanent benefit
resulted from this treatment. He became steadily weaker and more
emaciated, though his appetite remained good.

He next went into Clutton Union Workhouse, and from there to
Bristol General Hospital, where he was admitted in February, 1909.
Here he exhibited the same symptoms as on his second admission to
Paulton, in an exaggerated degree. He could not lie on a bedstead,
but had to be bedded on the floor. He was quite rational in his mind
during most of his stay there, but on February 27th he threw a chair
through the window, and owing to this was discharged.

He returned to the workhouse, continued in the same bodily state,
but became depressed, emotional, and violent. He tried to injure
himself, said he would shoot himself if he could obtain a gun, and that
he wished he were dead. He smashed the windows and the
crockery, and was violent to the attendants. On these grounds he
was certified as insane, and was admitted to Wells Asylum on May
12th, 1909.

On admission to the asylum he was wasted, anremic, and sweating
freely from his movements. He could not stand up without support.
He was executing similar movements to those he showed in the Bristol
Hospital. These were very forceful, continuous, and appeared to be as
much voluntary as spasmodic. They are, perhaps, best described as
“ writhing.” He would rotate his body, arch his back, throw back and
twist round his head, and execute purposeless movements of his arms
and legs. The arm movements were chiefly rotatory, those of the legs
chiefly extension, and at times purposive, e.g., he would try to steady
himself by planting his feet on the wall when lying down. He could
control his movements to a considerable extent when firmly ordered to
do so. He could stand up, supporting himself against the wall with his
arm, and remain fairly steady, with only an occasional jerk of his head
or shoulder, for some minutes. The movements were complicated, of
no definite constant type, and continuous for some hours; they
apparently had no localised beginning, no constant order of involve¬
ment of the different limbs or groups of muscles, and they were not
rhythmical.

He had no pain or tenderness except in his knees, which were super¬
ficially sore and red. The hair on the back of his head was worn away

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by previous friction (on pillows, etc.) due to his movements. There
was apparently no visceral disease in the chest or abdomen.

Mentally he was quite collected and rational apart from his ideas
about his movements. His memory was good ; orientation, comprehen¬
sion, and realisation of the general situation were normal. He could
converse sensibly and calmly about general subjects, but became
emotional and wept when encouraged to control his movements. He
said he could not help it; that it was due to “ disease of the spinal
column ” and “curvature of the spine.”

The subsequent progress of the case was marked by a continuance of
these movements at intervals of some hours, with steadily increasing
weakness. He was able to feed himself and to drink; he would seize
the cup, control his movements partially for a few seconds and take a
rapid gulp. He would continue the generalised movements for some
hours at a stretch, sometimes all day, and then when utterly exhausted
would sleep for nine or ten hours, during which he would be motionless.
At intervals he would lie awake for short periods perfectly still and
quiet, and would account for this by saying he was “ tired out.” On
one occasion he wrote a letter to a relative; it was just legible. He
was clean in habits.

About a month after admission as he became weaker, the movements
began to grow less vigorous. He would sometimes sleep in abnormal,
most uncomfortable attitudes, at other times would lie on his back or
side normally. While in the asylum he was treated in a single room
with mattresses on the floor. He was given bromides, chloral hydrate,
arsenic, and hyoscin hypodermically, with only very temporary benefit.
His appetite remained good throughout the course of his illness. His
mental condition continued as on admission; he showed no tendency
to violence or suicide.

He developed a subacute pleurisy on the left side, had two syncopal
attacks (due apparently to heart failure from exhaustion), became weaker,
and died on June 28th, 1909.

The duration of the illness was thus just over two and a half years.
At the post-moriem examination nothing of importance was found. The
skull was extra hard but normal in thickness. The brain and cord were
apparently normal, except perhaps for some slight softness ; the former
weighed 40 oz. There was a sero-fibrinous pleurisy on the left side and a
deficient amount of fat in the abdomen, i.e., omentum, etc. Nothing
else abnormal was found. No microscopic examination was made.

’ lam indebted to Drs. Costobadie, Friend, and Moore for notes of the
case while in Paulton, St. George’s, and Bristol Hospitals respectively.

(') A paper read at the Meeting of the South-Western Division, held at Fish¬
ponds, Bristol, on October 22nd, 1909.

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Occasional Notes.

The Lunacy Commission.

The Lunacy Commission, it is rumoured, is to be increased
to the extent of an additional medical and an additional legal
member, but the amalgamation of the Medical Chancery
visitors with the Commission is not yet carried out, even if
seriously contemplated.

The supervision of the insane in England and Wales, judging
from the present composition of the Lunacy Commission,
would appear to require different provision from that which is
demanded in Scotland, Ireland, our Colonies, the United States,
and all Continental countries. This difference consists in the
very large proportion of legal members.

It would be interesting to have a definite pronouncement on
the real reason for this. Is it due to difficulties in the inter¬
pretation of the law ? This, however, cannot be the cause, since
so very few questions arise, and even these are dealt with by
outside tribun. Is.

Is it that the persons who apply the law, the judges and
justices of the peace who sign orders, the medical men who
sign certificates, and the medical officers of asylums, are of such
a character as to need all this extra legal supervision ? The
small number of cases in which questions arise relating to the
legal procedure in this aspect would certainly not seem to
demand any large legal services, and the few cases that do occur
are also dealt with by outside tribunals.

Is the additional legal supervision necessitated by any
special proneness to break the law on the part of the medical
men or of the attendants who detain and control the insane ?
Here again it would seem that these officials are not of a less
law-abiding character than those in Scotland, or the other
countries mentioned.

It would be absurd to suggest that the able members of the
legal profession who act as Commissioners are specially useful
in the medicinal treatment of the insane, or that any complaints
in regard to property, detention, etc., could not as well be
attended to by the visiting magistrates. Such complaints
have always to be sifted primarily from a medical point of

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view to determine whether they are delusions or not, and when
so sifted are not usually of such a complex nature as to demand
the attention of an experienced barrister, and might equally
well be referred to a visiting justice.

It has been argued that the insane in English asylums are
more satisfied by having their complaints answered by a legal
than by a medical authority, but it is to be doubted whether
the majority of medical superintendents would endorse this
view, or that it would have escaped the observation of other
countries.

There must exist some very urgent reason for the pre¬
dominance of legal members on the Commission, but it
obviously does not exist outside of England and Wales.

It is to be regretted that the Commission has not been
strengthened by the appointment of Medical Deputy Commis¬
sioners, who would relieve their seniors of much of the work,
which could quite well be done by less experienced persons.
A great deal of the work is mere drudgery, entailing a vast
amount of travelling and discomfort on men whose experience
and energies would be expended more advantageously in the
more important parts of the work of the Commission. This has
been found to work satisfactorily in Scotland, and is a plan
commonly adopted in other public departments.

The Care of the Poor Insane.

Between the class of patients who can pay one pound a week
and those who only pay the ordinary rate of maintenance
in county and borough asylums is a large class of patients who
could pay something less than the cost of the private annex
and something more than the pauper rate of maintenance.

This class includes many persons of good education, to whom
it is a serious disadvantage to be driven, as many of them are,
into the ordinary wards of the (so-called) pauper asylums.

Some of the private annexes do take cases at less than £ I
per week, but many draw the line at this, although they make
very considerable profits, which are either used in diminution
of the rates or in improving the structure, etc., of the annexes,
thereby making them more attractive for patients capable of
paying higher rates. It is most desirable that full consideration

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should be given to the question of the possibility of helping
the patients in question more extensively. St. Luke’s largely
helps patients of this class, and several other registered hospitals
do the same, but from the Commissioners’ reports of the last few
years it would seem that many of these institutions do very
little, so that little help can be expected in this direction,
the tendency of these institutions being to provide for patients
at high rates, and their consequently enhanced rate of main¬
tenance limiting their charitable action.

The private annexes offer a more favourable hope for the
extension of aid, but these, too, are exposed to the temptations
to which some of the registered hospitals have succumbed.

The solution of the problem would seem to lie in the
establishment of special annexes or registered hospitals in
which the cost of maintenance shall not be allowed to rise
much beyond that of the ordinary pauper asylums, say I 5 s.
per week, and in which the profits of patients paying more
than that sum should be rigidly devoted to receiving as many
patients as possible who can only afford to pay less.

If such self-denying institutions would not commend them¬
selves, either to the founders of registered hospitals, or to the
authorities of our public asylums, they could probably be
established by the strong insistence of the Lunacy Commission,
acting on the larger county councils.

There can be no doubt that there is here a great gap in the
provision of treatment for a highly respectable and deserving
element of the lower middle class, and it is certain that the
establishment of institutions of the character indicated above
would relieve a large amount of unmerited suffering.

Post-mortem Examinations in the Tyrone and Fermanagh

Asylum.

A contemporary medical paper states that the committee of
management of the above-mentioned asylum has decided that
in future no post-mortem examinations shall be made on the
bodies of unclaimed persons, except in cases of suicide,
accidental or doubtful death.

In face of the great advances made in modern pathology
this appears to be a distinctly retrograde step. It would

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certainly place the medical staff of the asylum at a disad¬
vantage with other asylums in Ireland and other countries, in
which more frequent opportunities are afforded for verifying
their opinions and for investigating the forms of disease. It
must tend to weaken or hinder the development of that
keenness of interest and accuracy of knowledge of disease on
the part of the medical officers which is so important in the
successful treatment of their patients.

Such a retrograde restriction on the progress of medical
knowledge would assuredly affect the reputation of the asylum
adopting it.

The committee of management no doubt arrived at their
decision on grounds that appeared cogent, but it is hoped
that on a reconsideration of the subject they will appreciate
the overwhelming importance of this aspect of the case, and
save their institution from the stigma which so easily attaches
in the present day to anything approaching a relapse into
mediaeval inappreciation of scientific knowledge.

Part II.—Reviews and Notices.

An Introduction to Social Psychology. By William McDougall,
M.B.Cantab. London : Methuen & Co., 1908. Svo., pp. 355.
Price 5 s. net.

We regard this original and readable book as an important contribu¬
tion towards a clearer understanding of psychology. It is direct in
style, devoid of technicalities, and should be studied by all who desire
to have a reasonable knowledge of mind. The author fearlessly em¬
barks on a new venture, reconsiders the problems which lie in the very
beginnings of mental manifestations and continue urgent in the latest
phases of mental development. We are too apt to lose sight of funda¬
mentals in studying psychological manifestations, to begin with complex
and sophisticated materials. Here is a thinker who leads us back to
instinct and the instinctive process, who elaborates the principle that all
emotion is the affective aspect of instinctive process, who analyses
complex emotions by the comparative method, not by unaided intro¬
spection, and who in the end presents a noteworthy theory of volition.

The reduction of all motives to the search for pleasure and the avoid¬
ance of pain is actively combated, and the vague faculty of conscience
fares no better. Darwin indicated how this positive science must
proceed upon the comparative and natural history method, and this
work deals with mental characters which are of prime importance for

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1910.] REVIEWS AND NOTICES. 32$

the social life of man, and how they act and react in human societies.
The aim of the author is to convince the reader that the life of societies is
not merely the sum of the activities of individuals moved by enlightened
self-interest, or hedonistic ideals, but springs from common instincts and
tendencies rooted in remote ancestry. The analysis of those instincts
and the emotional excitement peculiar to each invites a lengthy synopsis
of the argument. That is impossible here. Suffice it to say that in
this analysis it is shown how few and how constant these primary con¬
comitants are, and how masterly are the methods by which they have
been distinguished.

The systematic rejection of the opinion that men always act in
accordance with intellectual principles is another nail in the coffin of the
utilitarian school. Mr. McDougall says : “ Directly or indirectly the
instincts are the prime movers of all human activity ... All
the complex intellectual apparatus of the most highly developed mind is
but a means towards these ends . . . while pleasure and pain do

but serve to guide them in their choice of the means." This is a hard
saying for the intellectuals , but it might well form a text for a new study
of the insane, relative to instincts and their mental developments and
retrogressions.

Manual of Psychiatry. By J. Rogues de Fursac, M.D., Paris, trans¬
lated by A. J. Rosanokf, M.D., New York. Second American
edition from the second French edition. London : Chapman and
Hall, 1908. 8vo., pp. 406. Price 10 s. 6 d. net.

Dr, Rosanoff intimates that this edition has been revised, and that he
has added notes on psycho-therapy, after-care, Meyer’s theory of
dementia praecox, and lumbar puncture, notes which are all enclosed in
brackets. He claims that Kraepelin’s classification is more useful to
those who study and treat insanity than any other, and consequently it
is very generally used in America. The book begins with an account
of general psychiatry—causes, symptoms, and practice—and deals with
special forms of mental disorder in the latter and larger division of the
volume.

Undoubtedly there is a keen and seaching analysis of the symptoms
of insanity, observed over a great area of experience during many years,
but the underlying facts of pathology are most briefly treated. We
look in vain for any notable advance on the work of Kraepelin and hi'
school. We note in the introduction that when mental symptoms
appear alone the disease is said to be idiopathic , and is called a vesania ;
when they are associated with alteration of the organic functions the
disease is said to be symptomatic or secondary , and the time is not
far off when the conception of the vesanias will be relegated to the past.
We make bold to say that the time has already arrived for the exclusion
of the word idiopathic from our vocabulary. If the physical conditions
operating as causal factors in any case of insanity have not been
recorded, the failure is usually because of their evanescence before
they are subjected to skilled observation. As Dr. de Fursac clearly
sees, there is a vast difference between the ankylosis of a joint and the

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326 REVIEWS AND NOTICES. [April,

arthritis which produced it. From the medical point of view it is the
arthritic state which is the important and elusive condition.

In seeking to define mental alienation and insanity, Dr. de Fursac
suggests that the former term should be applied to all cases in which
the mental disorders present an anti social character, whereas the
latter should be restricted to cases in which the mental disorder is an ex¬
pression of an active pathological process. Thus an idiot or a dement
is generally alienated but not insane. It is just this method of dealing
with psychiatry which leaves it with a discussion of symptoms and
imports into the discussion “antisocial” considerations. It is the
insanity, the mental disorder, the arthritis which is our concern. The
anti-social result is rather a question of medico-legal importance.

In the same way “ manic-depressive insanity ” is set up as a clinical
entity, without the slightest recognition of English opinion, which long
ago founded upon the three facts of depression, excitement and
dementia constantly observed and recorded, and, similarly, “adolescent
insanity ” is disregarded and replaced with the brand-new “ dementia
praecox.”

Although Chapter 8 is headed “ Dementia Praecox,” however, Dr.
de Fursac proceeds to say that the term is not very fortunate, for
dementia designates a general and profound intellectual enfeeblement
whereas this assumed entity presents an enfeeblement which is
often slight and habitually selective; and further, that the disease
does not as a rule run a rapid course, nor is it exclusively a disease of
early life. He holds that the specific element lies exclusively in the
sum of the psychical changes, which are generally permanent, and that
it is a disease of auto-intoxication, as Kraepelin has suggested, possibly
a disorder of the genital organs. Dr. Rosanoff, quoting Professor
Adolf Meyer, seems to deny any real pathology, and would regard any
such assumption as purely gratuitous, but indicates that it is the result
of vicious or abnormal mental habits. That, of course, leaves us
without explanation of the inception of these habits.

We are also disappointed on reading of psycho-therapy, which
Dr. Rosanoff regards as an important therapeutic measure, the only
means of directly combating a false idea, a baseless fear, or a morbid
tendency. After this promising introduction it follows that no full
discussion of methods or technique can be given, and the reader is
referred to Dubois for particulars.

We note drool as an equivalent for dribble on page 311, and have an
impression that Thoreau so used the word. Perhaps it is more widely
used in America than in this country.

On the whole, we prefer Kraepelin at first hand.

The Criminal Responsibility op Lunatics: a Study in Comparative Law.
By Heinrich Oppenheimer, I.T.D., M.D. London: Sweet and
Maxwell, Ltd., 1909. 8vo. Pp. 275. Price ioj. 6 d .

This important book has gained the approval of the University of
London when submitted as a thesis for the degree of Doctor of Laws
We could wish that the author had been more of a Doctor of Medicine

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327

when he entitled his work The Criminal Responsibility of Lunatics. We
have long endeavoured to eliminate that term from parliamentary and
legal practice. However, it is a great gain to have a full study of the
law at the hands of one who is versed in the lore of both professions.
It is from this standpoint that the author proceeds to develop his most
important contribution to a difficult subject, and we commend the result
to our readers. Dr. Oppenheimer recognises the differences which have
so long subsisted between lawyers and doctors, and the many endeavours
which have been made to compose their contentions. It is only when
doctors are face to face with the difficulty of proposing amendments in
the law that cannot be seriously attacked by lawyers conversant with
the practice of the Courts that they recoil from the task.

The author quotes with approval the saying of Chief Justice Parker,
of New Hampshire, to the effect that they might as well hang a beast
for homicide as condemn a human being who is deprived of reason.
On the other hand Dr. Oppenheimer concludes that an independent
and more concrete test than the subsumption of a criminal under the
loose term of “ insane ” is indispensable to sound jurisprudence. He
regards it as sufficient for the expert to show that the accused did not
possess sufficient intelligence to understand what he was doing, not
sufficient self-control to restrain his impulses, not that freedom of will
to enable him to regulate his conduct in a rational manner ; it is then
for the Court to draw therefrom the inference in relation to the deed as
V charged.

In his acute and comprehensive study of the subject comparative law
enlightens the discussion, and it is most important for us to study the
French penal code and German opinion as presented by Dr. Oppen¬
heimer. He has not omitted to give a long list of the principal works
consulted, but we much regret that no index is appended to the book.
A synopsis of contents would have been acceptable, but in such a far-
reaching production as this the want of a full index is deeply felt. It is
eminently a book for reference and consultation, and we hope that this
omission will be made good in a new edition. The wide and exact
reading demanded by work of this kind also would be greatly enhanced
in value by references to the authors and authorities quoted so that they
could be easily traced.

(1) The Psychology of Dementia Prcecox. By Dr. C. G. Jung, trans¬
lated by F. Peterson and A. A. Brill. New York, 1909. Pp.
153, 8vo.

(2) Selected Papers on Hysteria and other Psycho-neuroses. By Pro¬
fessor S. Freud, translated by A. A. Brill. New York, 1909.
Pp. 200, 8vo.

These two works form Nos. 3 and 4 of the Nervous and Mental
Disease Monograph Series, now being published in America under the
editorship of Dr. Jelliffe. Both are designed to introduce the English
reader to the school of psychology founded by Professor Freud, of
Vienna.

The psychological work of Freud commenced with the now classical

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Ueber den psychischen Mechanismus hysterischer PJuinomcne , published
in 1893 i° collaboration with Breuer. Since that day a vast amount of
research has been carried out both by Freud himself, and by his
followers in Vienna, Zurich, and Berlin, and some knowledge of the
results obtained is absolutely necessary to every modern student of
psychiatry.

A review of the original German edition of Dr. Jung’s Ueber die
Psychologie der Dementia Prcecox appeared in the Journal of Mental
Science for July, 1908. But little, therefore, need here be added con¬
cerning the subject-matter of the book. Its keynote is the extension
of Freud’s psychology to the sphere of dementia prtecox. Dr. Jung’s
work has become a classic, and will always remain one of the most
considerable landmarks in the progress of modern psychiatry. The
present translation will be cordially welcomed by all English readers.

Selected Papers on Hysteria contains a translation of various articles
which have been published by Freud from 1893 to 1908. Dr. Brill
has endeavoured to select those papers which enable the reader to form
a comprehensive and connected idea of Freud’s theories. He has
probably succeeded as well as it is possible to succeed, but there can
be no question that the task is one of extreme difficulty. This difficulty
depends on two factors. Firstly, Freud has never published any single
treatise containing a complete presentation of his psychology; the
student is forced to make himself acquainted with a considerable
number of isolated works, each dealing with some subdivision of the
subject. Of these works the most important are the Traumdeutung and
the Drei Abhandlungen ziir Sexualtheorie. Without some knowledge
of these two books an adequate understanding of Freud’s scattered
papers is probably almost impossible. This criticism could only be
met by the compilation of a Freud text-book, containing a co-ordinated
account of the entire subject. The construction of such a work would
certainly be far from easy, but its value would be incontestable. The
need for a general treatise of this type is becoming more evident every
day. Secondly, Freud’s views on certain details of his subject have
undergone a very considerable change during the years 1893 to 1908.
He has now definitely abandoned many of the hypotheses which he
sought to establish in his earlier works. It is therefore inevitable in a
selection of papers extending over almost the whole period of Freud’s
psychological career, that the later articles should contain statements
and theories which are incompatible with those appearing earlier in the
book. We may cite, for example, Freud’s change of theory regarding
the specific aetiology of hysteria and the obsession neuroses, and the
differentiation of hysteria into retention, hypnoid, and defence varieties
—and his change of practice leading to the abandonment of hypnotism
and the development of his modern method of psycho-analysis.
Chapter IX of Dr. Brill’s work includes Freud’s own statement con¬
cerning the alterations and developments which his theory has under¬
gone, but we could have wished that the book contained a more lengthy
and complete introduction in which these various alterations were
presented in their proper perspective. The method which has been
selected will undoubtedly tend to cause confusion in the mind of the
beginner. For those already acquainted with Freud’s work, on the

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other hand, the present translation will provide an excellent and con¬
venient summary of the whole historical development of the subject.

Bernard Hart.

Part III.—Epitome.

Progress of Psychiatry in 1909.

AMERICA.

By Dr. William McDonald, Jun.

It has not always been an easy task—this preparation of the American
section of the epitome on psychiatric work. Year after year the writer
has paused before that word "Progress ” with a big obsessed by
the limitations which it places on the subject-matter, perplexed at his
inability to sift the wheat from the chaff, and to delineate clearly in all
the activity called psychiatric only those features which surely made for
progress.

This year, however, no such doubts assail, for there is evident in this
country, as probably in all civilised parts, a reawakening to the needs
of the mentally afflicted, while a broad and powerful current of earnest
endeavour is bending toward the bettering of the insane and the preven¬
tion of insanity.

While there is still the same interest in the scientific problems of
abnormal mental action, psycho-analysis, diagnosis and classification,
there is a distinct departure from excessive meddling with the more
fanciful and finical of pure theoretical considerations, and a correspond¬
ing setting out upon work of a practical nature.

Clinics, institutions, reception wards, out patient work, laws for com¬
mitment and protection of the insane, interest in juveniles, alcohol and
immorality as causes of insanity, after-care, means of preventing insanity—
these and many others are matters which are now occupying the atten¬
tion of psychiatric workers, and, better still, of a vast army of philan¬
thropic laymen.

The public is awakening to its dangers from, and duties toward, the
ever-increasing body of the aberrant.

Strangely enough, the greatest apathy has been met with among the
general medical practitioners, whose lack of interest has not only proved
a decided hindrance to advancement, but whose unpardonable ignorance
of mental diseases has at times led to out-and-out active obstruction to
the strivings of those who are alive to the campaign. Many physicians
still look upon hospitals for the insane as they were regarded fifty years
ago, and, unconscious of their backwardness, consider the commitment
of the insane as a matter of abstract justice rather than as concrete
opportunities for the application of modern mental healing. And so, in
a recent attempt in Rhode Island to divorce the commitment of the
insane from the police court, we were astonished to find some of our
own brother practitioners loudly proclaiming the sacredness of human

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liberty standing in the way of the proposed changes in the law, and even
advocating a turning back to the former necessity for a court commit¬
ment in every case where treatment in a hospital for the insane is
desired.

It were well, therefore, if the American Medico-Psychological Asso¬
ciation would follow the lead of the Medico-Psychological Association
of Great Britain and Ireland in suggesting a curriculum and diploma in
psychological medicine “ for the more efficient teaching and training of
the coming generation of alienists,” and would, moreover, suggest such
changes in the ordinary medical curriculum as might prevent the
graduation of men ignorant of the rudiments of modern psychiatry.

For any individual to attempt, in an article such as this, to call atten¬
tion to every movement indicative of psychiatric progress in a land so
broad as ours would be presumptuous. Even omitting South America,
Mexico, and Central America, whence reports indicate a budding of
modern psychiatric ideas (Brazil and Chili leading the advance), to
mention the work of every State in the Union is impossible, both from
lack of space and lack of knowledge on the part of the writer. A brief
reference to the reports from a few States may serve as an index of what
is going on throughout the country.

In little Rhode Island we have had our troubles. In a State which,
in its proportion of insane persons, ranks second in the United States,
the legislature has been grossly negligent in its provision for the insane
until, with every available spot occupied in the State Hospital, the con¬
ditions have become intolerable. Now, however, we have hope of
better things, for §225,000 has just been appropriated for a new
reception ward in connection with the State Hospital for the Insane.

Reference has already been made to the movement on foot in Rhode
Island to do away with the required warrant and police court com¬
mitment of the indigent insane, together with the barbaric wording of
that warrant to which every such patient must listen: “ You are
charged with being an insane person.”

For persons able to pay board a private commitment is available, and
the laws in many respects are of the best. We are, however, somewhat
anxious lest in the agitation for still further improvement we may have
taken from us that which we already possess.

New York State, as usual, is setting the pace in all that is new. The
Survey , vol. xxiii, No. 14, contains an account of the new Neurological
Institute of New York City which was opened November 29th, 1909. I
take the liberty of quoting a brief characterisation of the new hospital,
written by Adolf Meyer in a private letter in response to my request for
the latest news from New York State.

“The latest and best thing out,” he writes, “is the Neurological
Institute . . . the most active little hospital for nervous and

mental cases I have ever seen, with an extensive dispensary and seventy
beds filled. It was especially designed for patients with “so-called
functional, curable, nervous and mental diseases,” and from all accounts
it is wonderfully equipped for both study and treatment.”

The New York State Charities Aid Association has a bill before the
legislature which will permit the treatment of drunkenness as a disease
rather than as a crime. The plan is described briefly in The Survey

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(vol. xxxiii, No. 21) as, “a follow up, progressive treatment of the
inebriate, with probation for the first offence, a farm institution for later
offences, with an indeterminate sentence which may be imposed by a
board of physicians on application of the patient himself, a relative, the
commissioners of public charities, or the trustees of Bellevue.”

There is also on foot in New York State another plan which seems
to promise further advancement toward the ideal humane treatment of
the insane for which we are all looking and longing. This plan
proposes to transfer, from the poor-master, the constable and the police
to the health officers, the duties and responsibilities relating to the care
and commitment of insane persons.

The change is suggested because of the unnecessary aggravation of
symptoms which arises from the methods of the constable and poor-
master in cases where the attention of physicians and nurses is
required.

Without criticising the care of the patient after commitment, Dr.
William L. Russell (New York Medical Record , January 22nd, 1910)
calls attention to two special reports issued by the Commission in
Lunacy, which show that “ even in the Borough of Manhattan in New
York City, where the work is in most respects managed well, 55 per
cent, of the cases obtain hospital care only through police channels,”
and that “altogether in the whole State, exclusive of Greater New
York, about 35 per cent, of the cases admitted to th£ State hospitals in
a year, or about 1000 insane persons, had, previous to their admission,
been confined in gaols or lock-ups, or subjected to gross neglect or ill-
treatment at home."

In Massachusetts a purpose somewhat similar to the above, but with
quite a different proposed method of accomplishment, is exhibited by a
Bill before the Legislature—“ Relative to persons suffering from certain
mental and other disorders or diseases in the city of Boston."

The Act orders that “ all persons suffering from the disorders herein¬
after referred to, now under arrest or who may come under the care
and protection of the police of the city of Boston, and who, owing
to the lack of suitable building or wards, are at present placed in the
city prison, the house of detention or the house of correction at Deer
Island, pending a medical examination and transference, shall be taken
directly to the Psychopathic Hospital for examination when said
hospital has been completed, etc. ... If after examination the
physician in charge of the Psychopathic Hospital decides the case to
be one of delirium tremens, he shall not be obliged to admit patient to
said hospital, but otherwise said hospital shall admit and observe or
care for all persons suffering from delirium, mental confusion or delu¬
sions and hallucinations until such persons can be transferred to the
hospitals or institutions appropriate in each particular case, etc.”

Dr. Adolf Meyer writes that the plans for the Phipps Psychiatric
Clinic to be erected in Baltimore, Md., are about being accepted, and
that construction should now begin.

On February 1st, 1910, Dr. August Hoch succeeded to Dr. Adolph
Meyer’s position as Director of the Pathological Institute of New York
State at Ward’s Island.

Dr. E. E. Southard was appointed on May 1st, 1909, pathologist to

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the State Board of Insanity, Massachusetts, with the duty of supervision
of the clinical, pathological, and research work of the institutions for
the insane, feeble-minded, epileptics, and inebriates under the general
charge of the State Board of Insanity. This position carries with it no
direct control of the medical work of the institutions, but grants the
right of visiting the institutions, investigation, and recommendation
under the Board of Insanity.

Dr. E. E. Southard was appointed Bullard Professor of Neuro¬
pathology in the Harvard Medical School, September ist, 1909. The
terms of this professorship are as follows :

“This professorship shall embrace study, research, investigation, and
teaching in relation to disease of the nervous system, whether functional
or organic, and shall include not only the affections ordinarily classed
under neurology, but all diseases and disturbances, both those classed
under psychiatry and any others that may exist. The methods and
detail of work under this professorship are not restricted. It should
include any form of research and investigation which may lead to the
increase of knowledge of nervous and mental disease. It comprises
the comparative study of these diseases in animals and all other living
forms.”

BELGIUM.

By Dr. Jul. Morel.

The asylums for the insane, since their transformation, have become
veritable hospitals; and the medical work, especially as regards the
curable and improvable cases, approaches that of the ordinary hospital.
The result is that the insane in all modern asylums are cared for and
observed day and night, as in a hospital, and assiduous nursing is given
alike to the excited, agitated, degraded, paralytic, turbulent, destructive,
suicidal, etc.

Great Britain has been closely associated with this movement in both
its humanitarian and reformatory aspects. Patients are not detained
for the profit and benefit of the medical staff, but, on the contrary, to
obtain the maximum of care and treatment with a view to their return
home.

In both England, Ireland and Scotland, an increase in night
supervision has resulted in immense advantages to the patient. Obser¬
vation at night is necessarily restricted to those patients whose condi¬
tion calls for constant supervision. In all asylums the greater part of
the patients do not belong to this class. The proportion of night staff
to patients varies, and depends upon the classes and the numbers in
each class. Generally, those who need most attention during the day
require the most observation at night.

In Belgium the tendency of most of the proprietors of asylums is still
to imitate what formerly was the practice in Ireland, namely, to have a
single night watch, who was not always a trained attendant, who patrolled
the different sleeping apartments, and whose duty was to summon the
regular attendants, who slept in rooms in close proximity to the dormi-

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tories, and solicit their help whenever a patient appeared to require it.
To facilitate the night work and to prevent the patients from injuring
themselves, numerous single rooms were in use in which the patients
were put in the evening, often restrained with fetters on hands and feet,
which were fixed to the beds, there to remain until the morning. The
paralytic patients were abandoned to themselves, and were necessarily
dirty because of want of any assistance. Suicidal patients and epileptics
with frequent attacks were also restrained. It is true that adjacent to
the dormitories there were bedrooms for the attendants, who, though
asleep, were supposed to have charge of them.

Upon this state of affairs coming to the knowledge of the Minister
of Justice, he demanded from the Committee of Medical Inspection
(i) their help as to what measures to take. The Committee of Medical
Inspection, in their report, proposed important improvements. They
were designed to suit the different wards of the asylums, and the
number of attendants for night duty was to be proportionate to the
number and class of the patients. All their propositions were not
agreed to, but the principles were accepted and most of their report
approved of. On March 24th, 1908, the Minister of Justice addressed
the following circular to the directors (2) of all the asylums for the
insane.

“ The reports addressed to my Department have shown that Article
23 of the Regulations framed on June 1st, 1874, which prescribed for
each establishment continuous night surpervision, is not observed in
most of the asylums for the insane.

“ The night supervision is generally entrusted to attendants who sleep
adjacent to the dormitories, besides the night patrol attendant who
makes his rounds at longer or shorter intervals. This system, which
evidently does not provide continuous supervision, is not of a nature
to prevent accidents, as experience has shown repeatedly.

“You are requested, in consequence, to take the necessary steps to
organise in your establishment a continuous night supervision, especially
in acute and observation wards and infirmaries. The night supervision
ought to be entrusted to the ordinary nursing staff and not to attendants
specially appointed for this purpose. There should be maintained at
the same time the round of visits which exists at present.

“J. Renkin,

11 Minister of Justice .”

It is to be noted that the directors of asylums were not even
invited to bring the ministerial decisions to the notice of their medical
officers.

We rejoiced at these new ministerial utterings, which were for the
welfare of the patients; and it was hoped the proprietors would be
eager to fulfil them faithfully, because the demands were not exorbitant,
and because in the new asylum, Fort Jaco, under the direction of Dr.
Ley, these innovations had already been quite independently decided
upon, the change to start from the day the religious orders left the
asylum to be replaced by trained attendants.

The moment had come for the proprietors of the Belgium asylums to
rise to the level of modern ideals, the more so that in the corresponding
asylums abroad, the reform of night care and observation had already been

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realised. In the United Kingdom there is a proportion of x attendant
to every xo patients. In Belgium the law is the same. For ten years
the inspectors of lunacy in Ireland have been congratulating themselves
on the notable improvement in their asylums, due to reformation of the
night service and resulting in the disappearance of a large number of
single rooms. These single rooms were formerly filled at night with
excited, noisy, destructive, turbulent and dirty patients. If indifference
is displayed with regard to excitement, depravity, dirtiness and sleep¬
lessness, we cannot express astonishment if the patients become pro¬
gressively worse both physically and mentally. We have been told by
patients who have recovered that finding themselves tied to the bed
aggravated their symptoms. It was not the doctors who carried out
the restraint. In very many of the asylums in Belgium the attendants
place patients under the restraint considered necessary during the night.
There are often, unhappily, omissions in the official journal of restraint, in
which ought to be duly recorded all the names of the patients placed
in restraint both by day and night. The medical officers are commonly
non-resident; they may live at a great distance from the asylum, and
they pay only a short visit to their 400-700 patients. This makes it
impossible for them to exercise proper supervision during the day and
less so at night. Abroad the medical officers are unanimously of the
opinion that in proportion as a better knowledge of the value of night
supervision is appreciated, so isolation in single rooms becomes less
necessary.

In England the ratio of night attendants to patients is 1 to 71, in
Scotland 1 to 72. It varies in different asylums. At Leavesden it is
1 to 30, at Aberdeen 1 to 49, and at Stirling 1 to 31 patients.

In Belgium there still exist blocks of single rooms, and the pro¬
prietors of certain asylums prefer to remain indifferent alike to the
progress made and the happy results shown in asylums abroad. In
some of our asylums with 500 patients, perhaps more, there is only one
night attendant. The Minister of Justice has just made a concession to
those proprietors who believed themselves unable to submit to the
instructions conveyed in the above circular. He addressed to them the
following letter:

“ Considering that the regulations prescribed in the circular of
March 24th, ordering the organisation in the asylums for the insane of
continuous night supervision by the ordinary nursing staff, at least in
the three principal divisions of each establishment, have given rise to
serious difficulties, I have decided to replace them by the following :

“ Each asylum for the pauper insane should have a special ward
where are placed during the night under continuous supervision those
patients having need of particular observation.

“ If this is adopted, then the night supervision such as is now actually
in practice at most of the asylums (viz., one attendant, at least, sleeping
in a room adjoining the dormitory, and a night patrol at intervals
through the inhabited parts of the asylum) will be considered sufficient.
It is important that the night-round should be at least every hour, and
that it should be possible to see all over the dormitory from the atten¬
dant’s room, and that the dormitory should be sufficiently lighted for
this purpose all night. Respecting the night staff, it is convenient that

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their direction should be confided to a specially qualified attendant,
and by preference one of the ordinary nursing staff. There is no
objection to the provision of special night attendants provided that they
have sufficient experience of service in asylums.

“J. RfcNKIN,

“ Minister oj Justice."

Once more this circular confirmed the impression that however
good the minister’s intentions were, and though he had consulted the
Committee of Medical Inspection, yet he believed it best not to refer
the matter to the medical staff so as to hear their views as well as those
of the directors on night supervision. This circular confirms the
Minister’s indifference to the opinions of the medical staff, and abandons
them entirely to the control of the directors. It also has all the appear¬
ance of an agreement made between the Minister and certain proprietors
of asylums, to nullify the changes ordered in the first circular and
replace them by others more in harmony with an egotistical spirit.
It is doubtful whether the Committee of Medical Inspection could
have wished to go back upon its original propositions, the more so that
its recommendations were in practice at the asylums abroad.

In the first circular the Minister rightly stated that he could not
regard as night supervision the attendants sleeping in rooms adjoining
the dormitory; in the second circular, apart from the supervision of
special patients congregated in a particular ward, the Minister accepted
the attendants sleeping in proximity to the dormitories as sufficient.
During the night they had the right to watch the patients through a
little window looking into the lighted dormitories. The second circular
insists upon an hourly patrol. The long intervals between the visits will
permit of sudden suicidal ideas being translated into action, and such
patients, owing to lack of proper supervision, will have time to carry
out their suicidal intention. Will the attendants sleeping in their
room hear the movements of epileptics when having fits ? What is to
become of the patients confined to bed who require to satisfy the calls
of Nature in the absence of the night attendant ? The wet and dirty
patients will have to remain so until the appearance of the night
attendant! The sick patient unable to call anybody will have to go
without help ! We could multiply the examples of what might happen
during the absence of the night patrol.

It is well known that it is impossible to accumulate in a single ward
all the patients who require continuous supervision. In addition, the
second circular permits the director to employ at night special attend¬
ants provided they have sufficient knowledge of asylums. Who is to
judge of this ? The director ?

To sum up, the medical staff have been completely ignored in the
organisation of night supervision in the asylums.

( l ) There is in Belgium an Inspector-General of Asylums, who is an official of the
Department of Justice and has no medical training. He visits each asylum twice a
year. The Committee of Medical Inspection (C.Cjis composed of three medical men
(unpaid), who receive their expenses. They have little to do with the Inspector-
General, and their reports never receive much attention.—(-') In Belgium practi¬
cally all the asylums are private institutions, and medical directors do not exist.
The directors are appointed by the proprietors ; also the two medical directors of

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the State asylums have not the same position as generally obtains in other
countries. In Belgium the religious bodies contract with the State to supply
the furniture of the staff, the food, clothing, bedding, and maintenance of the
patients.

FRANCE.

By Dr. Rkn£ Semelaigne,

During the year 1909 the scientific output has been highly satisfactory.
Its peaceful termination was in marked contrast to the discomforts we
have already experienced during the present year owing to the floods in
Paris. The members of the Soci^td Medico-Psychologique were not
able to meet in January, and the Maison de Sant£ d’lvry, founded by
Esquirol, was suddenly inundated, an event which entailed the hurried
removal of the patients to another establishment.

We have accordingly experienced in the twentieth century a disaster
such as was aptly described by the Latin poet:

“Vidimus flavum Tiberim, retortis
Littore Etrusco violenter undis,

Ire dejectum monumenta regis
Templaque Vestae.”

We hope that the remainder of 19x0 will be more agreeable. The
three societies devoted to the study of mental diseases, i.e., Soci^te
Medico-Psychologique, Society de Psychiatrie, Society Clinique de
Medecine Mentale, emulated one another in their activities : papers and
clinical cases have been numerous and interesting.

The Nineteenth Annual Congress of French alienists took place in
Nantes at the beginning of August. Dr. Vallon, Superintendent of the
St. Anne Asylum in Paris, occupied the chair. The attendance was
large, owing to Dr. Vallon’s scientific attainments and personal popu¬
larity. In his presidential address he criticised severely the new
Lunacy Law which has been so hastily enacted by the Chambre des
Deputes. Dr. Vallon regards it as a piece of retrograde legislation,
which, obviously directed against the alienists, will inevitably be
prejudicial to the insane. It is now under the consideration of the
Senate, and Dr. Vallon hopes that their discussions will be prolonged
interminably. Dr. Victor Parant, of Toulouse, presented a report on
the fugues and psychiatry. He divides the fugues into two classes,
according as they exhibit a specific type, or do not present definite
clinical features and distinct origin, but are common to various affec¬
tions. The following are examples of the former class :

(1) Fugues in melancholic states. They originate from an acute
attack of anguish or in states of simple depression. Of those that
originate in conditions of anguish, the onset is sudden, and without
premonitory signs.

(2) Fugues oniriques. A typical example is the fugue in alcoholism,
which is characterised by delirium and sensory disorders.

(3) Fugues in epilepsy. The impulse is irresistible, sudden, and
does not rise into consciousness. Ambulatory acts may precede the

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fit as an aura; they may also make their appearance during an in¬
complete convulsive attack, and in such cases seem to be only the
continuation of a commenced act, such as walking. This is not a true
impulse, but an automatic action. Where impulses are consecutive to
fits, sometimes a maniacal state of agitation is concomitant. Similar
impulses may also be observed without any convulsive attack.

(4) Fugues in dementia praecox. The impulses exhibiting a demented
type.

(5) Dromo-maniac fugues—they are impulses with or without obses¬
sion. The patients are always predisposed.

(6) Fugues in secondary states.

(7) Systematised fugues. Two conditions are indispensable—a
favourable soil and a hallucinatory delirium. Fugues are frequently
observed in delirium of persecution and in ambitious delirium. Fugues
not included in the above specific types may be noted:

(i) In general paralysis. They occur in the prodromal stage, or in the
invasion of the disease, and the origin seems to be an intellectual or a
motor hyperactivity.

(ii) In senile dementia. Such patients may exhibit amnesia, motor
hyperactivity, automatism, a delirious idea, or an emotional disorder.

(iii) In maniacal excitement. Such fugues depend on a general state
of functional exaltation, and may be observed in excited patients. There
is also sometimes alcoholism in addition.

(iv) In periodical psychoses. During the maniacal states.

(v) In idiocy and imbecility. The fugues are uncommon in idiocy
and frequent in imbecility.

(vi) In children. Fugues in children are not often pathological. In
such cases one may have to deal with a congenital debility of mind,
some nervous and episodical condition, or a delirious state.

(vii) Fugues a deux and fugues gemcllaires have been noticed by some
others.

Dr. Regis, of Bordeaux, is of the opinion that there is a constitutional
tendency to fugues. Such tendency is hereditary, precocious, durable,
paroxysmal, and gives rise, during the fits, to a peculiar mental con¬
dition, adaptable to intercurrent complications of delirium. In support
of that assertion he reports the case of Jean Jacques Rousseau. In the
family of Jean Jacques can be observed instability, migratory habits,
expatriation, and disappearances. His father presented during his life¬
time numerous and remarkable fugues. His brother, in early adolescence,
ran away and disappeared for ever. His uncle, and his cousin-germain
Abraham Bernard deserted Geneva and their families. Jean Jacques,
when he was sixteen, impulsively left his native town because the gates
had been closed one evening when he was on the point of coming in.
And during his whole life he was a perpetual traveller. During his
wanderings he enjoyed a peculiar state of euphoria—a remarkable
happiness—and may be regarded as the chief of those patients who are
enamoured with Nature. In dromomania there are not—as in dipso¬
mania or kleptomania—shame and remorse consecutive to the fugues.
Jean Jacques Rousseau was sorry for the mischievous deeds he happened
to perform during his pathological wanderings, but could not regret the
wanderings themselves, even when they entailed some loss in his estate

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or his prospects. He presented also impulsive fugues with delirious
determinations. He had ideas of persecution, but exhibited the charac¬
teristics of a melancholiac. Some of his fugues, at that time of his life,
were not pathological, being justified by the popular ill-feeling, but others
were impulses and exhibited genuine characteristics.

The most characteristic example seems to be his fugue to England
in the month of May, 1767. Dr. Regis concludes that there are people
with a hereditary tendency to migratory impulses—the fugue runs in
their blood. Dr. Cruchet, of Bordeaux, describes a fugue as a
sudden, irrational, or unreasonable act determining an immediate flight
from the place the sufferer chances to be in. Fugues may be divided
into the conscious, the subconscious, and the unconscious. Dr. Haury,
of Sathonay, observes that fugues are noticed in the army, and most
frequently take the form—from the military point of view—of vicious
delinquencies, absences without leave, and desertions. In a visit which
he paid to the asylum of Bel-air, near Geneva, he happened to find
amongst the lunatics several French deserters.

The two societies of neurology and psychiatry united for their
annual meeting. The subject discussed was the part taken by the
emotions in the genesis of neuropathic and psychopathic accidents.
Drs. Claude, Dupre, Hallion, and Pierre Janet, had undertaken the
duty of elaborating a guide to the debate. The two societies held four
meetings. Dr. Gilbert Ballet, Professor of Mental Diseases in the
Faculty de M^decine of Paris, and President of the Society of Psychiatry,
occupied the chair with his usual ability. Dr. Dupre presented the
report on the psychiatric side of the question. According to him there
is an emotional constitution, which can be detected by the following
signs : An exaggeration of tendon, pupil, and skin reflexes, a localised
hypersesthesia, vasomotor and secretory disturbances, a tendency to
spasms, and an abnormal distribution of the physical and psychical
effects of emotion. The emotional constitution seems to be character¬
ised not only by a diffuse exaggeration of sensation, but also by a
defective inhibition of motor, reflex, and voluntary impulses. The
emotional constitution is a favourable soil for all psychical anomalies,
such as obsessions, phobias, impulses, and sexual perversions. On
such soil may grow melancholic and maniacal syndromes. The pre¬
ponderance of the emotive element is recognised by the intense anxiety
which characterises the syndrome. Emotion is an important aetiological
factor in confusional and traumatic psychoses, and seems to have been
an important element in collective psycho-pathology, and in the
political, religious, and military history of every age.

Drs. A. Antheaume, of Paris, and Mignot, of Charenton, have pub¬
lished an interesting book on mental diseases in the French army.
A paper on this subject was read and discussed at the Congress of
Nantes. The authors describe all the varieties of mental diseases
observed in the army, and discuss the cases from the administrative,
medico-legal, and prophylactic points of view. They especially ask for
a compulsory psychiatrical examination of all soldiers who are brought
to trial at a council of discipline or at a court-martial.

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GERMANY.

By Dr. J. Brf.sler.

At the annual meeting of the German Association for Psychiatry, held
on March 23rd and 24th, at Cologne and Bonn, the principal subject
for discussion was the question of the connection between syphilis and
general paralysis. The speakers were Plaut (Munich) and Fischer
(Prague). Dr. Plaut came to the following conclusions: (1) Without
syphilis no paralysis. (2) It is not improbable that during paralysis
active virus still exists in the body, and spirochaetae are present.
(3) There are not sufficient reasons for presuming there is a syphilis
a virus nerveux. (4) The fact that, in those who afterwards became
paralytics, the early symptoms of syphilis were singularly mild, suggests
an abnormal predisposition. (5) The attempts to establish a connection
between heredity, degeneration and temperament, or constitution and
general paralysis, have had no definite results, and it would appear
doubtful if there are sufficient grounds for accepting a peculiar predis¬
position of brain. (6) The exogenous influences (alcoholism, trauma,
cerebral fatigue) have probably no essential effect, but act only as asso¬
ciated factors, diminishing the somatic and psychic resistance. (7) The
variability of the syphilitic changes in the different stages of the disease
does not appear to be caused by differences in the character of the
spirochrete, but by a gradual change in the way the patient reacts,
because this change of reaction leads to tertiary manifestations in only
a small percentage of syphilitics, and a further change may lead to para¬
lysis ; it is not astonishing that only a small number of syphilitics become
paralytics. (8) A number of considerations makes it probable that
paralysis is preceded by preparatory syphilitic processes of a chronic
kind ; it is impossible to say if these are localised in the central nervous
system or in any other part. The elapse of a long period of time
between syphilitic infection and the onset of paralysis is perhaps
explained by this circumstance. (9) The uselessness of mercury in
paralysis does not disprove a connection between syphilis and paralysis,
because of our ignorance of the pharmacology of mercury. (10) The
decision whether the histological changes in paralysis are of a syphilitic
character must be, and is, left to the anatomist. (11) The result of
serum diagnosis points to a very close connection between syphilis and
paralysis. Regarding this we have no clear idea as to the biological
position of the reacting substances at present, but some day a definite
answer will be forthcoming.

Dr. Fischer’s opinions were : (1) In paralysis there are very character¬
istic changes in the brain, but the diagnosis depends upon a considera¬
tion of the whole and not upon any one sign. (2) The histo-pathological
changes consist of a decay of the parenchyma associated with chronic
inflammation, but the one must be regarded as independent of the
other. (3) The clinical conception of paralysis is based upon its histo-
pathology. (4) From the clinical standpoint the varieties of general
paralysis are— (a) the common form, (b) paralysis by areas, (r) the
atypical form, ( d) the stationary form. (5) On anatomical grounds
paralysis cannot now be held to be a direct syphilitic disease.

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Professor Alt (Uchtspringe) read a paper on the treatment of the
young and adult insane epileptics and idiots in the same institution.
He stated: (i) It is erroneous to think that young epileptics and
idiots need less psychiatric care than corresponding adults; moreover,
patients of this kind are especially suitable for exact psychiatrical treat¬
ment and have need of it; (2) the separation of the young insane epi¬
leptics and idiots as regards curability or incurability into different
asylums is impracticable and harmful; (3) the presence of a con¬
veniently situated and properly constituted ward for juveniles in an
asylum for adults, e. the treatment of both young and old in the same
asylum, is preferable to a separate hospital for the young ; (4) the addition
to an asylum of a “ boarding out ” system for the juvenile insane, for
epileptics, and especially for idiots is a veritable blessing.

The Association accepted the following propositions (') made by a
special sub-committee as regards the training of judges : (a) Obligatory ;
(1) attendance at lectures on forensic psychiatry, also demonstrations
and practical work; (2) a knowledge of prisons, penitentiaries, and all
establishments for compulsory education, asylums, inebriate asylums.
(b) Optional; a knowledge of criminal psychology.

The following table shows the forensic practice of asylum physicians
in Prussia. It is known that alienists are reproached with certifying too
readily accused persons who are suspected of mental defect. This
opinion is refuted by this table, which shows that the number of accused
persons judicially remanded for mental observation in the asylums was,
during the years 1906-8, strikingly higher than during 1901-3. Although
the judicial authorities during the former period were more inclined to
this procedure, the number certified fell from 70 per cent, to 57*6 per
cent., which shows that the psychiatrical experts are exact and scrupulous
in their methods.

Table showing the number of persons received into the public asylums oj
Prussia for certification under § 81 of the Criminal Laiv.

Periods of

Total

Number suspected of a morbid mental state,
within the meaning of § 51 of the Penal Law
(Loss of Free Volition) at the time of the deed.

Number in ,
which no defi¬

time.

number.

Number certified—positive
opinion.

Number not
certified—nega¬
tive opinion.

nite opinion
expressed.

1906-07-08

1904-05

«727 (575
per annum)

915 (457
per annum)

996—(332 per annum) =
57’6 per cent.

'585 —(292 per annum) =

63 '9 per cent.

<579 = 393

per cent.
301 =329
per cent.

, 1

52 <= 3 per
cent.

29 = 3 2 per 1
cent.

As having existed.

Opinion negative or indefinite. J

1901-02-03

1085 (361
per annum)

760—(253 per annum) =

70 per cent.

325 = 29 9 per cent.

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PROGRESS OF PSYCHIATRY.

341

In the summer of 1909, the scientific world was surprised by the
publication of a new reaction of the blood peculiar to certain classes of
the insane. Drs. Much and Holtzmann stated that they had found that
the blood in cases of dementia praecox or those whose ancestry showed
this disease, and in epilepsy associated with circular mental disease, gave
a special reaction. Washed human blood-corpuscles were not dissolved
by cobra poison when the blood-serum of a patient affected as described
was added. If, however, the serum of healthy or unaffected persons
was added this solution takes place (see “ Psycho-reaction ” in Munch,
med. Wochens ., No. 20, 1909). Unfortunately experiments by a large
number of asylum physicians did not confirm these results (see Abstracts
in Psychiat. Neurol. Wochenschrift , vol. xi, 1909-10, Nos. io, ri, 17,
18, 19, 20).

(*) Vide proposals in extenso, Psychiat. Neurol. Wochensch., No. 14, 1909-10.

ITALY.

By Dr. Luigi Baroncini.

The psychiatrical works published in Italy during the year just ended
have been numerous and in some cases very voluminous. Some are
well compiled, some arrive also at interesting conclusions, but nearly all
either deal with questions too special or too minute, or leave the latter
aside and occupy themselves with neurological questions only. The
former, the clinical works, concern themselves in general with special
symptoms which have no importance in assisting the knowledge of the
nosography and psycho-pathology of the different diseases, or else
illustrate clinical cases which are remarkable by their rarity. In any
case they represent rather contributions to current ideas amongst the
leading men. It is, then, impossible to give a rcsumt of these works ;
we should only be able to quote their titles, which would be objectless.
I have no better news to give regarding the progress of pathological
anatomy. Dr. Perusini, of the Psychiatrical Clinic of Rome, proclaims,
in a powerful article, the necessity of propagating the anatomico-patho¬
logical ideas of the school of Kraepelin ; but up to now the histo-patho-
logical study of the nervous system has been pursued without uniformity
of method, as also without precision of aim. Only in Rome, thanks
especially to Drs. Cerletti and Perusini, they have organised an anatomico-
pathological section in the Clinic of Tamburini, and there they are
trying to put new life into this highly important branch of psychiatry.
But the greater portion of Italian psychiatrical works relates to neuro¬
logy, a branch which promises easier and more brilliant success. In
my last contribution I drew attention to the tendency amongst Italian
psychiatrists to direct themselves rather to neurological studies. This
tendency had its culminating point and its official sanction in the founda¬
tion of the Society of Neurology, which gathers around it all the per¬
sonnel of the psychiatrical clinics. This Society held in 1909 its Second
Congress at Genoa, at which the following general subjects were dis¬
cussed :

(1) The serum diagnosis of nervous and mental diseases (Rossi).

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342 EPITOME. [April

(2) Acute myelitis from the clinical and the experimental points of
view (Catola).

(3) The physiological pathology of the optic thalamus (D’Abundo).

A rather important meeting from the scientific and practical point of

view was held at Milan to organise the struggle against endemic
cretinism with the object of combating this scourge, which infests
some of the most beautiful and most populated regions of our
country. There sprang into existence a committee which organised
a meeting in Milan to discuss a programme of work which would
have to be developed in an organised form throughout the nation.
The report on this organisation was entrusted to Professor Tamburini,
who presented the very remarkable work accomplished by Doctors
Cerletti and Perusini in his clinic. These authors in their report
took up the scientific as well as the practical side of the question.
They presented a scheme of all the researches to be made in order
to bring to light the aetiology and pathogenesis of the disease, and
the application of prophylactic and therapeutic measures, of which
science and practice had demonstrated the utility. In order to carry
out this programme the meeting in Milan decided also to make an
appeal to as many of the leading men of the profession as possible in
order to interest them in the humanitarian work, and for the financial
part to have recourse to the State administration and to provincial
organisations. If the leading men and the other organisations to which
the appeal was made respond as it is wished, there is reason to hope
that soon the plague-spot of endemic cretinism will disappear from our
country, in the same way as those other scourges of pellagra and
malaria, which were formerly so widespread, and are yielding more
and more to the combined efforts of the scientists and the administra¬
tions.

The special nature and rarity of the cause which occasioned them
prompt me to recall to mind the treatises which appeared on the occasion
of the terrible earthquake which destroyed the towns of Messina and
Reggio in Calabria. Certain of these works are simple as well as very
interesting introspective analyses of those who escaped (such as those
of Parmeggiani and Provenzal, published in the Rivista di Psicologia
Af>plicata of Bologna), and others are simple psychological analyses of
the phenomena observed (Cesare and Paola Lombroso, G. C. Ferrari).
Others study the neuropathic phenomena observed in the case of
those who suffered in the disaster (D’Abundo and Neri).

Towards the end of the year there was established at Florence an
association of doctors belonging to the asylums in Italy, having as its
object the protection of the professional interests of the medical men
engaged in asylum work. It was hoped to accomplish this task by the
ancient Society Freniatrica Italiana, but after many efforts the doctors
decided to provide for their moral and material advantage by a special
society. During the first congress one of the questions which aroused
the greatest interest was that of the autonomy of the medical officers
in their departments after a probationary period of two years’ duration.
As all were not in agreement on this subject it was decided to submit
the question to a special commission, which was to present its con¬
clusions at the next Congress.

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PROGRESS OF PSYCHIATRY.

343

The regulation of 1905 dealing with the Lunacy Law, which had
many faults at first, has been modified this year by the Government in
accordance with numerous criticisms which had been addressed to
them.

The more important modifications relate to the chronic harmless
insane and the feeble-minded. Under the old regulations these patients
had to remain under care in the asylums; now, on the contrary, the
provincial authorities have power to classify the patients and place
them in special houses, either outside or within the asylum boundaries,
thus giving the asylums their true functions as hospitals for mental
diseases.

The new regulation encourages home treatment and also family care,
which is extending more and more around the asylums to the advantage
of the patients and of the provincial authorities. Discharges are also
made more easy.

Unfortunately there has not been any modification of ihe judicial
procedure relative to the admission of patients, a procedure which is
intended to protect the liberty of the subject, but which, unhappily,
prevents proper treatment from being given at a period when such
treatment would be most likely to prove helpful to the patients.

Italian science has sustained a sad and irreparable loss in the death
of Cesare Lombroso, whose name was so well known. His work dealt
with many and varied aspects of insanity—criminality, genius, prostitu¬
tion, political crimes, pellagra, cretinism, hypnotism. Lombroso’s
treatment of these vital questions was sometimes superficial, but ever
genial. Evidence of the great esteem in which he was held was given
four years ago by the cordial demonstration on the part of the most
eminent anthropologists and criminologists of the entire world who
assembled at Turin to celebrate his scientific jubilee.

SPAIN.

By Dr. W. Coroi.eu.

The Minister of War has done for psychiatry what no Secretary for
Public Instruction has ever done. In the Spanish universities psychiatry
is not taught at all. Now it has become compulsory for army doctors
to take up some special branch of medical work, and psychiatry is
included. It is sad that such an important subject should be optional,
but it is better than being ignored altogether. Dr. Fernandez Victorio,
a well-known military alienist, who has distinguished himself by publish¬
ing a book on Insanity in the Spanish Army , has been appointed to
give a psychiatrical course at St. Bandilius Lunatic Asylum at Barcelona,
where he is instructing some military students. As in former years a
few students of forensic medicine, during their ordinary medical
curriculum, have attended some lectures at the same asylum. This
is all the psychiatrical equipment they are provided with for their
practice. No remedy for this reprehensible state of things is being
suggested.

The Government has again interfered injudiciously with the asylums.

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344

EPITOME.

[April,

By an Order in Council the late Cabinet made the regulations for admis¬
sion more stringent than ever. Moreover, there was a proposal which,
if adopted, would empty our asylums of half their poor population.
Our medical staff at the asylums are very poorly paid, and posts are
often vacant for a long time. At last, after three attempts, a medical
superintendent for the asylum at Gerona has been found in the person
of Dr. Raiz Rodriguiz, well known in Spain for his philosophical
writings.

Dr. Dolsa’s death has bereft Catalonia of the doyen of alienists. He
was the founder of the Psychiatrical Institute at Barcelona, one of the
first private asylums in the city. His son, also an alienist of renown,
died a year ago. Dr. Dolsa, jun., had written several important
psychiatrical works showing adherence to the old school. He had
also intervened in famous medico-legal cases, such as Willie’s.

We regret to record the death of Dr. Bertran Rubio, a famous neuro¬
logical specialist, who contributed on psychiatrical subjects to various
medical reviews and magazines. Although not an alienist himself he
was a profound literary scholar, and made just use of his classical and
vivacious style of writing in trying to dissipate some of the errors and
prejudices of the public as regards insanity.

As a proof of the stagnation that reigns in Spain in all psychiatrical
matters, we may point out that at the last International Congress of
Medicine at Budapest only one Spanish physician was present in the
section of psychiatry.

Publications have been few. The Spanish Phrenopathic Review has
entered its eighth year. It has no companion in the Spanish medical
press. Its contents are not, however, all Spanish. It has often
articles by South Americans. Dr. Salceran’s Archives of Neurological
and Phreniatrical Therapeutics is also in its eighth year. No new books
on psychiatry have been published or translated. At the Medical
Congress of St. James of Galice modern psychiatry was discussed but
no progress made. The only satisfactory note in the deplorable state
of mental science in Spain is in the good and reliable lunacy statistics
published in the Phrenopathic Review. As this is compulsory work in
the provincial asylums all credit is not due to them; however, the
care taken is beyond praise. Private asylums do not publish their
statistics, as in Spain great secrecy is observed regarding one’s more
personal affairs.

Lombroso was the subject of a lecture by the Professor of Forensic
Medicine in Barcelona. A course of lectures, also in Barcelona, on
anthropology and criminology, by Dr. Tambard, was the occasion of
political turmoil. Some people were at pains to find in them heretical
and anarchistic ideas.

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PHYSIOLOGICAL PSYCHOLOGY.

345

Epitome of Current Literature.

i. Physiological Psychology.

Reverie and Delusions of Grandtur [Reverie et delire de grandeur].

( Journ. de PsycholSept.-Oct ., 1909.) Borel, P.

If the reveries which are common to most normal people are analysed,
they are found to contain all the ideas which when developed constitute
the delusions of the megalomaniac. All such thoughts of richness, power,
honour and the like are the intellectual expression of “self-feeling” ( senti¬
ment de la personali/e), a feeling which is also manifested by certain
acts and emotional reactions—pride, vanity, courage, ambition. Since
these ideas of grandeur are simply the translation into images of this self-
teeling, one would expect that they would follow an evolution in the
individual life parallel with the growth of this sentiment. Such is found
to be the case. In young children, the reveries bear on play and motor
activities. From eight to fifteen years, ideas of riches, expensive clothes,
large houses, etc., appear. Later, the sentiment gives birth to love of
approbation, desire of praise, and parallel with this reveries of future
greatness and glory. Still later, the feeling becomes broader and is asso¬
ciated with the personality of others. At this epoch, altruistic reveries
appear which attain their full development in the so-called “ paranoia
reformatoria.” With the expansion of the intelligence reveries of inven¬
tion and intellectual expansion become manifest. This is the basis of
the so-called “ P. inventoria,” and is also observed in obsessional cases.
During puberty also the sentiment of the personality associates itself
with sexual feelings leading to amorous reveries. In the earlier years
of this period, the thoughts consist chiefly of ideas of a future home, etc.,
but later they become much more systematised, and consist of romances
of love and seduction in which the dreamer plays the chief and usually
successful role.

The writer then proceeds to discuss the psychological characters of
these conditions. The common characteristics of all reveries are the
turning of the attention from external stimuli and the more or less
automatic course of the representations. Reverie is favoured by solitude,
music, monotonous sounds, lectures, conditions in general leading to
fatigue of the attention. It appears most often before sleep, in the
hypnagogic states when the attention is weakened and dispersed, or in
the period following wakening when the attention is not yet established.
Contrasted with dreams, reveries always show evidence of mental
synthesis, a construction of representations implying a retained con¬
sciousness of the ego, transformed momentarily into a superior person¬
ality. In some individuals the day-dreams, instead of being variable,
continue one upon the other from day to day, forming a complicated
romance. Such attain their greatest development in children, and are
more common in women than men.

Attention is next directed to the pathological aspects of the subject.
In some delusional states, the expansive ideas have precisely the same
characters as reveries of ambition. Krafft-Ebing has described the case
of an epileptic in which ambitious crises replaced the convulsive

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1910.] PHYSIOLOGICAL PSYCHOLOGY. 347

The Conception of the Subconscious. ( fount, of Abnormal Psychol ., Feb-

March, 1910.) PIart, B.

While the conception of the subconscious has been of undoubted
utility in furthering the progress of psychiatry, considerable disagree¬
ment exists as to the precise meaning to be attached to the term,
notably as to whether a subconscious process is to be regarded as a
mental or physical phenomenon. The conception denotes an attempt
to regard mental experience, which is apparently disconnected and
irregular, as a continuous and regular series of processes.

The first important contribution towards such an end was that of
Janet’s, who demonstrated that a large number of morbid phenomena
could be explained by assuming the existence of dissociated mental
elements outside of the personality. This view has been developed by
Morton Prince, who divides psychological material into that of which
the individual is personally conscious and that of which he is not per¬
sonally conscious. The latter he subdivides into co-conscious (Janet’s
subconscious, i.e., ideas dissociated from the personality) and unconscious
elements—memory, traces, etc.—which are not at the moment actively
functioning.

Now while most writers are ready to consider consciousness psycho¬
logically, many regard the subconscious from a purely physiological
point of view, i.e., as brain processes which have no mental accompani¬
ment. The main object of this paper is to demonstrate that the
question as to whether the subconscious is a brain fact or a mind fact
is based on a misconception, and that the solution of the question is
obvious when the meaning of the terms is correctly apprehended.

The author first devotes consideration to the general nature of
scientific concepts. He shows that a scientific law is purely conceptual
in character, enabling some portion of human experience (phenomena)
to be classified into sequences, and reducing an indefinite number of
sequences into a single formula. A scientific law is therefore valuable
as a working hypothesis, enabling us to resume our sense impressions
and predict future occurrences. Bearing this in mind, it becomes
apparent that when one distinguishes between mental and material, the
distinction is purely conceptual. On the phenomenal plane, the same
entities are being dealt with, viz., sense impressions. The physicist
resumes his sense impressions by means of a conceptual model involving
time and space, the psychologist regards them as actual or potential
constituents of a consciousness.

Now while both conceptions have their value, a not uncommon error
is to jump from one conception to the other, e.g., the psychologist fills
up the gaps in his chain of cause and effect by introducing physiological
conceptions such as nerve-cells and currents. The conceptions of
psychology, however, must all be constructed within the psychical
series. Therefore the term “ subconscious,” which has been devised to
explain mental phenomena, must be regarded as a psychological
conception.

Coming now to the most important applications of the term in
question, it becomes apparent that Janet, in his “subconscious,” is
dealing with phenomena and not conceptions. In the same way that

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one infers consciousness in others from their speech and actions, so
Janet infers dissociated mental elements in his patients from the
observation of such phenomena as automatic writing and the like.

On the other hand, the subconscious of Freud is non-phenomenal, it
is conceptual in character. He has imagined certain entities (complexes,
unconscious ideas and effects) which have certain properties. He has
found that the facts of consciousness can be explained by conceiving
the existence of such complexes. An unconscious idea is, on the
phenomenal plane, an impossibility, as are the atom and ether of the
physicist. None of them have phenomenal existence, they are not
facts of experience, they are simply devised to explain and predict
experience.

The relation between Janet’s subconscious and Freud’s unconscious
is not therefore one of rivalry. The former is a description of pheno¬
menal facts—the phenomena of dissociation—and the latter is a
conception which has been devised to explain those facts.

In the light of these observations the writer makes it clear that the
term “subconscious” has been employed for three distinct categories of
facts, and would group them under the following headings :

(a) Marginal elements of consciousness (subconscious of Stout).

Ib ) Dissociated elements of phenomenal consciousness (co-conscious
of Morton Prince and subconscious of Janet).

(c) A non-phenomenal conceptual construction designed to explain
the facts of phenomenal consciousness (the unconscious of Freud).

H. Devine.

Experiments to determine Co conscious ( Subconscious) Ideation. ( Joum .
of Abnormal PsycholApril-May , 1908.) Prince , Morton.

In this paper, the writer draw's attention to the difference of opinion
which exists as to the interpretation of the manifestations of the sub¬
conscious. More especially he attacks those writers who hold the view
that these manifestations “ are compatible with the interpretation that
they are the result of physiological processes without any association
with ideas whatsoever.” In support of the psychological interpretation,
viz., that co-conscious (subconscious) manifestations are the expression
of subconscious ideas more or less dissociated from the personal con¬
sciousness, the writer describes several experiments carried out by
himself on cases of multiple personalities, giving both simple and more
elaborate tests in co-conscious perception and reasoning. In addition,
there is a short description of one of a series of experiments carried on
in conjunction with Dr. Frederic Peterson, by means of the psycho¬
galvanic reaction method, with a view of demonstrating the presence of
subconscious emotions of which the subject was unaware. The reader
must be referred to the paper itself for details of these experiments,
which do not lend themselves to epitomising, but which substantiate
Dr. Prince’s conclusion, viz., “ that such perceptions, interpretations,
calculations, and translations could have been made by pure physiological
processes without thought is inconceivable, and not substantiated by
anything that we know of physiological processes.”

G. F. Barham.

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/ETIOLOGY of INSANITY.

349

2. /Etiology of Insanity.

On the Inheritance of the Diathesis oj Phthisis and Insanity; a
Statistical Study based upon the Family History of 1,500 Criminals.
(. Drapers' Company Research Memoirs; Department of Applied
Mathematics, University College, London ; published by Dulau and
Co., price 3 s., 1909.) Goring, C.

Apart from its intrinsic value as a notable contribution to a subject of
very great scientific importance, Dr. Goring’s essay is of much interest
as an example of the immense possibilities of the prison population as
a field for biological and bio-social research. The material which
forms the basis of the paper has been drawn from the data accumulated
in the extensive anthropological survey of the convict population, which
has been in progress for some years past under the direction of the
Prison Commissioners. It consists of a series, collected by the author,
of 723 family histories of convicts, concerning which definite informa¬
tion was given in each case as to the occurrence or non-occurrence, in
parents and children, of pulmonary tuberculosis, and of a series, similarly
collected, of 1,433 histories in which corresponding information was
given with legard to insanity. The author claims that this material may
be regarded as a random sample of the general population as far as the
diseases under consideration are concerned, and that it therefore supplies
the direct evidence needed to control the conclusions of Pearson and
Heron, which were partly based on assumptions as to the prevalence of
these diseases in the general population.

Working on this material by the usual biometric methods, Dr. Goring
reaches the following conclusions :

(1) The tubercular diathesis is inherited, and the intensity of the
inheritance factor lies between 0^4 and o - 6, being thus about the same as
with all other physical characters in man.

(2) The prevalence of tuberculosis in the population—taking the
duration of individual life as the unit—lies between 8 per cent, and 10
per cent., and is probably nearer the lower limit.

(3) In the class dealt with there is no evidence of marital infection.

(4) There is no definite evidence that the correlation between parents
and offspring is greater in the poorer classes, where environment would
increase the liability to infection.

(5) The importance of the hereditary factor as opposed to direct con¬
tagion in the causation of phthisis is further supported by the facts
(a) that the prevalence of phthisis amongst children of infected mothers
is not appreciably greater than it is amongst the children of infected
fathers ; (b) that the prevalence of phthisis amongst workers exposed
to constant infection in a consumption hospital has been found to be
not significantly greater than amongst individuals with the same degree
of diathesis in the general population.

(6) The criminal data confirm Heron in his conclusion as to the
inheritance of the insane diathesis, and present a correlation between
parents and offspring sensibly the same as the correlation in phthisis.

(7) The prevalence of insanity—the life of the individual being
taken as unit—appears to be somewhat greater (lying between 3 percent.

LVI. 23

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[April,

and 4 per cent.) than the value assumed by Heron, or else it is greater
in criminal stock as distinguished from the normal population.

An appendix to the paper gives some interesting data regarding
marital correlation for “insanity,” “phthisis,” “criminality,” “alco¬
holism,” and “ freedom from constitutional disease.” In relation to
each character considered the cases are classified according to social
status, and it is found in most instances that the value of the correlation
co-efficient consistently increases as we pass upwards in the social scale ;
the inference drawn from this fact is that in the socially better classes
the influence of assortative mating makes itself felt. With regard to the
individual values found, it may be noted that the co efficient of marital
correlation for insanity in all classes was ascertained to be o‘o6, for
criminality o - 2, and for chronic alcoholism the extraordinarily high
figure of o - 7. W. C. Sullivan.

The Influence of the Brain on the Development and Function of the Male
Sexual Organs \L'influenza del cervello sullo sviluppo e sulla
funzione degli organi sessuali maschili\. ( Riv . Sper. di Freniat .,
vol. xxxiv, fasc. 2-4.) Ceni, C.

Professor Ceni has during recent years been studying the influence of
the cortical centres upon the phenomena of generation and perpetuation
of the species. In a former communication, he described the effect of
operative destruction of the cerebral cortex upon the sexual life and
general health of fowls, and drew attention to a peculiar condition of
cachexia accompanied by extreme atrophy of the testicles which beset
the animals operated upon long after they had recovered and lived in
an apparently normal manner for a period of one to two years.

The present communication gives the result of a large number of
experiments which aimed at determining the nature of the atrophic
process in the sexual organs, the relation between the atrophy and the
operation (removal of one hemisphere down to the basal ganglia), and
the influence exerted upon the atrophic process by the age, and more
especially the precise state of development of the genital organs with
respect to the time of operation.

Sixty young cocks about three months old, i.e., with immature
sexual organs, and forty-one about eighteen months, sexual organs
completely developed, had one cerebral hemisphere removed during
the months of maximum sexual activity (April and May). Of the
former, twenty-one died during the operation, and thirteen from shock
within ten days. The remaining twenty-six recovered from the shock
and survived the period of life in which the sexual organs normally
acquire their full development.

Ten of these twenty-six failed to reach normal development, notwith¬
standing the healing of the wound by first intention and an abundant
ingestion of food. They remained in a state of physical torpor and
skeletal deficiency, accompanied especially by a notable arrest of
development of the external sexual features. The bright feathers and the
crests and wattles of normal cocks either failed to grow or appeared
atrophic and scanty. They did not crow nor did they give any sign of
sexual instinct whatsoever. In three which came to the post-mortem

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AETIOLOGY OF INSANITY.

351

table several months after the operation, the recognition of sex was
impossible from external features. These ten cocks died or were killed
at periods from three to nine months after operation. In all, the
testicles were found greatly atrophied, and in some cases almost
irrecognisable. Those animals which were not killed died in a state of
severe cachexia, which supervened in the latest period of their lives.

The remaining young cocks, having recovered from the traumatic
shock, underwent an apparently normal evolution, and differed little, or
not at all, from control animals, either in external appearance or in
sexual instinct and capacity. Four were killed, five, eight, ten, and
fourteen months respectively after operation, and whilst in the best of
health. Their testicles were found to be normal in colour, consistence,
volume, and weight. Three fell into a state of progressive cachexia
after fourteen to nineteen months of health and normal sexual activity.
The testicles of these were markedly atrophied. The remaining nine
were still alive after two years of almost normal sexual activity. The
microscopic findings are still more noteworthy. Even in those which
died within ten days after operation modifications were present in the
size and form of the seminiferous tubules and the spermogenetic cells.
The spermatozones were much fewer in number than in control cases,
and showed evidence of degeneration. In those which died from the
third to the eleventh month after operation with external features of
sexual infantilism, the microscope revealed a state of arrested develop¬
ment and even retrogression of seminiferous tubules and spermogenetic
elements.

In those which developed normally and were killed at intervals from
five to fourteen months after operation, the intimate structure of the
testicles was normal.

In the case of the three young cocks which died in a state of cachexia
after a long period of health and virility, remarkable alterations were
found, indicative of an extremely destructive and atrophic process,
affecting both the true glandular elements and the interstitial tissue.

Of the forty-one adult cocks, eleven died during the operation and
nine during the following fifteen days without recovering from the
traumatic shock. In the latter, the testicles presented a degree of
atrophy, increasing from the third to the fifteenth day. Three died
after twenty-two, twenty-five, and twenty-seven days in a state of pro
gressive marasmus after having partly recovered from the shock, and
the testicular atrophy in these was more marked.

Nineteen survived and gradually re-acquired their former vital and
sexual activity in about thirty-five to forty days. Of these, five were
killed after they had recovered from the shock, but before the sexual
instinct was regained (four to twenty days), and in them a marked
degree of testicular atrophy was found. Four were sacrificed from
the thirtieth to the fifty-seventh day, t'.e., during the period of re-awaken¬
ing sexual instinct and restoration of physical condition. Their testicles
were normal in consistence and colour, but slightly below normal in
weight. Five were killed after four, five, seven, ten, and thirteen months
respectively, and in them the testicles presented a normal appearance.
Of the remaining four, two died in a state of progressive cachexia after
eighteen and twenty-five months respectively of health and sexual activity,

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and in them an enormous degree of atrophy of the testicles was found.
The other two were alive and well after more than two years. The
histological findings in the testicles of these adult cocks are perhaps even
more striking, and are fully described and figured by the author. In the
case of the five killed after four to thirteen months, whilst in a state of
complete restoration, the microscopic appearances were normal. In all
the others atrophic and degenerative processes were in evidence. Even
during the first few days after operation, the form of the seminiferous
tubules and the disposition of the mobile elements (spermatocysts and
spermatids) is notably altered as well as the pre formed spermatozoa.
When the traumatic shock is followed by progressive marasmus the
above changes are accompanied by a necrobiotic process affecting all
the elements of the tubules—fixed and mobile. The spermatocysts and
spermatids are always most affected and first destroyed. When shock
is recovered from and health gradually restored, the histological and
physiological condition of the testicles returns gradually to the normal.
When, after a long interval of health, the state of cachexia supervenes,
the necrobiotic process in the testicles is extreme, and under the micro¬
scope the spermogenetic elements are seen to be completely destroyed
and the interstitial tissue profoundly altered.

It is evident from these experiments that there is an intimate connec¬
tion between cerebral integrity and normal sexual function. The
precise nature of the connection it is as yet impossible to define. The
results of cerebral destruction are both immediate and remote. In Ceni’s
opinion, the immediate phenomena cannot be related to traumatic shock,
which is sometimes entirely or almost absent, especially in adult fowls,
whilst in some cases they remain very prominent long after shock has
been recovered from. They might be thought to be due to loss of the
habitual physiological cerebral equilibrium necessary for the regulation
of the general metabolism. This, Ceni remarks, is simply an hypothesis
to be accepted with the greatest reserve. The remote effects are no less
enigmatical. They certainly cannot be ascribed to disturbance of
cerebral equilibrium, for the sexual organs have previously re-acquired
their normal functional activity, notwithstanding the loss of a hemi¬
sphere, whilst the animal has shown, during a long intervening period,
an almost normal equilibrium in the organic interchange. These
animals, however, have a shorter life than usual, and die in a state of
precocious vital exhaustion that reminds us of the involutionary pheno¬
mena of senility. This idea is merely a tentative explanation, and
further researches are needed to throw light on these complex and
important biological questions. J. H. MacDonald.

The Influence on the Function oj the Testicles exerted by some Substances
which Act especially upon the Brain (Coffee, Veronal , Absinthe).
\L'influena di alcune sostanze tTazione prevalentemente cerebrate sulla
funzione dei testicoli ( caffee , veronal , absinthe).) (Riv. Sper. di
Freniat., vol. xxxv, Fasc. ii-iii-iv.) Ceni, C.

This paper gives an account of some experiments carried out on dogs
to determine whether substances which alter the cerebral function with¬
out producing organic lesions in the brain are capable of inducing

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/'ETIOLOGY OF INSANITY.

353

functional changes in the testicles. Coffee was administered to three
and veronal to two dogs, in doses sufficient to produce exterior mani¬
festations, without compromising the life of the animals, for varying
periods of time. The microscopic examination of the nervous system
was negative in each case, whilst the findings in the testicles were always
positive. The severest alterations followed the administration of coffee.
The seminiferous tubules and spermogenetic elements at first show signs
of involution or simple atrophy, and in the later stages a truly necrobiotic
process is evident, resembling that found after ablation of a cerebral
hemisphere. In the testicles of the two dogs subjected to the action of
veronal the changes were less severe, and indicated an arrest of the
spermogenetic process without determining a true involution of the
elements.

In the case of dogs poisoned during fifteen days with absinthe, the
histological findings were similar but less marked. Why coffee should
exert such a powerful action on the function of the testicles as compared
with veronal and absinthe it is difficult to explain, especially when we
contrast the external manifestations of poisoning by these substances.
It cannot be a direct action, else we should expect to find (a) the
severest changes following absinthe, the deleterious effects of which, on
the organism generally, are well recognised ; (b) gross changes in the
central nervous system in the case of coffee and veronal, which act
selectively on the cerebrum. Ceni suggests that the action may be
mainly indirect , and dependent on functional disturbances in the central
nervous system. J. H. MacDonald.

Tobacco in Relation to Insanity \Der Tabak in der sEtiologie der
Psyc/wsen\ {Wien. klin. Rutid., No. 48-50, 1909.) Nacke , P.

The author prefixes to his cases an interesting summary of the some¬
what conflicting modern opinions on tobacco as a factor in the causa¬
tion of insanity. He thinks the tendency is to assign to tobacco a less
serious part than formerly, greater care being taken to distinguish
between the post hoc and the propter hoc. ./Etiology is so complex that
it is difficult to assign a precise place to nicotine. The abuse of
tobacco can only in very rare cases be alone a sufficient causation of a
psychosis. Nacke believes, however, that very exceptionally the
chronic abuse of tobacco may produce a condition clinically corre¬
sponding to general paralysis (for he is not one of those who consider
syphilis as an absolutely essential factor of this disease), and he accepts
the case brought forward by Krafft-Ebing. He also agrees with Arndt
and Schiile that, as in other cases of chronic poisoning, tobacco may
enfeeble the nervous system, act as an intellectual and moral depressant,
and even by affecting the germ-cells influence offspring. But, even as
a merely co-operating cause, the misuse of nicotine in the production of
psychosis is very rarely seen. In thirty years’ psychiatric activity among
a vast number of cases, Nacke has seen very few cases in which
tobacco, to his knowledge, played any part at all, and never any
case of pseudo-paralysis thus caused. He brings forward two cases he
has recently met with in which tobacco was influential. The first
was that of a cigar sorter (from age of sixteen) in a tobacco factory, and

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himself a great smoker. There was some insane heredity on paternal
side but otherwise his record was good ; no alcohol, syphilis, or trauma.
He was, however, rachitic. At the age of twenty he became nervous,
displayed fears and anxieties (at first in regard to diet), then highly
irritable, and later violent and destructive, finally presenting “a classic
picture of amentia,” with confusion, hallucinations, and corresponding
delirium. Two years after outbreak he left the asylum cured. On the
physical side tobacco had at the outset produced definite neurasthenic
symptoms as well as some amblyopia. The chief cause of the psychosis,
Nacke concludes, was the abuse of tobacco. The second case was
somewhat similar, though here the heredity was fairly sound, and
smoking only began at nineteen, from which age cigarettes were con¬
sumed in great excess. At twenty he fell on a staircase and struck
parietal region, being rendered unconscious, and later had another
somewhat similar injury to head. There were neurasthenic symptoms,
later culminating at age of twenty-five in a sudden outbreak of amentia,
and for four days he was completely amnesic. Recovery took place four
or five weeks later. In this case, Nacke holds that abuse of tobacco was
one of several depressing conditions influential in bringing on the attack.

How does the use of tobacco affect the insane? Nacke has never
seen any seriously bad results. Nor has he seen any evil effects from
suddenly breaking off the habit. Rather more than half of the patients on
the men’s side at Hubertusburg smoke, nearly a quarter of these at their
own expense. The cost per head for the others is less than four
shillings a year, and Nacke considers that the money is well spent, as
no luxury is cheaper or more appreciated.

Finally, Nacke brings forward a case of acute nicotine poisoning due
to idiosyncrasy. The young wife of a clergyman went with her children
to tea at the schoolmaster’s, a man who smoked cigars all day long.
Everything in the house smelled and tasted of tobacco, and on returning
home the clergyman’s wife suffered from headache and vomiting. For
a week she was unable to eat, and for a month she was pursued by the
hallucinatory odour of tobacco. One of the children suffered to a slighter
extent. Havelock Ellis.

3. Clinical Psychiatry and Neurology.

Remarks on a Case of Obsession \Bemerkungen iiber einen Fall von
Zwangsneurose \. ( Jahrb . /. Psycho.-analyt. Forsh ., Bd. r, 1909.)

Freud, S.

Freud here presents a fairly typical case, as psycho-analytically inves¬
tigated, and accompanies it by many illuminative remarks of a charac¬
teristic kind. He observes at the outset that, contrary to what one
might expect, the mechanism of obsession is more difficult to under¬
stand than that of hysteria. The victims of obsession conceal their
condition as long as possible, seldom come to the physician, and then
only at a very late stage. The patient in the case investigated—an
intelligent young man of academic training—had had obsessional ideas
from childhood, and in a pronounced form during the last four years.
His chief trouble lay in the fears he felt concerning two people he had

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355

great affection for, his father and a lady, while he also had impulses to
cut his throat, and a tendency to make vows and rules in regard to
trivial acts. He felt that he was wasting much of his life in fighting
against these impulses. Freud traced back the condition to facts of
childhood : he wished to see women he liked naked, but he had the
fear that if he did his father would die. Though no obsession had yet
arisen, there was a wish and an opposing fear, a painful emotion and an
impulse to ward it off, and therewith Freud believes the inventory of the
neurosis was complete. “ More clearly than hysteria, obsessions may be
traced back to the sexual life of childhood.” It is the infantile part of
life which becomes the unconscious element in the neuroses of later life.
It thus comes about that there is what Freud calls a mesalliance between
the contents of the idea and the emotion that accompanies it; between the
reproach and the occasion for the reproach; so that to the lay mind it
seems that the emotion is greater than the occasion warrants. That is not
so, says Freud; the emotion is justified, but it belongs to other groups
of mental ideas, which are unconscious and must be sought for. In
this way obsessions, which seem as fantastic as dreams, become intelli¬
gible. It is necessary to ascertain when the obsession first occurred, and
under what circumstances it recurs. Freud finds a simple illustration
in a suicidal impulse of this patient, at a time when he was distracted in
work for an examination, by the departure of the lady he was in love
with to nurse her grandmother. “ I should like to do away with the old
lady” is his real thought, but it is at once followed by the command :
“ Do away with yourself for harbouring such a murderous thought.”
On another occasion, when this lady was about to leave the neighbour¬
hood, he sees a stone on the road, and carefully removes it aside lest it
should cause an accident to her carriage; then he returns and replaces
the stone, saying to himself that the idea of an accident was foolish.
But there was more than that in the action, Freud argues. A little
before the patient had had a quarrel with the lady, and his actions with
the stone really symbolised his love and his hate. A contradictory
process of this kind is typical of obsession ; it is always an opposition of
love and hate, though the patient tries to rationalise it by introducing a
secondary motive. This is theoretically interesting, because it represents
a special type of symptom-formation, differentiating the neurosis of
obsession from hysteria. “ Instead of, as in hysteria, finding a compro¬
mise which covers both opposites with one representation, killing two
birds with one stone, the two opposites are here satisfied separately,
first one, then the other.” In obsession, as thus understood, mere ideas
come to the surface, robbed of the emotional contents, which yet are
their unconscious motive force. Repressed hate, especially, the sadistic
component of love, here plays a large part, as also in hysteria and
paranoia. And when we have this conflict of love and hate the result
is a partial paralysis of will and perpetual irresolution for all actions of
which love should be the motive force. Such irresolution necessarily
extends beyond that sphere. So we have the endless doubt of the
victim of obsession, whose obsession is really an attempt to compensate
that doubt and to correct the unbearable state of inhibition. The
commands and prohibitions are attempts to set in action the choked
energies in a transformed shape.

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It is not possible to summarise the whole of this lengthy paper, for,
like all that Freud writes, every page contains fruitful and original
ideas or suggestions which demand attention and study, even though
they may not always command assent. Havelock Ellis.

Delusions of Possession by Animals in a Case of Per seat lory Mania
[.Delire de Zoopathie Interne chez une Persecutee ]. (Rev. de

Psychiat., Nov., 1908.) Vallet, A., and Fas sou, A.

This paper records the case of a woman, aet. 37, of poor general
intelligence and education, who, six years prior to admission to the
asylum, developed symptoms of persecutory mania. She heard voices of
an abusive nature, both at home and in the street; people pointed at
her in passing ; the police whispered to her to get a revolver to protect
herself. She fancied she was electrified and chloroformed.

In the asylum she was quiet for nearly a year, but then became excited,
and expressed the delusions of animal possession. She said the
doctor and the police commissioner chloroformed her at night and intro¬
duced various animals into her belly through rectal and vaginal specula.
The animals were mainly reptiles, vipers, lizards, crocodiles, etc. Later
on she became a perfect menagerie, rats, dogs, weazels, monkeys, lions,
and owls forming the fauna of her intestines. These animals feed on
her intestines, the wounds they make healing like cracks on the hands;
they live for varying periods, and at night the doctor removes the dead
ones and inserts fresh animals.

She feels the movement of the animals most when she is up; they
are quiet when she sits. When she closes her eyes she can best dis¬
tinguish the various kinds.

Her health is good, there are no signs of visceral disease, and the
only sensory disturbance is a slight general hyperaesthesia.

Suggestion and all other methods of treatment have proved useless in
this case. W. Starkey.

A Contribution to the Study of Suggestion in Mental Pathology. A Case
of Family Insanity \Un Cas de dllire familial\ (Rev. de
Psychiat., Nov., 1908.) Schwartz.

A married man, set. 34, was brought to the asylum by his wife and
amily. He was confused and disorientated, with persecutory delusions;
thought he had sold his soul to the Devil, that his will had been taken
away, and that his condition was due to the enchantments of a sorcerer
living in the neighbourhood.

His wife firmly believed these ideas, and said the sorcerer had
magnetised and paralysed her husband because he refused to pay him
money for curing her of an illness.

The author states that the belief in witchcraft is still prevalent in the
district, and he attributes the patient’s insanity to the influence of such
an environment on a man of weak intellect, and to the influence exerted
by his wife and family on his mind.

He thinks this case exhibits all the factors which Last:gue and Falret
consider essential for the production of folie a deux, viz .:

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I 9 IO.] CLINICAL PSYCHIATRY AND NEUROLOGY. 357

(1) The delusions are originated by the more intelligent, or at least
the more active, of the individuals.

(2) The two individuals must live in close relationship, sharing the
same pleasures, worries, etc.

(3) The delusions of the active subject must have an air of veri¬
similitude.

The treatment adopted in this case was : complete isolation from his
wife and family, no visits being allowed, rest in bed, and baths to relieve
the restlessness; reasoning with the patient to try to remove the
delusions, and, later, cold douches to rouse him from his lethargic state.
Recovery was complete in a month. W. Starkey.

Juvenile General Paralysis and Spasmodic Paraplegia [Paralysie ginirale
juvtnile et paraplegia spasmodi(]ue\. {Bull. Soc. Clin. Med. Ment
Nov., 1909.) Pactet, M.

This paper records a case in which the diagnosis lay between
dementia praecox with paraplegia and general paralysis. The patient
was a youth, set. 19, whose development up to the age of fourteen had
been normal ; there were no stigmata of degeneracy and no insane
heredity. His education was fair, his health good, and his intelligence
average. At fourteen years of age he began to deteriorate mentally,
speech became hesitant, and his gait was affected. When brought to
the asylum a year ago his articulation was impaired, his pupils unequal,
knee-jerks increased, and gait uncertain. His mental state was one of
general feebleness with some exaltation. There was no lymphocytosis
in the cerebro-spinal fluid. The author had seen a similar case some
years ago, which at post-mortem showed the lesions characteristic of
dementia praecox and not of general paralysis. In this present case,
however, the retention of a certain degree of psychic activity, the
presence of emotional reaction and the affections, and the absence of
the impulsiveness so usual in dementia praecox, confirm the diagnosis
of general paralysis. W. Starkey.

Obesity Associated with Changes in the Generative Organs and Tumour
of the Pituitary Body \Le Syndrome Hypophysaire Adiposo-Glnital\
{Gas. des Hop., Jan., 19ro.) Lannois, P. £., and CUret, M.

This article was written to show how lesions of the pituitary body
associated with pathological or functional changes in the generative
organs do produce an excessive formation of adipose tissue throughout
the body.

Twelve cases in all are recorded, eight in women and four in men.
The clinical accounts are minute and detailed, and in the majority of
the cases accompanied by photographs, which give a very good idea
the enormous obesity of the individuals under discussion.

The symptoms of the disease usually present themselves about
puberty, or even as late as twenty-one. Heredity does not play an
important part. In females, menstrual abnormalities are noted. Men¬
struation does not commence in some; in others, even if established,
the menstrual discharge is scanty, and ultimately ceases at an early age.

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In males, the genital organs are poorly developed. Visual troubles
commence early, and all lead to more or less impairment of vision.
Obesity is in all cases extreme, and shows itself about three years after
the initial cerebral symptoms make their appearance. In contrast to
obesity the result of feeding in excess, the neck is not particularly
thickened. All the classical symptoms of cerebral tumour may be
present—headache, vomiting, etc. The pulse is quickened, but the
temperature lowered. The psychical phenomena are variable at the
commencement of the illness, but later apathy and lethargy are always
present, the patients having a “passion for sleep.”

The writers lav great stress upon the importance of radiography in
making a diagnosis. If, together with the symptoms already mentioned,
an enlargement of the sella turcica can be made out, the diagnosis is
complete, but not before.

Post-mortem the ovaries are found to be sclerotic. The excessive fat
is no protection against tuberculosis, as one patient died of the miliar)’
form of the disease. The size of the growth involving the pituitary
body is variable; it is usually of a sarcomatous nature. One case was
due to traumatic lesions following a gunshot wound.

Colin McDowall.

Adenomatous Tissue in the Hypophysis; Pathological Sleep : Absence of
Symptoms of Acromegaly [Struma adenomatosa dell'ipofisi; Sonno
patologico; Assenza di manifestaziono acromegaliche\ ( Riv . di

Patol. nerv. e ment ., vol. xiv,fasc. 7.) Sandri, O.

Sandri, with the intention of contributing to the study of the function
of the pituitary body, presents a case showing unusual clinical manifes¬
tations, and in which the whole of the gland exhibited pathological
changes.

A countrywoman, aet. 48, was admitted to the clinique for mental and
nervous diseases at Florence. Her family history was good. The
illness of which she complained was of eight years’ duration, and the
signs shown previous to admission were, tired and depressed feelings
and a bodily condition which left her easily fatigued. She had also
vertigo and frequent and annoying headache. At first these symptoms
were intermittent, but latterly they became more frequent and constant.
A year previous to her admission to the clinique, the patient showed
noteworthy intellectual weakness, indifference to surroundings, incapacity
of attending to things, until she passed days immovable, silent, happy
only when lying in bed, where she remained in a state of stupor. These
symptoms developed still further, until, about two months before her
first admission to the clinique, the stuporose state became that of
somnolence, from which she awoke only to satisfy her vegetative
requirements.

An examination on admission revealed in the ocular fundi white
bilateral atrophy of the papillae, which were more detached on the left
side than on the right. The cerebro spinal fluid was limpid, contained
no albumen, and its centrifuged sediment showed a few lymphocytes.
Otherwise the bodily functions appeared normal. The mental condi¬
tion was as follows: the patient lay in bed wrapped in a sleep which

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was only interrupted to satisfy the needs of vegetative life. When
questioned she answered with sufficient precision, but the question had
to be energetically repeated, otherwise the patient, after answering in a
monosyllable, would relapse into sleep. Ideation was poor, perception
slow, and memory somewhat uncertain and confused. Judgment was
weak, and the patient did not respond to the news of her parents or
show emotion in their presence. She complained of headache, heavy
sensation in the skin of the head, vertigo, and ringing in the ears.
Intractable vomiting occurred at times, and, despite every stimulus, she
sank into a deep sleep from which she could not be awakened.
Immediately before death symptoms of gastro-enteritis appeared.

At the autopsy, a tumour involving the whole of the hypophysis was
found. This tumour was of greyish colour, slightly harder than the
brain-substance and somewhat flattened at the base. It measured
6 cm. transversely and 4 cm. longitudinally. It tapered above, and
was inserted immediately in front of the cerebral peduncles.

A histological examination presented a characteristic type of adeno¬
matous tissue reproducing the structure of the epithelial lobe of the
hypophysis, from which it took its origin. Sections of the whole tumour,
in series, were made. It was not possible to observe any traces of the
tuber cinereum, the mammillary tubercles, or the nervous lobe of the
hypophysis. In the optic thalamus and in the cerebral convolutions, in
immediate contact with the tumour, no neoplastic infiltration was found.
The cells in these regions presented the same appearances as those of
the frontal and occipital convolutions. Although the nucleus was
central in many elements, it was swollen and uniformly coloured. The
chromatic bodies were scarcely differentiated, broken, and rare; the
yellow pigment was very abundant ; the cellular processes coloured
well, and were visible for long distances. In certain parts they were
surrounded by abundant neuroglial nuclei. Hamilton C. Marr.

A Suggested Serum-diagnosis of Syphilis by means of a Chromatic Re¬
action [A proposito delle siero-diagnosi delle sifilide per mezzo di
una reazione cromatica\ ( Riv . di Patol. Nerv. e Ment ., vol. xiv,
Rase. 7.) Turchi, G.

The method of deviation of the complement applied in the serum-
diagnosis of syphilis, of tabes, and of progressive paralysis by means of
the examination of the cerebro-spinal fluid has assumed an undoubted
diagnostic value. The reaction of Wassermann, however, presents some
notable technical difficulties, and can only be carried out in a fully
equipped laboratory. Various modifications have been suggested,
tending to render the researches more accessible, but fortunately,
studies directed to control the practical value of these modifications
have demonstrated that they are almost all unacceptable. The methods
of Porges and Meier, which were founded on the precipitation of lecithin
and of glycocholate of soda, have been demonstrated non-specific and
inconstant in researches carried out in the cliniques of Tanzi and
Belmondo. Foreign and Italian literature ascribe the same defects to
the methods of Klausner. At the same time, every new attempt to
simplify the sero-diagnosis of syphilis is quite justified. The latest

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methods suggested are those of Campana and Schiirmann. The present
paper is concerned with Schtirmann’s method. The theory that under¬
lies this method is based on a chromatic reaction. Starting with the
idea that in the reaction of Wassermann lactic acid plays a considerable
part, Schiirmann has made some researches on this acid in the serum
by means of the known reaction of Uffdmann, but without any appreci¬
able result. Tiirchi is of opinion that the colouring substances of the
blood, contained in varying quantity in the different sera, masked in
part the results of the chromatic reaction. To obviate this incon¬
venience he resorted to successive oxidation and reduction of the liquids
to be examined, and after some preliminary researches propounded the
following method:

“o’i cm. of serum is placed in a glass tube. It is diluted in 3 cm. or
4 cm. of physiological solution (075 per cent. NaCl 2 ). To this solution
a drop of perhvdrol Merck (aqueous) is added, and the tube is shaken.
This first part of the method, according to the author, gives some
criterion in deciding if the serum examined belongs to a syphilitic
individual. If the case is a positive one, there is an abundant precipitate.
o - 5 cm. of the following reagent, freshly prepared and preserved in deep,
well-closed bottles, is added: Phenol, o'5 gr. ; sesquichloride of iron
(purest) 5 per cent., 062 gr.; aqua destillata, 34^5 gr. The reagent,
when prepared, should have a beautiful lilac colour. The serum of
normal blood, with the addition of the reagent, shows on the surface a
light green coloration, which on shaking either disappears completely or
leaves a light green tint. The mixture always keeps transparent. The
blood in syphilis, on the other hand, behaves in quite a different
way. The addition of the reagent causes a greyish black, opaque
colour; the mixture is turbid and remains so after shaking. The reaction
occurs in from one to two minutes. To the changes in colour which
appear after this limit of time no definite significance should be attached.
It is immaterial whether active or negative serum is used.”

Schiirmann examined by his method eighty-four sera. In all of
these he has obtained results in accordance with the reactions of
Wassermann. Negative results were obtained in two cases of sera
of scarlatina—sera that some authors hold to have the power of giving,
although very slightly and transiently, the reaction of Wassermann.
Negative results were obtained in examining the sera of normal animals
(rabbits, guinea-pigs, and sheep).

Turchi has made trial experiments on Schiirmann’s method. He
points out that Biach instituted researches on eighty cases, and is of
opinion that the method has no practical value. In Turchi’s observa¬
tions, which are tabulated in four tables, the Schiirmann and Wassermann
methods were used simultaneously. It was found that the chromatic
phenomena may happen in the way demonstrated by Schiirmann, but
Turchi’s conclusion is that Schiirmann’s method, as a means of sero-
diagnosis in syphilis, is not acceptable in practice. It does not give
either constant or specific results, and, as now employed by the author,
cannot be accepted as a substitute for Wassermann’s reaction.

Hamilton C. Marr.

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1910.] CLINICAL PSYCHIATRY AND NEUROLOGY. 361

Cholesterin in the Cerebrospinal Fluid of Paralytics and its Participation
in the Reaction of IVassertnanti [La coles/erina nel liquido cefa/o
rachidiano dei paralylici e sua participazione alia reazione di
IVassermanu]. {Extractfrom Reforma Medial, anno xxv, No. J.)
Pighini, G.

In a recent work, Pighini has demonstrated that cholesterin has, in
an emulsion of nervous substances, the properly of hindering the
haemolytic properties of lecithin and specific sera.

Starting with the hypothesis that in the cerebro-spinal fluid of general
paralytics and in extracts of syphilitic foetal liver the antibodies and
antigens in the well-known phenomena of VVassermann contain as their
chief elements cholesterin, the author has made a research embracing
the examination of various ependymal fluids and sera in several mental
diseases.

Cholesterin is present in alcoholic extracts of the liver of a syphilitic
foetus in much greater quantities than it is in the extracts of normal
liver. Traces of cholesterin are present in normal blood, and are
probably derived from the destruction of red blood-corpuscles, the
stroma of which contains it in notable quantity. The amount diffused
normally by blood ought to be slight. In ethereal extracts of 20 to
30 c.cm. of serum, the author has not succeeded in showing its presence,
either by Liebermann’s reaction or by microscopical examination for
crystals. Cholesterin is not normally present in cerebro-spinal fluid ;
when present it is pathological.

The method followed in the researches is the following : Eighteen to
20 c.cm. of cerebro-spinal fluid, or of serum, are extracted twice with
ether, using a glass vessel. The ethereal residue is disengaged by
boiling in absolute alcohol, and saponified by shaking in sodium alco¬
holic solution (1 gr. of metallic sodium in 20 of absolute alcohol). The
alcohol is then evaporated, salted water is added and mixed, and the
liquid is evaporated to dryness. As a result salts are precipitated,
which are powdered with a pestle and completely dehydrated in vacuo.
The extracts are now placed in a Soxhlet apparatus and equal parts of
absolute alcohol and ordinary boiling water are added. This mixture is
reduced to small volume and left to crystallise slowly. In the alcoholic
extracts thus obtained an oily, yellow substance is always present, which
has avoided saponification, and which smells strongly of paracresol. It
is soluble in all the solvents of cholesterin. When in small quantities
it does not disturb the reaction and crystallisation. It is a substance, or
rather, a mixture, which has been demonstrated chiefly by Panzer in his
process of isolating cholesterin from various pathological organs. If it
is desirable to avoid this in great part it is necessary to clear with neutral
acetate of lead.

Cholesterin, when it is in sufficient quantity, is precipitated in long
rhomboidal crystals, with characteristic angles—76‘3 or 87'3—or else
in small traces (0 001), with the reaction of Liebermann. When it is
not possible to obtain at once a sufficient quantity of cholesterin, such
as can be demonstrated microscopically, satisfactory results, especially
for serum, may be got from the reaction of acid anhydride.

The cases investigated were ten of progressive paralysis, seven of

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dementia prascox, five of epilepsy, two of apoplectic dementia, two of
pellagra, two of moral insanity, and one case of alcoholism recovered.

The researches show—

(1) That normally cholesterin does not exist in the cerebro-spinal
fluid and in the serum.

(2) Eight out of ten cases of general paralysis had cholesterin in the
ependymal fluid, i.e., 80 per cent. In five of these eight, crystals were
demonstrated. In the two cases with negative results, the paralysis was
of many years’ standing, and in the last phases of the malady. In the
serum the research was positive in 90 per cent, of the cases.

(3) In seven cases of dementia praecox, five, or 57 per cent., showed
cholesterin in the cerebro-spinal fluid. In the serum it was not demon¬
strated in any case. The reaction is more intense in catatonic forms,
and in these cases crystals are very easily obtained.

(4) Five cases of epilepsy were examined, and a positive reaction was
obtained in three cases, 60 per cent., both in the cerebro-spinal fluid
and in the serum. All three cases were those of marked epileptic
dementia, or approaching dementia, and in which fits occurred daily.

(5) In the two cases of apoplectic dementia and in the two of
pellagra, negative findings resulted in the cerebro-spinal fluid as in the
serum.

Pighini’s conclusions are that cholesterin is present as a pathological
constituent in the cerebro-spinal fluid of cases of progressive paralysis,
grave cases of dementia praecox and of epilepsy. It may also be present
in abnormal quantities in the serum of general paralysis and marked
epilepsy. It is probable that the prevailing active substance in the
alcoholic extracts of the cerebro-spinal fluid and serum used in the
researches of Wassermann is cholesterin. Hamilton C. Marr.

A Contribution to the Serum Diagnosis in Syphilis [A proposito di “ una
propaggine della sierodiagnosi della sifilide ”]. {Riv. di Patol. nerv.
ement., vol. xiv, Fasc. 7, 1909.) Tommasi, C.

This paper deals with the method of Campana, which suggests as a
specific reaction in syphilis with active manifestations special pheno¬
mena which are obtained from urine mixed with lecithin (when the
urine does not contain albumen or mucus).

Campana’s method: To 10 c.c. of fresh morning urine, filtered and
collected in a well-cleaned glass, 20 drops of 1 per cent, suspension of
lecithin are added. The urine is then agitated with a clean glass rod,
which is moved rapidly from the top to the bottom of the glass until a
homogeneous mixture is obtained. Three c.c. of a mixture of absolute
alcohol and sulphuric ether, recently prepared, is added and mixed in a
similar manner. The glass is then put vertically on to a support. It is
noticed that the ether at first rises to the surface, and, if the urine is
normal, the mixture remains opalescent. If the urine is that of a
syphilitic person with active manifestations it changes colour, either
suddenly or in from fifteen to thirty minutes. It is also more limpid
and transparent. The reaction in this case is positive in nine times
out of ten.

Tommasi has used the method in twelve non-syphilitic, in eight
syphilitic cases, and in ten cases of general paralysis. He finds that

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the reaction gives constant enough findings in syphilis with active
manifestations, primary or secondary. In progressive paralysis the
findings are not reliable, and are inconstant in the same individual.

Hamilton C. Mark.

4. Pathology of Insanity.

Six Cases of Traumatic Encephalitis Cas d'encephalite traumatique\

{Bull. Soc. Clin. Med. Merit. y Nov., 1909.) Marie andDavidienkow.

This paper records the pathological findings in six cases of insanity
following head injury. In four of the cases, the type of insanity was
general paralysis, in one senile dementia, and in the other dementia
praecox. In all, the site of injury was in the neighbourhood of the right
temporal lobe, and the authors point out that this region is one very
often injured, being exposed and fragile. The general paralysis
followed the trauma at intervals varying from seven to thirteen years.
In three of the paralytics there was a history of syphilis, and the fourth
gave the Wassermann reaction. While the diffuse lesions were those
characteristic of the dementia or paralysis, as the case might be, the
local lesions were almost identical in all. They were superficial
erosions, or excavations, whose bases and edges were formed of neuro¬
glial scar-tissue. They are probably due to haemorrhages, with necrosis
of the superficial layers of the cortex, and the absence of blood-pigment
in the cicatricial tissue is due to the fact that the pigment is completely
absorbed after some years. Koppen has insisted on the exclusively
traumatic origin of such lesions. According to him, whenever we find
small cavities or superficial cicatrices (especially if these are on the
bases of the hemispheres, or on the upper surface of the temporal
lobes), we can be sure that we are dealing with lesions of traumatic
origin. The paper is illustrated with twelve figures.

W. Starkey.

Causes of Death and Anatomico-Pathological Findings in the Insane [ Uber
die Todesursachen und andere pathologisch-anatornische Befunde bie
Geisteskranken\. (Allgem. Zeits. f. Psychiat., vol. Ixvi, jVo. 34.)
Ganter, R.

This article is based on the results of examination of 1017 autopsies
(513 males and 504 females) which were investigated from 1880 to 1904.
The cases are grouped clinically as follows : General paralysis, 299 (224
males, 75 females); dementia pnecox, 233 (98 males, 135 females);
presenile disturbances, 77 (18 males, 59 females); senile dementia, 204
(75 males, 129 females); imbecility, 50 (20 males, 30 females); epilepsy,
87 (48 males, 39 females); recurrent insanity, 20 (2 males, 18 females);
trauma 15 (13 males, 2 females); alcoholic insanity, 11 males; puer¬
peral insanity, 12 females; tumour, febrile conditions, etc., 9 (4 males,
5 females).

The causes of death are set forth in tables showing the percentage of
the different causes in each of the several mental conditions. Most of
the patients died of diseases of the lungs (244. percent.). Tuberculosis
is next in frequency (i9'8 per cent.). In dementia praecox (45 per cent.)

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imbecility, and presenile disturbances the figures show that tuberculosis
predominates. In paralysis and epilepsy death is chiefly assigned to
fits, and in senile dementia to pneumonia.

Hamilton C. Marr.

5. Treatment of Insanity.

New Bromine Preparations for the Treatment of Epilepsy [Neuere Brom-
praparate in der Epilepsiebehandlung]. (A/legem. Zeits.f Psychiat.,
vol. Ixvi, No. 1.) Haymann.

At the thirthy-ninth meeting of the Sudwestdeutschen Irrenarzte in
Karlsruhe on November 7th and 8th, 1908, Dr. Haymann, of Freiburg,
spoke on the use of different preparations of bromine in the treatment
of epilepsy. For years experiments have been made with the object of
discovering a preparation to take the place of bromide of potassium, so
as to avoid bromism. Many of the preparations tried were useless ; they
either contained too little bromine or were absurdly expensive. Experi¬
ments have been carried on in the Freiburg Psychiatric Clinique with
the newer preparations—brominin, neuronal, bromglidine, and sabromin.
As a result sabromin is recommended for the treatment of epilepsy
in all cases where the bromides of potassium cannot be used, with the
exception of temporary excited conditions.

Further details are to be published in the Aledizinischen Kiinik.

Hamilton C. Marr.

6. Sociology.

The Value oj the School as a Preventive of Criminality [Sull’efficacia
della scuola nella lotta contro la criminality. (II Manicomio , vol.
xxv, Nos. 1 and 2, 1909.) Bianco and Gandolfi.

This paper is a critical review of the question whether education is
preventive of crime. The authors point out that a great change has
come over informed opinion since the time when Guizot coined his
famous epigram that the opening of a school meant the closing of a
prison. So far from this optimistic prediction having been realised,
we now seen that in almost every country the spread of education has
been attended with an increase in the amount of criminality; and those
who defend the obscurantist thesis are able to quote statistics showing,
as do those of Joly for France, that the wealthier and the better educated
classes have a higher rate of criminality than the poorer and more
ignorant, or they can even claim that in some countries, as, for instance,
in Portugal, the least criminal members of the community are those
who are most illiterate. While admitting the increase in criminality,
and admitting, too, that there has also been an upward movement in
prostitution (as to this the statistical evidence is not clearly indicated),
in suicide, and in insanity, the authors dispute the conclusion that this
is to be attributed to the coincident spread of popular education, and
they argue that the facts are to be explained with more probability when

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we take account of the growth of industrialism and of town life during
the same period. As confirming this view, they point out that in Italy
the increase in juvenile crime has been shown to keep pace with the
increased employment of children and young persons in factories.

On the other hand, the writers of the paper freely admit that popular
education as at present organised is not to any appreciable degree a
moralising influence. Possibly it could only be so to a limited extent
under any condition, as the effect of circumstances on character is
practically confined to modifying its expression, and cannot alter its
nature; but at all events a better attempt might be made to give moral
education and to develop the emotions as well as the intellect. To
attain this object, it is suggested that in addition to reorganising the
schools it would be necessary to absorb into them more of the life of
the children, so that they should become places of recreation and
amusement as well as of instruction. In this way the child would be
withdrawn from the influences of the home and of adult society, which,
reflecting as they do the economic spirit of the moment, tend to foster
criminal tendencies. W. C. Sullivan.

Sexual Education and Nakedness. (Artier. Journ. of Psychol., July, 1909.)

Ellis, H.

This paper, which is designed to form a chapter in the final volume
of the author’s Studies in the Psychology of Sex, deals with the psycho¬
logical and ethical influence of familiarity with nakedness.

Public opinion on this subject has varied greatly from period to
period. In Sparta, women practised dancing and gymnastics naked,
and in the presence of men—a custom strongly approved and advocated
by Plato. The Romans, on the other hand, regarded nudity as a
licentious indulgence only to be permitted on the stage. Christianity,
both early and recent, has tended to adopt a similar view. The primi¬
tive Church, in its desire to fight against the “ flesh,” fell into the error
of confusing the subjective question of sexual desire with the objective
spectacle of the naked form. There can be no doubt of the fact that it
is the adorned body, not the naked body, which acts as a sexual
excitant. Later, Christian missionaries have insisted, almost with
ferocity, on natives adopting the clothing of Europe. It is this false
feeling about nakedness which leads to the development of prudishness.

Nudity was, in mediaeval times, practised to a considerable extent in
public baths, etc.; but during the nineteenth century the revolt against
it has been almost completely victorious. Its advocates have, however,
never entirely disappeared, and in recent times a steady movement in
its favour has made itself felt.

Nakedness was upheld for its aesthetic value by Stratz, but the
majority of nineteenth century advocates have adopted the hygienic
standpoint. Rikli established air- and light-baths more than half a
century ago, and sun-baths are now common in Germany.

Those educationalists who are equally alive to sanitary and sexual
considerations support the claims of nakedness as part of both physical
and moral hygiene. Nakedness makes for the health of the body.
Wherever primitive races have abandoned nakedness for clothing, at
once the tendency to disease and degeneracy notably increases—though
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other factors certainly enter into this. Familiarity with the sight of the
body abolishes petty pruriencies, trains the sense of beauty, and makes
for the health of the soul.

There is still a wide difference of opinion as to the limits to which
the practice of nakedness may be carried, and also as to the age when
it should begin to be restricted.

Gerhard points out that in this, as in many other matters of sexual
enlightenment, it is the adult who needs education far more than the
child. Parents educate their children in prudery, and flatter themselves
that they have thereby promoted their modesty and morality. Forel,
in his Die sexuel/e Frage, adopts the same point of view.

The intense absorption of thought in the minds of many boys and
girls concerning the physical conformation of the other sex, and the
time they devote to the solution of this problem, is not generally
realised. The fact that such matters are generally regarded as being in
some way “ wrong,” and that therefore thoughts relating to them must
be kept secret, tends, of course, to produce sexual excitement. If the
knowledge were gained openly, no unwholesome results would follow.

Some progress in the desired direction is certainly being made. Not
many years ago an English actress regarded as a calumny the statement
that she appeared on the stage barefoot, and obtained substantial
damages in an action at law. This is scarcely possible to-day.

James Hinton has “sought to make clear the possibility of a positive
morality on the basis of nakedness, beauty, and sexual influence,
regarded as dynamic forces which, when suppressed, make for corrup¬
tion, and when wisely used serve to inspire and ennoble life.”

Bernard Hart.

Tuberculosis in the London County Asylums. ( L.C.C. Arch, of Neurol,
and Psychiat., vol . iv, 1909.) Mott, F. IV.

In this interesting and important paper, Dr. Mott concludes from his
researches that the evidence adduced does not support the contention
that infection is one of the strongest causative elements in the prevalence
of tuberculosis in the London County Asylums. Still less does it sup¬
port the view that the causes of tuberculosis inhere in the asylums
themselves, and not in the character of the patients sent to them.
Ward incidence is not comparable with that shown by dysentery. If
tuberculosis is communicable, it cannot be regarded as an infectious
disease in the same sense as dysentery, smallpox, scarlet fever, etc.

The average proportion of living patients reported as tuberculous is
20 per 1,000 inmates. The incidence varies from io - 6 in Cane Hill
to 40'3 in Claybury. With respect to the association of tuberculosis
and mental disease, Dr. Mott comes to the conclusion that young sub¬
jects suffering from melancholia, dementia praecox, and imbecility are
specially prone to the disease. This conclusion is confirmed by post¬
mortem statistics. A large number of general paralytics die with recent
active tuberculosis which is not diagnosed during life. There is a
relatively larger number of female general paralytics compared with male
general paralytics affected by tuberculosis. Dr. Mott ascribes this state
of affairs to the social conditions under which a large number of female
general paralytics live prior to admission. Exposure to cold and wet,

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insufficient nourishment, poverty, overcrowding, and alcoholism, com¬
bined with an inborn mental and physical deficiency in a considerable
percentage, produce a suitable soil for the development of tuberculosis
in the female sex.

In i4 , 8 per cent, of the autopsies made at the London County
Asylums during the past five years, active phthisis was found. It
cannot be shown that the variation in the incidence of tuberculosis in
the various London County Asylums depends in any measure upon the
class of patients received, the parishes from which they are taken, the
construction and age of the asylums, or the dietary or treatment.

Comparing the death-rate for 1907 at the several age-periods in the
sane and insane, the mortality from phthisis among the insane is highest
at a much earlier period than among the sane. At the age-period of
forty-five to fifty-five, when it reaches its maximum among the sane, it
is a question whether the incidence among the insane is much greater
than among the sane pauper population. The death-rate from
phthisis for the insane from the age of fifteen to thirty-five is about five
times that for the sane of the same age-period. The Jewish population
at Colney Hatch (mostly aliens) shows a higher death-rate (257 per
cent, of the total deaths) from tuberculosis, than the Christian. Dr.
Mott accounts for this by the fact that Jewish patients are generally
composed of aliens who have not been long in this country. They come
from Russia for the most part, where they and their progenitors
have lived in great pauperism and degradation, and, therefore, unlike
the prosperous Jews whose progenitors settled in this country generations
back, have already the seeds and soil of consumption in their bodies
when they arrive in this country.

It is of special interest that the several London County Asylums
officials do not contract tuberculosis from the patients.

From 1,892 necropsies made in Claybury during the past ten years,
active phthisis was found in 20-9per cent., and the post-mortem statistics
for the past ten years show that 51 "6 per cent, of all the patients exhibited
either obsolescent or active tuberculosis, or both. It was inferred from
the post-mortem examinations that no less than 10 per cent, of the
cases in active phthisis at autopsy could have acquired the disease in
the asylum.

Infection of the disease depends upon dosage and resistance.

Dr. Mott concludes that the preventive measures against tuberculosis
are good in the London County Asylums as regards milk, food, personal
cleanliness, ventilation, clothing, warmth, and exercise in the open air,
and the liability to infection is less than in the houses from which the
majority of the insane are taken. He suggests the following additional
measures, consistent with proper and due economy :

(1) The earlier and more frequent diagnosis of active phthisis, with a
view to isolation and treatment.

(2) The adoption of the verandah system of open-air treatment in all
asylums.

(3) The encouragement of patients suffering from phthisis to expec¬
torate into proper receptacles, which would possibly diminish the amount
of intestinal tuberculous ulceration caused by auto-infection.

Hamilton C. Marr.

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Part IV.—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT BRITAIN

AND IRELAND.

The ordinary Quarterly Meeting of the Association was held, by the courtesy of
Dr. Rothsay Stewart, at the Leicestershire and Rutland Counties' Asylum, Nar-
borough, near Leicester, on Thursday, 24th February, 1910, Professor W. Bevan-
Lewis, M.Sc., President, in the Chair.

Present: The President and the following twenty-seven members: David
Bower, C. Hubert Bond, M. A. Collins, Thos. Draper, E. Faulkes, H. W. Hodgson,
H. Hayes Newington, Th. Johnston, H. Kerr, Richard Legge, T. McDowall,
H. J. Mackenzie, J. Rutherford Macphail, W. F. Menzies, James Middlemass,
Ch. Mercier, A. Miller, W. F. Nelis, Bedford Pierce, R. C. Stewart, R. Percy
Smith, J. G. Soutar, J. B. Spence, W. H. B. Stoddart, G. E. Shuttleworth, D. G.
Thomson, G. Scott Williamson, and several others who did not enter their
signatures.

Visitors: Mr. F. Perkins Pick, F.R.B.A., and Mr. R. L. Mackenzie-Wallis, B.A.

Apologies were received from Drs. Aveline, Beach, Bowes, Bowles, Ireland Bowes,
Briscoe, Sullen, Caldecott, Carswell, J. B. Cooke, Dawson, Dickson, Langdon Down,
Eager, Elkins, Gayton, Griinbaum, B. T. Hine, Hitchcock, Hotchkis, Robert Jones,
Lawless, Lindsay, Maine, R. M. Mcllraith, A. McDougall, W. F. and P. IV.
McDonald, Marr, Middlemass, Mtiles, Neil, Nolan, Oswald, Owen, Rainsford,
Richards, Rogers, Rowe, Sankey, Sail, Sleiger, Steele, Stilwell, Steen, Street, Sujfern,
F. R. P. Taylor, A. Turner, A. R. Urquhart, Watson, Whitcombe, E. White,
Wilkinson, Outterson Wood, Wolseley-Lewis, and Yellcnvlees.

Council attendance. —The President, and Drs. Adair, Bond, Hayes Newington,
Mercier, Miller, Mould, R. Percy Smith, Stoddart, and Vincent.

The minutes of the last Meeting having already been printed and circulated in
the Journal, were taken as read, and were duly confirmed.

Election of new members. —The following four gentlemen, whose names had
appeared on the agenda, were balloted for and elected as ordinary members:
Bartlett, George Norton, M.B., B.S.Lond., M.R.C.S., L.R.C.P., Assistant Medical
Officer, London County Asylum, Bexley (proposed by E. Faulks, G. Clarke, and
C. Hubert Bond); Walters, John Patrick, M.B., B.Ch., B.A.O.(R.U.L), Assistant
Medical Officer, District Asylum, Melton, Suffolk (proposed by James Whitweil,
S. G. Longworth, and C. Hubert Bond); Wilson, James, M.D., Ch.B.Glasg., Senior
Assistant Physician, District Asylum, Hartwood, Lanarkshire (proposed by Neil T.
Kerr, C. J. Shaw, and G. Dunlop Robertson); Younger, Edward George, M.D.Brux.,
M.R.C.P.Lond., M.R.C.S., L.S.A., Physician to the Finsbury Dispensary),
2, Mecklenburgh Square, W.C. (proposed by H. C. MacBryan, G. F. Barham, and
C. Hubert Bond).

Asylum Officers’ Superannuation Act, 1909.

Dr. Hayes Newington laid before the meeting the following Report of the Joint
Advisory Committee:

Report of the Joint Advisory Committee.

The Report of the Joint Advisory Committee, appointed by the Medico-Psycho¬
logical and Asylum Workers’ Associations, to consider the Superannuation
Act, and to suggest, from the experience of the Associations, the best way of
meeting any doubts or difficulties that might present themselves.

The Committee had before it the shorthand notes of an informal meeting held
at 11, Chandos Street, on December 20th, 1909, for the same purpose. This
meeting was attended by several medical superintendents and others connected
with asylums. Free discussion of the whole Act was held, and various points

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were raised. These and other fresh ones have been further considered by the
Committee at later meetings. At all meetings Mr. Keene, Clerk to the Asylums
Committee of the London County Council, was present, and gave the Committee
assistance, information, and advice which were found to be very helpful.

Classification of established officers and servants ("Sects. 1 and IJ — interpretation).
—The Committee recognises that the language of the Act very much narrows its
opportunity of offering any suggestion on the assignment of officers to one or the
other of the two classes constituted. It is also seen that the discretion in the
partition of the staff, which is absolutely in the hands of the various visiting com¬
mittees, with the consent of their local authorities, must turn, for the purposes of
Sect. 1, on the meaning to be assigned to the expression, " have the care or charge
of the patients in the usual course of their employment." Incidentally this expres¬
sion will affect the other partition of staff into "established” and the residuum,
as contemplated by Sect. 17. Looking to the definition of “ established," it would
seem to be contrary to the Act to place in the residuum any officer or servant who
has the care or charge of patients in the usual course of his employment.

The Committee cannot suggest anything like a model classification, since while,
as to the holders of certain offices there can be no doubt about their right to enter
Class I, the varying duties appertaining in different asylums to other offices,
bearing the same name generally, make it impossible to treat the occupants by
fixed method. For instance, a case was stated to the Committee where laundresses
did the whole work of the asylum alone, while in almost all others the laundresses
have the responsible and trying care of patients in their work. In the latter case
the care and charge of the patients is " in the usual course of their employment,”
for they would not be engaged unless they were prepared to assume such charge.
The same argument may be extended to almost all, if not all, the doubtful cases
where similar conditions obtain. The Committee wishes to point out that as to
many patients who are set to work, it is impossible to say that they will not cause
trouble at any time when working by reason of their insanity; while in acute
cases, in whose interest work under care other than that of attendants is neces¬
sarily prescribed for the promotion of recovery, such care involves serious responsi¬
bility, which has to be taken as part of the " usual course of employment."

The Committee further points out that, in the opinion of those who have
intimate knowledge of the working of an asylum, there are very few officials who
have not in some way or other the " care or charge of the patients.” Indeed, the
rules of the asylum itself impress on every official, from the highest to the lowest,
his responsibilities at all times and under all circumstances in regard to the
inmates. This in itself constitutes a material difference between the onerousness
of asylum service and its counterpart elsewhere. It is therefore felt that all such
responsibility should be recompensed by assignment of the benefits of Class I,
without which service with responsibility of a personal nature would be on the
same footing as that of a poor law or civil servant having no such responsibility.

The Committee thinks that the term " permanent" in the definition of estab¬
lished officer or servant in Sect. 17 should not be considered to necessarily exclude
officers and servants whose office is regarded as likely to be held by the occupant
as long as he fulfils the duties of the office, whatever may be the terms of his
engagement.

Time of actual commencement of service for the purposes of the Act. —Some
questions arise as to this. In England, at least, the appointment and removal of
officers and servants is entirely in the hands of the visiting committee, who meet
so many times each year. The engagement of the lower orders of officers is, for
convenience, performed by the medical superintendent, but subject to confirmation
by the committee at its next or some succeeding meeting. Until such confirma¬
tion the officer might not be regarded as an established officer, but this point would
be determined by the terms of his engagement. His pay, however, commences to
accrue from the actual date of his beginning to serve, and, if he comes under the
Act, contribution must be deducted. This question, which is a small one in this
instance, assumes larger proportions when probation (in some cases lasting some
months) is a sine qud non. It seems necessary that a committee should provide
for such a contingency. As, in case the probationer is found to be inefficient, the
committee have power under Sect. 10 to return contributions on giving him notice
to leave, all difficulty in regard to the latter ceases. In the matter of actual length

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of service, any loss of time in the computation of service would be small in the
case of those who serve up to the stipulated age. But in case of a claim either
under Sect. 2 (i and 2), or under Sect. 6, the time lost, should it be held that a
probationer is not an established officer, might just debar him from justifying the
claim on ten years’ service under the former, and from aggregation under the
latter.

Again, should the probationer not be held to be on the establishment, great
hardship would arise in the case of those on probation at the commencement of the
Act, Sect. 20 (i and 2). It is suggested that to avoid this hardship in such case it
would be wise that the committees should place all probationers on the established
list on or before March 31st, 1910.

It is to be noted that the probationer, unless he is an established officer, will not
benefit by Sect. 2 (4).

Aggregation of service. —It has been suggested to the Committee that a plan
should be formulated, for general agreement by visiting committees, to facilitate
the collection of contributions from an asylum liable to pay a proportion of any
superannuation grant. It is possible that the Secretary of State, who would have
to intervene in the event of disagreement between two visiting committees, will be
asked to express an opinion upon such a scheme. It seems hardly necessary to
suggest that in every case of the removal of an officer or servant from one asylum
to another a formal certificate should be obtained by the receiving asylum ; such
certificate to state not only the exact length of service, but also its nature and the
class to which the applicant belonged in respect of the division made by Sect. 1.
It is suggested that this certificate should bear on it the written sanction of the
Committee to the removal.

It was stated to the Committee that a legal opinion had been given that the words
"first asylum ” in line 8 of Sect. 6 should be read as “ every asylum except the
last." It is pointed out that, while there is ample power to enforce the payment
of contributions from an asylum in respect of superannuation allowance, there is no
such power in respect of the return of contributions under Sects. 5 and 10. In the
former and in the second sub-section of the latter the Committee has discretion as
to the return. In Sect. 10 (1) there appears to be no discretion.

Source of superannuation allowance payments. — Sect. 12 presents, at first
sight, some difficulties. The object of the section is to provide the “ ways and
means ” of paying superannuation allowances which heretofore have been paid out
of the county or borough or analogous funds. Allowances granted under the new
Act are to be provided out of the “ asylum maintenance” funds, and it was there¬
fore necessary to extend the operation of Sect. 283 of the Lunacy Act, 1890, so as
to include pensions, etc., as part of the expenses of the " weekly sum ” payable by
Guardiansand otherbodiesforpatientschargeable to them. There appears, however,
to be some inconsistency in the statement that the allowance is to be “paid out of
the fund out of which the salary or wages and emoluments of the officer or servant
is or has been paid,” and the further direction later on that the weekly sum shall
be sufficient to pay all such superannuation allowances, etc., etc. The words “ paid
out of the fund, etc., etc.” were inserted as an amendment in the House of Lords, and
the intention was to introduce them at the end of the section as a proviso, in which
case there would have been less ambiguity. The object of the provision was that
in the case of pensionable men working on “ repairs ” the local authority should
pay the pension as they do the wages. It is suggested that the apparent contra¬
diction may be met by reading after “all sucb superannuation allowances or
gratuities” the further words—“for which the maintenance fund may be liable.”
Or it may, perhaps, be contended that although the weekly sum is to be sufficient
to pay in the first place all pensions, this does not prevent recovery from the local
authority of sums paid in pensions to "repair” men.

A question has been raised on this section in connection with the emolument of
a house or lodging, whether such being provided out of the local authority’s funds,
a proportionate part of the pension (as represented by the house or lodging) is pay¬
able by the local authority out of tbe county or borough fund. It is thought that
the interpretation of the word " emoluments ” must be, in this connection, limited
to emoluments which involve payments to an officer, such as are specially referred
to in Sect. 16. A house or lodging would come under the expression of “ money
value,” not" payment ” ; and therefore such proportion of the pension as is repre-

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sented by the house or lodging would be properly payable out of the fund liable
for payment of salary or wages.

Contracting out. —The Committee was informed that the practice under the Poor
Law Officers’ Superannuation Act is that a person contracting out can never come
in again. It is thought that an asylum officer or servant contracting out under
Sect. 20 would be debarred for all time from benefitting under the Asylum Officers’
Superannuation Act. It is hardly necessary to emphasise how important it is for
asylum officials to consider their position in this connection.

Position of non-establisked officers and servants appointed after April 1 st, 1910.
—It appears that such officers and servants will have no right to any pension either
under the Lunacy Act or the present Act, the superannuation clauses of the former
having been repealed, except in favour of those actually in the service at that date.
This fact will doubtless be borne in mind by asylum committees before determin¬
ing who shall not be established officers and servants.

Schedule of value of emoluments. —It has been suggested to the Committee that
there is nothing to prevent this schedule being placed in conspicuous parts of the
asylums in sections, should it be found desirable to do this.

H. Hayes Newington (Chairman).

G. E. Shuttleworth (Hon. Secretary).

Papers.

Mr. Mackenzie Wallis, B.A.Cantab., from the Physiological Laboratory’
University College, Cardiff, and Dr. Edwin Goodall, F.R.C.P., Cardiff City
Mental Hospital, read a paper entitled, “ Electric Bath Treatment in 120 Cases of
Mental Disorder ; with Results of an Experimental Inquiry into the Influence of the
Baths upon Excretion of Creatinine in Certain of Them.”

The paper was illustrated by lantern-slides, and excited very lively interest.

In a good discussion which followed, the President, and Drs. Percy Smith,
Scott Williamson, Bedford Pierce, and Stoddart took part. The Secretary
read a communication from Dr. Robert Jones, detailing some experiences of the use
of an electric bath at Claybury.

The authors replied.

‘‘Typhoid Carrier Infection” was the title of a paper read by Dr. Scott
Williamson. It was commented on by the President, who added some
interesting allied reminiscences.

The Next Census.

Dr. Bond said the President had asked him to mention a matter which came up
at the Council Meeting. Some time ago Mr. Byrne wrote from the Home
Secretary’s office asking if the Association would consider whether they thought,
in reprinting the next census form, which would need to be done soon, the present
column asking for information of every family as to whether they had any imbecile
or feeble-minded member of it need still remain in, having in view the fact that the
medical inspection of all school children was now compulsory. It was evidently in
the minds of the Home Office that that compulsory school examination made it
unnecessary to inquire in future as to whether there were any imbeciles or
feeble-minded persons in the family. The matter had been discussed by the
Council, who were of opinion that the column ought to be retained, but, as there
was a somewhat small Council attendance, it was thought best to ask for the views
of the Association on the subject.

Dr. Percy Smith said there must be a large number of families the children of
which did not attend county schools in which there were inspectors. He did not
think there were inspectors in all the private schools in the country. The column
in question was put into the form with the object of ascertaining the sort of pro¬
portion there was of cases of the kind in the country, and he did not think it
would be right to omit it now. The answer to the letter, he thought, should be
that there were not, otherwise, sufficient data to enable a positive answer to be
given to the question, and that they therefore were of opinion that the column
ought certainly to be retained.

This was agreed to, and the meeting terminated.

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Previously, during the day, members had been shown over the asylum by the
architect, Mr. Perkins Pick, F.R.B.A.

In the evening a well-attended dinner was held at the Royal Hotel, Leicester, at
which there were several visitors from the neighbourhood, including Messrs. H. P.
Rodgers, Vice-Chairman of the Narborough Committee of Visitors; Geo. Rowlatt,
Under-Sheriff for the county; Geo. Chitham, Mayor of Leicester; C. J. Bond,
F.R.C.S., Mr. Perkins Pick, Drs. Astley Clarke, Pope, Macalister-Hewlings,
Langworthy Laurie, and G. C. Franklin.

Dr. Astley Cooper kindly showed the members round the newly built and
equipped Nurses’ Home at the General Infirmary.

IRISH DIVISION.

The Autumn Meeting of the Division was held at the Royal College of Physicians,
Dublin, by the kind permission of the President and Fellows of the College, on
Saturday, November 6th, 1909, at 2.30 p.m. Dr. Hetherington was voted to the
Chair, and there were also present Drs. T. Drapes, G. F. Shepherd, R. R. Leeper,
T. A. Greene, J. O’C. Donelan, M. J. Nolan, J. J. Fitzgerald, J. Mills, Dora Allmann,
H. M. Eustace, J. M. Redington, and W. R. Dawson (Hon. Sec.). Expressions of
regret for inability to attend were received from Drs. P. O’Doherty, F. O'Mara,
O. F. McCarthy, and W. Graham.

The minutes of last meeting were read, confirmed, and signed, and the Hon.
Secretary reported shortly on certain matters arising out of them.

The following was unanimously elected an ordinary member of the Association -.

John P. Cahir, M.B., B.Ch., B.A.O., R.U.I., Assistant Medical Officer, District
Asylum, Ennis. Proposed by Drs. F. O’Mara, J. M. Redington, and W. R.
Dawson.

The kind invitation of the Drs. Eustace to hold the Spring Meeting of the
Division at their institution was unanimously accepted with thanks.

Dr. M. J. Nolan reported on the present position of the Asylums Officers Super¬
annuation Bill, and after some discussion it was agreed that an attempt should be
made to secure certain amendments to Clauses 2 (1), 4, 11, 12, and 16. The
following resolution was then proposed by Dr. Mills, seconded by Dr. Drapes, and
passed unanimously:

“That the Irish Division of the Medico-Psychological Association desires to
express to Dr. Nolan its heartiest thanks for his untiring work in attending in
London at the different stages of the Superannuation Bill, and for his consummate
skill and tact in the matter.”

A letter was also read from Dr. W. Graham, expressing high appreciation of Dr.
Nolan’s work in connection with the Bill, and suggesting that his expenses should
be defrayed by the Division.

Dr. Nolan thanked the Members and Dr. Graham, but said that his expenses had
been in part defrayed by the Irish Asylum Officers’ Superannuation Committee, and
would be entirely so defrayed if the asylums which had not made their second con¬
tribution to the funds of that Committee would now do so.

A discussion took place at the instance of the Hon. Secretary on the desirability
of appointing a Managing Committee for the Division. The question was decided
in the negative.

The Divisional Committee for promoting interest in the work of the Association
amongst the Assistant Medical Officers of Irish Asylums presented a report
embodying suggestions with regard to the regulations for the proposed Divisional
Medals, and also expressing the view that, as no response had been received to the
invitation to send in collective reports, a further notice should be issued extending
the time until the Summer Meeting of the Division. The report was adopted.

Dr. Donelan read an account of “ A Case of Hallucinations apparently due
to Morbid Physical Conditions,” which was discussed by Drs. Leeper, Drapes,
Dawson, and Hetherington, and Dr. Donelan replied.

The Hon. Secretary read a paper entitled “ Some Points Concerning the Dia¬
gnosis and General Treatment of the Feeble-Minded." Drs. Greene, Mills,
Fitzgerald, Nolan, Leeper, and Hetherington spoke, and Dr. Dawson
having replied, the meeting terminated.

In the evening the members dined together at the Shelbourne Hotel.

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POST-GRADUATE CURRICULUM AND DIPLOMA IN PSYCHO¬
LOGICAL MEDICINE.

The two following communications have been sent to all medical examining
bodies in Great Britain and Ireland :

Sir, —I am instructed by the Committee of the Medico-Psychological Association
of Great Britain and Ireland to approach the Universities and other examining
bodies on the subject of post-graduate instruction in psychiatry.

It has long been felt by those most intimate with the subject that there is in this
country no adequate systematic instruction in psychiatry. The evils of this neglect
become year by year more and more manifest. This Association is impressed with
the urgent necessity for post-graduate teaching in psychiatry in medical schools,
and for the granting of a special diploma to candidates after examination, as has
already been done with such conspicuous success in public health and tropical
medicine. The position of psychiatry as a branch of medicine is unsatisfactory;
it is not properly affiliated to other departments of medicine, to their mutual
detriment; and under present conditions cannot make full use of those modern
methods of research which have resulted in such advances in general medicine.

Young medical men, on their appointment as medical officers to asylums, find
themselves face to face with work and problems of which they have had no previous
knowledge, and in preparation for which they can obtain no systematic and
scientific training or teaching. As is well known, lectures on psychological
medicine and pathological laboratories have been established here and there, and
in one or two universities chairs of experimental psychology have been founded;
but there is no systematic course of instruction and no recognised diploma at the
end of such course. It is submitted that the time has now arrived when such a
course and diploma should be established in the principal medical schools of this
country, and a diploma in the subject should be instituted by the examining bodies.
My Association is of opinion that the institution of a diploma would impose a high
standard of acquirement in the officers of asylums, would stimulate the scientific
study of insanity, and would have an effect in widening and deepening our know¬
ledge of the subject, comparable with the effect produced in public health and
tropical diseases by the institution of diplomas in these subjects.

In this letter it is unnecessary to enter into details as to the time required for
this post-graduate work and the subjects to be studied; probably each university
and examining body will form its own views on these points. I may say, however,
that my Association considers that the minimum period should be one year; that
provisionally the subjects should be divided into (a) compulsory and (6) optional;
that in the former should be included—(i) anatomy, physiology, and pathology of
the nervous system ; (2) psychology, normal and morbid ; (3) clinical pathology ;

(4) clinical neurology; (5) psychiatry, systematic, clinical, and medico-legal. The
optional subjects suggested are—(1) experimental psychology; (2) bio-chemistry;
(3) bacteriology; (4) comparative anatomy and physiology of the nervous system ;

( 5 ) eugenics. It is suggested that only one optional subject be required of candi¬
dates. The Council of my Association respectfully asks that its proposals may
receive earnest consideration, so that in the near future it may be possible to place
the teaching of psychiatry on a sound, scientific basis, and so bring it into line with
other special departments of medicine in this country.

I am, Sir,

Your obedient servant,

CHARLES MERCIER,

President (1908-9).

The letter of the President of the Medico-Psychological Association on this
subject has elicited many inquiries from Universities and other examining bodies
as to the intention of the Association with respect to the scope and range of train¬
ing and examination.

In response to these inquiries the following is submitted :

For many years those engaged in the practice of psychiatry have been profoundly-
dissatisfied with the lack of opportunity of teaching and training in this subject
that are available for young medical men entering the speciality. This feeling

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found expression on May 19th, 1908, when Dr. David Thomson, of the Norfolk
County Asylum, read before the Medico-Psychological Association a paper on the
subject which aroused the liveliest interest.

At the Annual Meeting, 1908, Dr. Thomson formally proposed a resolution to
the effect that a scheme of post-graduate teaching and training in the subject was
necessary, together with the institution of degrees or diplomas by the examining
bodies. A committee was appointed to consider the matter. The first result of
their deliberations was the letter to the examining bodies, which, having been
ratified by the Association at annual meeting assembled, was duly forwarded to
every examining body in the Kingdom. The Committee consisted of Drs.
McDowall, Morpeth (chairman) ; Bevan Lewis Wakefield; Whitcombe, Birming¬
ham ; Percy Smith, London; Robert Jones, Claybury; Bedford Pierce, York;
David Orr, Manchester; David Thomson, Norwich. To these were added
subsequently Drs. Stoddart, London; Rows, Lancaster; Bond, Epsom; and
Mercier, London.

It may be desirable to recapitulate the main points in Dr. Thomson’s paper:

Firstly, whereas in other special departments of medicine, such as public health,
tropical medicine, military and naval surgery, there are recognised and complete
courses of post-graduate teaching and training at some of the great medical schools,
and degrees or diplomas are given by most of the examining bodies, yet in the
special and important department of psychiatry no such course of training and
teaching, no degree except in two Universities, and no diploma is available.

Secondly, the young medical men who take up this department of medical work
do so without being trained for it; and once engaged in asylum service they are
usually too distant from centres of education and too much absorbed in routine
duties to acquire a knowledge of the prolegomena of psychiatry or of modern
methods of research.

It is to remedy this anomalous state of affairs that the Medico-Psychological
Association now approaches the examining bodies. The defects to which
attention has been drawn are felt both keenly and widely, and the Association has
confidence that the great advance in knowledge and efficiency of practitioners that
has followed the institution of degrees and diplomas in public health and tropical
medicine will be equalled by the advance that will follow the institution of degrees
and diplomas in psychiatry.

It may be fairly assumed that the Legislature will have as much reason to enact
that medical officers of institutions for the insane shall be properly trained, taught,
and qualified, as it had when it made the holding of a diploma in public health
legally essential to obtaining a medical officership of health of a town or district
containing more than a certain number of inhabitants.

From the general tenor of the discussions on Dr. Thomson’s paper it could be
gathered that, in principle, the proposal is unassailable; but the difficulties of
carrying the scheme into practical effect are considerable.

Some of the more obvious are :

(1) The isolation of many asylums and their distance from large towns and
teaching centres.

(2) Certain inherent peculiarities of asylum work under present conditions, e.g.,
enforced residence as medical officers for an indefinite number of years, celibacy,
uncertain promotion, the attitude of certain committees of management towards
the medical aspect of asylum work.

(3) The difficulties of arranging a post-graduate curriculum, part of which must
consist of holding a resident appointment in an asylum.

We believe, however, that these difficulties are not insuperable; in fact, the
Association has for many years granted, after examination, a certificate of com¬
petency in the subject, which has been sought after and obtained by many, but the
time has now come when the matter is too important to be left in the hands of a
private body.

Suggested Regulations for Curriculum and Degree or Diploma
in Psychological Medicine.

In response to its circular letter, the Association has received from various
examining bodies requests for information as to the curriculum it would propose.

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Under these circumstances the Association makes the following suggestions to
those examining bodies who have asked for guidance on the subject.

The Association suggests:

(1) That the candidate must be a registered medical practitioner of not less than
two years’ standing at the time of examination.

(2) That the candidate, subsequent to qualification, must have been in the practice
of a recognised institution for the insane for not less than twelve months, that is
to say, he must have held a whole-time appointment therein as medical officer or
clinical assistant for that length of time.

(3) That the candidate must produce evidence that he has attended, subsequent
to qualification, courses of lectures and practical instruction on the following five
compulsory subjects, or that he has otherwise diligently studied the same :

(a) Neurology : the anatomy, physiology, and pathology of the nervous system

( b ) Psychology.

( d ) Clinical neurology.

(e) Psychiatry, lectures and demonstrations on, and the jurisprudence of
psychiatry.

And on one of the following five optional subjects :

(a) Advanced psychology.

(A) Bio-chemistry.

( d ) Comparative anatomy and physiology of the nervous system.

( e ) Eugenics.

(4) That the curriculum should consist of three terms of approximately three
months each, or equivalents of these periods to suit local terms or sessions.

Having regard to the important position of neurology to the other subjects, it is
believed that it will be necessary to devote not less than one third of the time of
the extra-institutional part of the curriculum to its study.

A syllabus detailing the scope of the subjects enumerated above will doubtless
be made by each examining body, but a model syllabus is in course of preparation.

FOREIGN DIFFICULTIES.

The Standard of March 15th reports that 280 patients have been discharged
from the public asylums of Bohemia owing to financial difficulties. These
arise from political complications preventing the Budget being passed, so that the
Provincial Government has been impelled to this extraordinary course. The
criminal insane will in future be confined in prisons because they are found to be
far cheaper than asylums, and this enforced economy has also suspended all build¬
ing, and stopped all subventions to charitable institutions.

From St. Petersburg it is reported that the patients in the asylum have become
so numerous that beds cannot be found for them, and the staff is subjected to the
greatest difficulties in management. Indeed, a short notice in a German news¬
paper makes a statement of a nature implying a want of all decency and ordinary
comfort such as can hardly be believed in this country. The Lancet says that
Professor Bechtereff, President of the recent Congress of Russian Psychiatrists, has
given a similar account of the terrible position of the neglected patients, and
according to Dr. E. V. Erickson the condition of the insane in Poland is most unsatis¬
factory.

COMPLIMENTARY.

Presentation Portraits to Dr. Clouston.

A numerous company of ladies and professional gentlemen assembled in the
hall of the Royal College of Physicians, Queen Street, yesterday afternoon, on the
occasion of the presentation of portraits of Dr. Clouston, subscribed for by friends
in recognition of his long connection with the Royal Edinburgh Asylum for the
Insane. In the absence of Mr. Adam, Chairman of the Managing Board of the
Asylum, Professor Rankine presided.

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The Chairman said he occupied that position because for over twenty years, as
a Manager of the Royal Edinburgh Asylum, he had been associated with Dr.
Clouston in its administration, and during that period his feeling had been
one of ever-growing admiration for him as a physician, as a man of business
affairs and as a friend. Dr. Clouston had attained a most eminent position
as an alienist, and that his fame had gone through all the earth was well illus¬
trated by the list of subscribers to the testimonial. As an administrator
there were three noteworthy features which he would mention. The first was
the initiation of that mental pathological scheme which had done much, and
would do still more, for the advancement of psychiatric science. The second
notable event which one liked to recall was the smooth way in which the very
onerous contract with the Poor-law authorities of Edinburgh was altered into the
agreement upon which the matter now rested. That agreement was largely due
to the good sense of the Parish Council of the time, but it owed its initiation and
most of its success to the diplomacy of Dr. Clouston and the late Mr. Ferrier, who
was then parochial inspector. But above all, tangibly, at least, Dr. Clouston's
monument rested on Craighouse, that magnificent pile of buildings which was unsur¬
passed by any in the Kingdom. The best proof of the success of the scheme and
of the prescience of Dr. Clouston was that while he began in the East House in
1873 with sixty paying patients and a bare income of £8,600, when he left the
institution there were at Craighouse 220 paying patients and an income of
£35,000; and better still, from the business boint of view, the huge debt which lay
upon the scheme was disappearing with most gratifying regularity. (Applause.)
It was a very sad hour to the managers when two or three years ago Dr. Clouston
intimated his intention to retire. At the same time, they felt that, after a career
of thirty-five years as superintendent of the Asylum, Dr. Clouston had well earned
a period of comparative repose, and they all hoped he might long continue
among them, not an idle man, but not tied down to the daily care of a great insti¬
tution. (Applause.) Of Dr. Clouston personally, he would only say that it
astonished the managers to see the buoyancy and cheeriness which he brought to
bear upon what must have been at times depressing work. (Applause.) He con¬
cluded by calling on Principal Sir William Turner to unveil the portraits.

Sir William Turner said he might call attention to one or two points in
Dr. Clouston’s career which had assisted him largely in attaining the position of
a great specialist. His acquaintance with Dr. Clouston dated from 1861, the year
in which he took the degree of Doctor of Medicine in the University of Edinburgh,
and presented a thesis for the excellence of which he was awarded by the Faculty
of Medicine the gold medal. It was a thesis on " The Anatomy and Physiology
of the Nervous System in Invertebrate Animals.” In that year the youngest
pathologists and physiologists had been doing their best to unravel the mysteries
of the nervous system, a task of great difficulty, because the methods then in use
were crude to a degree. He (Sir William) drew from that thesis and its subject
the moral that Dr. Clouston’s mind, in his early professional life, was bent on
a certain kind of medical research—an inquiry into the nervous system and its
functions. At that early period he recognised the line which he should follow in
his professional career, and they were there to testify how well he had followed it.
Shortly after obtaining his degree he was appointed one of the assistants of the
Morningside Asylum, and in 1873 he became the physician superintendent. In
1879 he was appointed the sole lecturer on mental diseases to the University of
Edinburgh, and that marked another very important advance in his career, because
he could combine with his work as a teacher his practical experience as the head
of the great Edinburgh asylum. It was a great point in medical education that
with the theoretical instruction there should always be combined the practical
methods in applying theories in the elucidation of disease. Dr. Clouston was,
therefore, in a position to become a great teacher of his subject and a great trainer
of physicians who were to take up as their practice mental diseases. They all
knew how well he had succeeded in his theoretical and practical teaching. No
man had trained so many who had been and who were still superintendents of
asylums as Dr. Clouston, and they had in these pupils practical illustrations of
what his power was over the young men who came under his charge. There was
another point bearing upon Dr. Clouston’s scientific work, and that was his power
of illustrating his ideas by his pen. His professional brethren recognised that

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He was for some years the editor of their official journal, he was appointed
President of the great Association which represented that branch of the profession ;
he was also President of the distinguished College in which they were assembled,
and he produced from time to time writings which attracted attention, lectures on
mental diseases, mental hygiene, and other works. But he thought in the main
some of the most remarkable products of his pen were his annual reports on the
work done at Morningside, which were always read with the greatest care, not only
by the physicians, but by the public, because there was usually a moral in each
report which the public were asked to consider and give effect to. The Chairman
had referred to the depressing influence of Dr. Clouston's work, but there was
always a cheery optimism about him. He liked to look at the bright side of his
patients’ cases, and that, no doubt, had an important influence on those who came
under his care. (Applause.)

The portraits were then unveiled amid applause. Both are admirable works of
art by Mr. Fiddes Watt, representing Dr. Clouston in familiar attitudes, and afford¬
ing a striking likeness of the subject. The larger picture, a full-length portrait in
medical gown and hood, is to be hung in the hall of the asylum, and a three-
quarter portrait, showing Dr. Clouston in ordinary morning attire, is a personal
gift to the doctor.

The Rev. Dr. Fisher, on behalf of the managers of the asylum, accepted the
custody of the larger portrait.

Dr. Clouston, in returning thanks for the gifts, said he was appointed to the
Carlisle Asylum as a sort of boy physician at the age of twenty-three, the youngest
ever appointed to that position. When he was appointed to Edinburgh at the age
of thirty-three his experience was no doubt deficient, but he had fairly high ideals,
and he had enthusiasm, and, as the Chairman had indicated, an almost unbounded
optimism. An optimist he had lived, and an optimist he hoped to die. He was
most anxious, in the interest of the patients, that the institution should be brought
up to the highest position attainable, and he had also the ambition, which he
thought they would not blame him for, to make the hospital for the insane at
Morningside one of the great circle of educational, medical, and philanthropic
institutions which the capital of Scotland possessed. (Applause.) They were all
aware that mental disease, through a series of unfortunate accidents, as it were, and
partly from its very nature, was regarded with quite an undeserved feeling of
repugnance and want of interest; and to take away what, in certain respects, one
might call the reproach of mental disease was one of his intense ambitions. In his
annual reports he did try to secure that, and he believed the reproach was now
dying out, and that insanity was coming to be regarded with no other feeling than
one of the utmost sympathy. His ideal was to connect his administrative duties
with the scientific study of brain and mental disease, and his opportunity of
lecturing to nearly three thousand students in the University was a perpetual
incitement to himself and his staff. In regard to the scientific work, there was no
more difficult subject in human study than the relationship of mind to brain. It
was very backward, but they were doing something to lay the foundations of the
generalisations of the future. They had done something at Morningside in that
way, for there had been published during his time nine volumes and at least two
hundred papers in the medical journals. His University connection he looked
upon as being at the very core of the kind of work one had to do in keeping up
one’s enthusiasm and interest in one's work. (Applause.)

On the motion of Mr. Garson, W.S., a vote of thanks was passed to the
Chairman, to Sir William Turner, as chairman of the Committee of Subscribers,
and to Mr. R. Scott Moncrieff, W.S., the honorary secretary and treasurer.—
Scotsman, January nth, 1910.

Dr. James Hyslop.

We congratulate Dr. James Hyslop on the honour which he lately received in
recognition of his distinguished services to Natal. When Dr. Hyslop was in this
country last year his portrait was painted by Mr. Fiddes Watt, and it has now
been presented to the Art Gallery of Pietermaritzburg. The presentation was
made by Sir Henry Bale, who said that it had been his high privilege to perform
many duties of a pleasant nature, but never one which he performed with greater

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appreciation than the ceremony which was the occasion of a large attendance of
ladies and gentlemen representing every part of the Colony. Continuing, Sir
Henry Bale said that Dr. Hyslop had rendered great and valuable services
in his own peaceful profession, at the head of the medical service. He was
glad to have that opportunity of recognising Dr. Hyslop’s work in connection
with science and education, and in many other beneficent directions. He recog¬
nised his work as honestly and faithfully done, and his success as well-earned.
The Natal Witness gave the following list of Dr. Hyslop’s qualifications and
appointments, and we heartily congratulate him on the results of his strenuous
labours in Natal in a time of great difficulty, and especially upon the esteem and
respect in which he is held after twenty-seven years in the Colony:

Bachelor of Medicine and Master of Surgery, Edinburgh University, 1879;
Lieut.-Col. on the Staff and P.M.O., Natal Militia (twenty-eight years’ service),
Medical Superintendent, Natal Government Asylum since 1882. President, Natal
Medical Council since 1896. Chairman, Health Board, from 1904 to 1909, and
still a member thereof. Member Natal Pharmacy Board since 1896. President,
South African Association for the Advancement of Science, 1906. President,
South African Medical Congress, 1905. Delegate to Medical Congresses in South
Africa from Natal Branch of British Medical Association, 1906, 1907, and 1908.
Delegate to the annual meeting of the British Medical Association, Belfast,
Ireland, 1909, from the Natal Branch; and Edinburgh, 1898. Local President,
Cancer Research Committee; ex-President of the Natal Branch, British Medical
Association, and of the Pietermaritzburg division of the same, and of the Pieter¬
maritzburg Medical Society. One of the Natal representatives on the Council of
the University of the Cape of Good Hope. Appointed by Government as the
Natal Representative to the Conference of South African States and Colonies on
Plague, held at Pretoria, 1899, and Chairman thereof at Durban the same year.
Chairman of Inter-Colonial Medical Conference of Delegates appointed by South
African Governments, 1904; Government Delegate to Conference on Higher
University Education called by the High Commissioner, 1906. Member of
various Government commissions of inquiry, etc. Ex-President of various local
institutions, such as The Natal Society, Horticultural Society, Botanic Society,
etc. Served as P.M.O., Natal Volunteers, South African War, 1899-1901 ; present
in Ladysmith during the siege. Twice mentioned in despatches. P.M.O. of
Forces, Natal Native Rebellion, 1906.

OBITUARY.

Sir Arthur Mitchell, K.C.B., M.D.

Fourteen years ago we recorded the proceedings of a meeting held in Edinburgh
on the occasion of Sir Arthur Mitchell’s retirement from the General Board of
Lunacy. Lord Kinnear said many fine things about this distinguished Scotsman,
who made a happy reply. He was not conscious of decrepitude and hoped that there
was still some work in him, although his official career had ended. That hope
was well fulfilled, and the evening of his days was calm and bright. He died in
his eighty-fourth year, on October 12th last. The following article appeared in
the Scotsman, and we feel that it will be acceptable to our readers in these pages,
not only to those for whom he is an historical figure, but also to those who have lost
a friend whose place can never be filled.

“Sir Arthur Mitchell was born on January 19th, 1826, and was the son of Mr.
George Mitchell, C.E. After receiving his early education at Elgin, he proceeded to
Aberdeen University, and afterwards studied in Paris, Berlin, and Vienna. At the
passing of the Lunacy Act of 1857 he was appointed one of the Deputy Com¬
missioners, and in 1870 he became a Commissioner. It is beyond doubt that lunacy
administration in Scotland has drawn its inspiration from Sir Arthur Mitchell
more than from anyone else. Connected with the Board from its institution, he
may be truly said to have been the guiding spirit in shaping and developing its
policy. Of the system of caring for the insane in private dwellings as it exists at
present in Scotland—that feature of Scottish lunacy administration which specially
distinguishes it from the lunacy administration of any other country—Sir Arthur

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was the creator. His work on The Insane in Private Dwellings, written in 1S64,
did much more than merely sow the seed from which the system of caring for the
insane out of asylums has been developed. The views which it enunciated were
mature, and they established the system virtually as it exists in Scotland at this
day. In this matter, as in every matter connected with lunacy, Sir Arthur’s fore¬
most consideration was to promote the well being of the insane, and to secure for
them the greatest possible amount of individual liberty of which their condition
admitted ; but he never forgot the economic side of the question, and he never con¬
sidered any scheme for providing for the insane of a locality without keeping
prominently in view the interests of the ratepayer.

" As a public servant he spared no pains to inform himself thoroughly as to all
the facts and circumstances of whatever subject came before him ; and this being
done, he possessed in an eminent degree the power of seeing at once where the
kernel of the matter lay, and of going straight to its heart. To this faculty must
in no small degree be attributed the power and success with which he impressed
his views upon district lunacy boards, superintendents of asylums, and parochial
boards. Even when these views were not at first welcome, they were at all events
seen to be the views of a man who thoroughly knew his subject, and who had
looked all round it before coming to a conclusion. But something in addition even
to knowledge and reason, backed by a powerful will, enabled him to win over
others to his way of thinking. He possessed a profound knowledge of men, and
while his views were always expressed and maintained with perfect firmness, they
were also expressed with a perfect courtesy and tact that might well have secured
the adoption of views in themselves less convincing. It is not wonderful, there¬
fore, that his relations with all officials with whom he came in contact were of the
most cordial character, and that his advice and assistance were constantly sought
and highly valued, both by public officials of all kinds and degrees and by private
persons. His wide sympathies, kindly nature, and ready recognition of merit drew
out the highest qualities of those under him, and proved him an official chief of the
best type.

“ In 1880 Sir Arthur Mitchell was appointed a member of a commission on criminal
lunacy (England). He regularly attended the meetings in the Home Office, and he
greatly influenced the character of the report and of the Act which followed it. In
1885 he was appointed a member of a departmental committee on criminal lunatics
in Ireland, and in 1889 he became chairman of a commission to inquire into the
whole lunacy administration of Ireland. From 1867 to 1871 he held the position
of Morison Lecturer on Insanity to the Royal College of Physicians, and many of
the lectures he then delivered were published. His published papers on lunacy are
very numerous, and deal not only with its social and State aspects, but also with
its strictly medical aspects. In many directions they have had an important
influence on opinion and practice. The book on The Insane in Private Dwellings
formulated and settled one of the most important features of the lunacy admini¬
stration of Scotland.

“ In addition to the recognition by the State of distinguished merit implied in his
appointment to the English and Irish commissions already referred to, Sir Arthur
was the recipient of the Orders of Companion of the Bath from Mr. Gladstone in
1886, and of Knight Commander of the Bath from Lord Salisbury in 1887.
Among academic and other honours conferred upon him may be mentioned the
degree in 1875 of LL.D. from his Alma Mater, the Aberdeen University, of which
he graduated as M.A. and M.D.; Hon. Fellow of the Royal College of Physicians
of Ireland in 1891 ; Professor of Ancient History to the Royal Scottish Academy
and H.R.S.A. in 1878; hon. secretary of the Meteorological Society; Morison
Lecturer on Mental Diseases to the Royal College of Physicians, Edinburgh, 1867-
1871; and member of the Universities (Scotland) Commission. While holding
an official position, though not physically robust, he was scarcely ever absent from
his post through illness. He was a hard worker, and whatever matter he took in
hand he went into with all his heart and soul, his great store of nervous energy,
upon which he could draw at will for any special exertion, standing him in good
stead.

“ Sir Arthur Mitchell, from the time he became connected with the Society of
Antiquaries of Scotland, almost half a century ago, took a prominent position by
his contributions to its Proceedings, and afterwards by his services on the Council.

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He was the youngest, and he lived to be the last of the little band of eminent
men—Joseph Robertson, Cosmo Innes, W. F. Skene, and David Laing on the
historic side, and Daniel Wilson, John Stuart, Sir James Simpson, John Alexander
Smith, Captain T. W. L. Thomas, and himself on the side of antiquities—whose
work and influence did so much to stimulate the progress of the Society and
settle its aims and methods on the basis of true science. A keen and careful
observer of men and things, endowed with a singular faculty of penetration, and
power of expressing his observations and conclusions in terms of the most careful
exactitude, he touched no subject which he did not present in new and unex¬
pected aspects and relations. Fortunate in his opportunities of observation, his
duties as Deputy-Commissioner in Lunacy taking him frequently to all parts of
the country, he had also the methodical habit of taking notes on the spot, so that
in the course of years he amassed a body of original materials, from which he was
able to draw as occasion occurred. When he met with an object which interested
him he secured it if possible; but he was far from being a mere collector of
curiosities for their own sakes, being one of those who care less for the object than
for the lessons that may be drawn from it. Many of the things he thus collected
or took notes of were apparently trivialities to the ordinary observer, but when
properly grouped and studied disclosed their relations with other things of more
importance and interest, of which they were but the wasted and disguised survivals.
In this way he became a pioneer in a new path of inquiry, the investigation of
what he called the neo-archaic, that legion of oddments and customs in everyday
use which he used so successfully to reflect unexpected light on customs and
conditions of life that have long passed away, and whose chief interest lay in the
lessons he drew from them as affording useful checks on incautious conclusions
relating to the condition and culture of early man.

“ In 1861 he was elected a corresponding member of the Society, and in the same
year he contributed his first paper to its Proceedings. The subject was the con¬
genial one of superstitions he had met with still existing in the Highlands and
islands, especially in relation to lunacy. In it he struck the keynote of the theme
to which he returned time after time, and which he finally elaborated in The
Past in the Present. After telling what he had himself seen, and what had been
testified to him by living witnesses of these superstitious practices, some of them
so cruel and heathenish as to be almost beyond belief, he says—‘I am not here
detailing what happened in the Middle Ages ; it is of the nineteenth century, of
what living men saw, that I write.’ The record of his official position in the
Society is a notable one. In 1867 he was elected a Fellow, and in 1869 a member
of the Council. In 1870 he was elected one of the secretaries, his colleague being
Dr. John Stuart. This position he held till 1882, when he resigned the secretary¬
ship, and was made a vice-president. Subsequently, after his nomination by the
Crown as a member of the Board of Trustees, he was elected as one of their repre¬
sentatives on the Council of the Society, and on the abolition of that Board he was
again elected by the Society as one of their vice-presidents.

“ When the Rhind Lectureship in Archaeology was instituted in 1876 by means of
a bequest for that purpose by Mr. A. Henry Rhind, Sir Arthur Mitchell became
the first lecturer, delivering the first three courses of six lectures each. These
lectures, which were attended by large audiences, were subsequently published in a
condensed form in the volume, entitled The Past in the Present: What is Civilisa¬
tion ? Both during their delivery and after publication they aroused great interest,
not only in scientific circles, but also among the general public. The novelty of the
facts collected from personal observation in the northern and western islands and
mainland of Scotland, and the originality of the manner in which they were used in
their bearing on the conclusions drawn by archaeologists from the relics of early
man, attracted much attention. Perhaps the most important outcome of the
lectures, however, was his answer to the question, ‘What is civilisation?’ The
tendency of archreological writers had been to confuse civilisation with culture, but
he showed that while culture was personal to the individual, civilisation only
belonged to the aggregate, which included all varieties of culture, from the highest
to the lowest. Civilisation he defined to be ‘the outcome of the war which man
in society wages against the law of natural selection, and the measure of the success
in the fight is the measure of the civilisation attained.’ ’’

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38.1

James Rutherford, M.D., F.R.C.P.Ed., and F.F.P.S.Glas., formerly Physician
Superintendent, Crichton Royal Institution, Dumfries.

By the decease of Dr. Rutherford on March 8th, the speciality of psychiatry has
lost one of its most distinguished exponents in this country since the passing of the
modern Lunacy Acts.

James Rutherford was the eldest son of the Rev. A. C. Rutherford, Falkirk,
where he was born on January 18th, 1840. He was educated at St. Andrews and
Edinburgh. During his student career, amongst other distinctions, he gained the
gold medal of his year in anatomy and the third certificate of honour in Laycock’s
class of medical psychology and mental diseases. In the spring of 1863, towards
the close of his student career, he acted as locum tenens at Murray's Royal Asylum,
Perth, for Dr. W. C. McIntosh, who shortly afterwards became Medical Super¬
intendent of the Perth District Asylum at Murthly, and has for many years occupied,
with distinction, the Chair of Natural History at St. Andrews. Dr. Rutherford
graduated as Doctor of Medicine at Edinburgh in 1863. During the ensuing
year he went abroad to Berlin and Vienna, studying at the former pathology under
Virchow and mental diseases under Westphal, and at Vienna he studied under
Hebra and Oppolzer. Returning to Edinburgh in 1864, he was engaged during
the ensuing winter as Resident House-physician to Dr. D. R. Haldane at the
Edinburgh Royal Infirmary. In the spring of 1865 he started general practice at
Bo’ness in Linlithgowshire, not many miles distant from his native place, and in
the autumn of the same year he married the future helpmate of his life, Miss Freer,
of Melrose, a member of a well-known Border family. During the two or three
years of his practice at Bo'ness, Dr. Rutherford contributed several papers to the
literature of medical psychology, these taking inspiration chiefly from his observa¬
tions in Germany and Austria. While at Bo’ness he also translated, along with
Dr. C. Lockhart Robertson, a brother of the late Dr. Argyll Robertson, the second
edition of Griesinger’s classical work on Mental Disease, which was published by the
New Sydenham Society in 1867, and they thereby laid British alienists under a lasting
obligation. Griesinger, the father of modern psychological medicine, published his
first edition in 1845, and, as is well known, he profoundly influenced psychiatrical
thought and literature during the latter half of the nineteenth century. In the
same year Dr. Rutherford was elected a Fellow of the Royal College of Physicians of
Edinburgh. His translation of Griesinger’s great work so effectually aroused his
natural interest in, and leanings towards, the study of psychiatry, that he there and
then decided to devote his life to the treatment and management of the insane.
Accordingly, in 1867, though married, he succeeded in obtaining an appointment
as assistant medical officer at Winson Green Asylum, Birmingham, then under the
superintendentship of Mr. Green. After this step promotion was rapid. In 1870
he succeeded Sir John Sibbald as Medical Superintendent of the Argyll and Bute
District Asylum at Lochgilphead. In 1874 he became Medical Superintendent of
the large Barony Parochial Asylum (now the Glasgow District Mental Hospital) at
Woodilee, Lenzie ; and in 1875 he was elected to the Fellowship of the Faculty of
Physicians and Surgeons of Glasgow. At Lochgilphead and Woodilee Asylums Dr.
Rutherford made his reputation as a leading asylum physician and administrator.
His bold and original views on the treatment of the insane, especially in the
direction of their outdoor employment and greater liberty, and the development of
the open door and parole methods, attracted much attention both at home and
abroad. In June, 1883, he was finally promoted to the onerous and responsible
post of Physician Superintendent to the Crichton Royal Institution, whose bounds
and reputation he greatly advanced during his regime of nearly twenty-five years.
When he took office the property of the Institution extended to 150 acres, and the
patients were accommodated in the First House, the Second House, and the Villa
of Maryfield. When he retired the property had extended to upwards of 1300 acres,
including the estate of Friar's Carse, the former residence of Dr. and Mrs. Crichton,
the founders of the Institution, and the patients were accommodated in fourteen
separate houses, many of them stately and imposing buildings which will remain
a memorial of him in future times. Amongst the additions and improvements
which owed their inception to his unbounded energy, special mention may be made
of the introduction of the present copious water supply from the famous artesian
well of the Institution; the installation of electric light, which was pronounced by

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Dr. Bottomley, the nephew of the late Lord Kelvin, to be one of the finest private
installations in the Kingdom ; the addition of the handsome dining hall at the First
House, the enlargement of the north portion of the Second House ; and the erection
of Johnston House as a laundry residence; the extensive model farm buildings;
the sanatorium for tubercular patients; the various hospitals and villas for both the
privateand parochial patients; and,lastly,the magnificent Crichton Memorial Church
of cathedral proportions, which was commenced in the jubilee year of the Institution
and finished in the Diamond Jubilee year of the late Queen Victoria, and was erected
as a memorial to the revered founders of the Institution. The Crichton Church is
one of the most beautiful modern ecclesiastical structures in Scotland, and it was
fitting that the idea of such a memorial should have emanated from the brain of a
reverent and religious man, and a son of the manse. Owing to failing health Dr.
Rutherford found it necessary to give up the reins of office in October, 1907, and
he thus enjoyed his retirement for little more than two years. The end, though
not altogether unexpected, came somewhat suddenly, from heart failure, late in the
evening of March 8th at his residence at Mountainhall, Dumfries. The interment
took place at Dumfries, the coffin being borne by eight of those who had been
longest in the Doctor’s service at Lochgilphead, Woodilee, and Dumfries from the
cemetery gate to the grave, where all that was mortal now reposes in the long
sleep close to the scene of his strenuous labours during the latter half of a busy
life. A funeral service was held the following day in the Crichton Memorial
Church, and was attended by a large congregation of friends and mourners from
the Institution and district around.

Dr. Rutherford’s work for the insane was well recognised both at home and abroad.
With the exception of several original and striking papers in his early graduate
days, and his translation of Griesinger’s standard work, Dr. Rutherford contributed
little to the scientific literature of psychiatry, but he used to the full his remarkable
gifts of administration in translating theory into practice. He will be remembered,
therefore, not so much for his writings as for what he did to advance the care and
treatment of the insane. He did not seek the posts of honour in the Psychological
and Neurological Societies of the home country, but few of his contemporaries in
this country received as much recognition in the specialty abroad as did Dr. Ruther¬
ford, who was elected foreign associate, corresponding, or honorary member of
various Medico-Psychological Associations in Belgium, France, Italy, and America.
When Dr. Rutherford decided on his life work the modern humane treatment of the
insane, which is indissolubly associated with the efforts of Pinel, of the Bistre at
Paris, and of Tuke, of the Retreat at York, during the close of the eighteenth
century, had long been established, and furthered in this country by such workers
as Charlesworth, Gardiner Hill, Conolly, Browne, and others, who during the first
half of the nineteenth century abolished mechanical restraint from their asylums,
and introduced many novel methods of moral treatment which were based on the
principle of extending to the treatment of the insane the same privileges, recreations,
and occupations as were enjoyed by their more fortunate sane brethren. Much,
however, still remained to be done, and Dr. Rutherford was bold and fearless in his
methods, regarding the mentally afflicted as capable of more trust and responsi¬
bility than had hitherto been accorded them by asylum physicians. He was not
only a strong supporter of the non-restraint system ; he went further than this, and
warmly advocated the cause of greater liberty for the insane, and this took shape
in his practice in the adoption of the open-door system, the liberal prescription of
healthy outdoor employment and exercise, and the generous use of parole both
within and beyond the grounds of the institution. No man had a kinder heart for
the insane than Dr. Rutherford, and there can be no doubt that the wide adoption of
his methods in this country and abroad has promoted the recovery and conduced
towards the greater contentment and happiness of numberless afflicted ones. His
Majesty’s Commissioner in Lunacy, writing at the time of Dr. Rutherford’s retire¬
ment, said of him : ‘‘The loss to the Institution and to the cause of progressive
lunacy administration in Scotland, which Dr. Rutherford’s resignation entails, can
only be truly estimated by those who have watched his career, and who are
interested in the difficult problem in the care of the insane. Dr. Rutherford was a
bold and original administrator, who never hesitated from motives of timidity or
self-interest to introduce new and original methods of care and treatment which he
considered to be of advantage to the insane as a class.

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"At a time when the general provision for the housing of the insane in the
asylums of Scotland was not so liberal as it now is, he was one of those who, by his
example and action, promoted a movement which resulted ultimately in a complete
structural renovation of almost all the institutions in the country. This movement
was, no doubt, often open to the charge of extravagance, but its general influence
for good was unmistakable. In addition, he promoted the industrial employment
of the insane, the open-door system in asylums, and liberty on parole to individual
patients.”

Dr. Rutherford was a man of tall and commanding physique, energetic and
sanguine, and of great amiability and personal popularity. His kindly heart and
genial sympathy endeared him personally to his directors, staff, and patients, and
to his many friends both in and outside of the profession. He was for many years
a Justice of the Peace for the county of Dumfries, and he leaves a widow and
family of four sons and four daughters. Three of the former are in the medical
profession, and two of the latter are married to doctors in the speciality.

C. C. E.

Professor Lombroso.

On announcing the death of Professor Cesare Lombroso on October 19th, the
Times published the following memoir:

"Cesare Lombroso was born at Verona on November 18th, 1835. He was
descended from a line of Jews, many of whom had attained to eminence as authors,
rabbis, lawyers, and physicians. Among his progenitors on his mother’s side was
David Levi, the poet, who took part in the struggle for Italian liberty. As a
boy Lombroso gave signs of extreme precocity. The monuments of antiquity
which he saw around him impelled him to study Roman history with avidity, and
he devoured Livy, Sallust, and Tacitus ere he had hardly left the nursery. When
he was twelve years old he wrote, and actually obtained publication for, an essay
on The Greatness and Decline of Rome. A year later his attention was attracted
by an obscure work on The Elucidation of Historic Monuments by Philological
Analysis, written by Paolo Marzolo, of Treviso, a thinker who deserved to be
better known, and who in this incomplete work anticipated many later discoveries.
Lombroso wrote an enthusiastic review of the book in a Verona newspaper.
Marzolo sent him a letter of thanks and expressed a desire to make his acquaint¬
ance. He was astounded when the youthful reviewer presented himself. An
acquaintance which lasted many years ensued. Lombroso abandoned the ordinary
high-school course and applied himself, under Marzolo's supervision, to the study
of Oriental philology. He learnt Hebrew, Chaldee, Egyptian, and Chinese, and
endeavoured to discover a common basis for all these tongues. Marzolo recognised
however, that owing to the troubled state of the times no living could be earned at
philology, and on his advice Lombroso turned his attention to medicine.

" Early career .—He graduated at Padua, and went for some time to Paris and
Vienna to continue his studies. At the very outset of his medical work he was
attracted by nervous and mental diseases, and while still a student he published
two treatises—one on Insanity in Antiquity and the other on The Insanity of
Cardan (the sixteenth century mathematician). In the latter essay he first
advanced the theory of the relation between genius and crime, which was to form
the chief purport of his later work. When the Austro-Italian war broke out in
1859 Lombroso enlisted as a surgeon and remained in the army for six years.
His experiences at the front he embodied in a treatise on amputations, which
gained for him the Riberi prize, the only academic distinction of the kind he was
ever awarded. His regiment was ordered to Calabria, and his attention was
attracted by the diversity of type exhibited by the soldiery, who were drawn from
all parts of Italy. He conducted a series of studies which he endeavoured to
make the basis of an anthropological chart of Italy. He measured and examined
no less than 4000 individuals, and gained an invaluable experience, which stood
him in good stead in his subsequent criminological investigations.

“The removal of his regiment to Pavia, a University town, gave Lombroso an
opportunity of continuing his study of nervous diseases at the district asylum, but
his military superiors did not look with favour on these scientific labours; difficulties

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were placed in his way, and Lombroso finally determined to leave the army. He
established himself as a private lecturer on nervous diseases at the University, and
took charge, in an honorary capacity, of a department at the asylum. After a year's
struggle Lombroso was unexpectedly appointed Professor of Psychiatry at the
University of Pavia at a small salary. He prepared a short inaugural address,
entitled “ Genius and Insanity,” in which all the main ideas of his magnum opus
were outlined. The lecture at once marked him out as a scientist and thinker of
great originality.

"A notable discovery. —In 1872 Lombroso incurred a great deal of odium for
a discovery which proved to be of considerable scientific and economic importance.
He noted the fact that a large number of the inmates of the asylum were suffering
from " pellagra,” a curious disease, which first affected the skin and afterwards
attacked the brain and nervous system. Lombroso discovered that the disorder
was to be traced to a poison contained in diseased maize, which the Lombardian
landowners were in the habit of doling out to the poor peasantry. At a time when
toxins were unknown, Lombroso succeeded in extracting the poison from the
maize and infecting animals with it—quite in the manner of modern bacteriologists.
His discovery was received with a howl of derision and objurgation ; the land-
owners were especially indignant, as Lombroso called upon the Government to
forbid the distribution of the dangerous cereal. At a meeting of the Lombardo-
Venetian Institute one of his colleagues called him a dreamer and declared that
his experiments were pure imagination. Lombroso demanded a scientific commis¬
sion, to whom he demonstrated his experiments on lower animals. The members
were still unconvinced, and this time accused Lombroso of mixing strychnine with
the juice extracted from the maize, and they even demanded his dismissal from the
University. A friend of Lombroso, M. Alfred Maury, reported the facts to
Berthelot, the Parisian chemist, who analysed the poison and established the fact
that the maize contained an injurious substance resembling strychnine, but differ¬
ing from it in important particulars. The validity of Lombroso's discovery was
thus triumphantly established. He was not satisfied hith this initial success, but
for several years fought on the platform and in the press for an improvement in
the economic conditions of the peasantry whereby the ravages of the disease might
be combated. He met with most virulent opposition, which made the tenure of
his post extremely uncomfortable, and he welcomed the offer of the Chair of
Psychiatry at Turin, the home of his wife’s family.

“ Genius and crime. —At Turin Lombroso continued his criminological studies.
He established an’extensive museum of crime, the contents of which served as the
raw materials for his work. He was the first to apply the anthropometric method
to the study of criminology, and his collection of skulls was unique. His examina¬
tion of the skull of a notorious murderer named Vilella led to his anatomical
theory of crime, which he regarded as an atavistic reversion to a primitive type,
the nervous and structural characteristics observed in criminals being also present
in early members of the human race and certain monkeys. Lombroso showed
that the overwhelming majority of criminals suffered from some form or other of
nervous disease. These views he embodied in his great work entitled L'Uomo
Delmquente, published in 1889. Lombroso had a somewhat similar theory for the
existence of genius, which he declared was a form of larvate epilepsy; this some¬
what fantastic thesis was presented in his L'Uomo di Genio, which has been trans¬
lated into several languages. Lombroso, perhaps, over-rated the physical causes of
crime and laid too little stress on economic conditions. But his pioneer labours,
in which he was ably seconded by a devoted band of pupils, led to the creation of
the modern science of criminology, of which the deceased treated in almost every
phase. He had a curious explanation of the recurrent waves of reaction and
political crime which have stained the annals of history. There are mental
epidemics as well as physical, he declared, and he attributed the frequent outbreaks
of anti-Semitism, by which his own race was afflicted, to this cause. Towards the
close of his life he devoted himself to an examination of spiritualist phenomena,
his view being that these were rather the result of abnormal mental conditions than
of hidden external causes. The principal works of the deceased have been
mentioned above. He was the associate editor of the Archivio di Psichiatria.
Among his disciples may be mentioned his two sons-in-law, Professor G. Ferrero
and Signor Carrara, Enrico Ferri, Baron Garofalo Roncoroni, Patrizi, and

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Zerboglio. His daughters are well known in the literary world, and on the
occasion of the thirtieth anniversary of his appointment at Turin published a
biography of the deceased together with an account of his principal works."

BERLIN INTERNATIONAL CONGRESS.

The Fourth International Congress on the Care of the Insane will be held in
Berlin from October 3rd to 7th next. The Congress will be concerned not
exclusively with current problems as to cure and treatment of the insane, but also
with all matters relating to the preservation of mental health. It will therefore
consider injuries to mental health resulting from social evils and hygienic
defects, the production of mental disorder in earliest childhood and its prevention,
the prophylaxis of psychical abnormalities, treatment inside and outside of asylums,
family care, employment, support of the insane and their families, and after-care.

An exhibition will be held in connection with the Congress showing completely
the progress in the care of the insane in Germany in the last three decades, with
a survey of what has been done in other civilised countries.

A committee of the German Verein fiir Psychiatrie, in conjunction with the
permanent committee for organising these congresses, of which Sir G. O'Farrell
and Dr. John Macpherson are the British representatives, have organised discussions
on the following subjects: The relation between civilisation and mental disease,
the increase of insanity, the importance of organised care of infants and children
for the prevention of epilepsy, idiocy, and psychopathies, bacillus-carriers in
asylums, voluntary boarders, polyclinic treatment of the psychoses, insanity in
relation to naval and military service, psycho-pathology in modern art and
literature, social re-instatement of the insane by graduated work.

Notice of papers to be read should be sent as soon as possible to Prof. Dr.
Boedeker, Fichtenhof, Schlachtensee, Berlin. General information may be
obtained from Dr. Falkenburg, 79 Herzbergstrasse, Lichtenberg, Berlin.

Questions relating to the Exhibition should be addressed to Prof. Dr. Alt,
Uchtspringe, Altmark, Germany.

Particulars as to subscription to membership are not yet issued.

AMERICAN MEDICO-PSYCHOLOGICAL ASSOCIATION.

The Programme of the Sixty-sixth Annual Meeting of the American Medico-
Psychological Association for May 3rd to 6th is to be held at Washington, D.C.,
under the Presidency of Dr. Drewry. It gives evidence of great activity in the
Association, and we heartily congratulate the members on the scheme of work sub¬
mitted.

Address of Welcome, by Dr. George M. Kober, Washington, D.C., and others.

Reports from Committees.

Memorial notices: Dr. E. H. VanDeusen, by Dr. Justin E. Emerson, Detroit,
Mich. Dr. B. D. Eastman, by Dr. T. C. Biddle, Topeka, Kansas. Dr. William C.
Krauss, by Dr. Arthur W. Hurd, Buffalo, N.Y. Dr. W. A. Gordon, by Dr. M.
T. White, Milwaukee, Wis. Dr. M. J Stack, by Dr. I. W. Blackburn, Washington,
D.C.

Presidential Address, by Dr. Wm. M. F. Drewry, Petersburg, Va.

General Congress, "Artificial Immunisation.” Dr. Ludwig Hektoon, "The
Formation of Anti-bodies.” Dr. Frederick P. Gay, " The Relation of Anaphylaxis
to Immunisation.” Dr. S. P. Beebe, “ Immunisation in Non-Bacterial Diseases.”
Dr. Walter R. Brinkerhoff, "Immunisation in Leprosy.”

Congress: Address of the President, Dr. Edward L. Trudeau, Saranac Lake,
N.Y.

" Review of the Histopathology of Dementia Pracox,” By Dr. E. E. Southard,
Harvard University. “A Discussion of the Mental Make-up in the Dementia
Pracox Group,” by Dr. August Hoch, Director, Psychiatric Institute, Ward’s
Island, N.Y.C. “ Intermittent Forms of Dementia Prrecox,” by Dr. William
Rush Dunton, jun.,Towson, Md. “ Ethical Aspects of Medical Expert Testimony
in Relation to the Plea of Insanity as a Defence to an Indictment for Murder,”

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NOTES AND NEWS.

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by Dr. Carlos F. MacDonald, New York. "Studies in Cerebral Arterio¬
sclerosis,” by Dr. Charles I. Lambert, New York.

" Immunity in Relation to Psychiatry,” by Dr. John G. FitzGerald, Toronto,
Ontario. "On a History of the American Medico-Psychological Association,” by
Dr. Henry M. Hurd, Baltimore, Md. “ Possible Preventive Measures in Insanity,”
by Dr. Albert Warren Ferris, President, State Commission in Lunacy, Albany, N.Y.
"Types of Sleep in the Insane,” by Dr. Albert M. Barrett, Ann Arbor, Michigan.
" Mild Manic States or the Cyclothemias," by Dr. Smith Ely Jelliffe, New York.
" Notes on Non-Syphilitic Forms of Meningitis,” by Glanville Y. Rusk, New York.

" Organisation and Conduct of the Acute Service in State Hospitals,” by Dr.
Frank P. Norbury, Kankakee, Ill. Discussion by Dr. George H. Kirby, Ward’s
Island, N.Y., Dr. Harry W. Miller, Washington, D.C. “Alcoholic Amnesia," by
Dr. C. W. Pilgrim, Poughkeepsie, N.Y. “ Cardio-genetic psychosis—Report of a
Case with Autopsy,” by Dr. Henry A. Cotton, Medical Director, New Jersey State
Hospital at Trenton, N.J.; Dr. D. S. Hammond, Pathologist, New Jersey State
Hospital at Trenton, N.J. “ Insanity among Adolescent Criminals,” by Dr.
Charles H. North, Dannemora, N.Y. Paper by Dr. B. D. Evans, Morris Plains,
N.J. “ Certain Disturbances of Thought,” by Dr. J. M. Keniston, Middletown,
Conn. “Syphilitic Disorders of the Brain,” by Dr. C. B. Dunlap, Psychiatric
Institute, Ward's Island, New York.

Meeting held at the Government Hospital for the Insane at the Invitation of
Dr. William A. White, Superintendent: (i) “Control of Epidemic Diseases in
Hospitals for the Insane,” two or three papers from Laboratories in Massachusetts;
or (2) “ What Our Summer and Winter Colonies are doing for the Restoration
and Improvement of Patients,” five-minute addresses, by Dr. E. H. Howard,
Rochester, N.Y., Dr. A. W. Hurd, Buffalo, N.Y., Dr. C. G. Wagner, Binghamton,
N.Y. “ Military Psychiatry,” by Captain Robert L. Richards, Medical Corps,
United States Army, Washington, D.C.

Annual Address: “Some Suggestions on the Psychology of Superstition,” by
Dr. J. B. Dresslar, Professor of Psychology, University of Alabama. “ Pellagra,”
with lantern-slide demonstrations, by Dr. C. H. Lavinder, P. A. Surgeon, Public
Health, and Marine Hospital Service, Washington, D.C.

“ Mental Symptoms of Pellagra," by Dr. Eugene D. Bondurant, Mobile, Ala.
"Possibility of Improving Demented Patients by Instruction,” by Dr. R. H.
Hutchings, Ogdensburg, N.Y. “ Problems of Immigration,” by Dr. Sydney D.
Wilgus, President Board of Alienists, New York City, N.Y. “Juvenile Paresis
—Clinical and Anatomical Report of a Case,” by Dr. Henry W. Miller, Clinical
Director, Government Hospital, Washington, D.C. Paper by Dr. Nicholas
Achucarro, Histo-pathologist, Government Hospital, Washington, D.C. “ Lesions
of Spinal Cord in Old Age,” by Dr. Arthur S. Hamilton, Minneapolis, Mjnn.
Paper by Dr. William W. Richardson, Norristown, Pa.

THE LIBRARY OF THE MEDICO-PSYCHOLOGICAL ASSOCIATION.

The Library is open daily for reading, and for the purpose of borrowing books
Books may also be borrowed by post, provided that at the time of application
threepence in stamps is forwarded to defray the cost of postage. Arrangements
have been made with Messrs. Lewis to enable the Association to obtain books
from the lending library belonging to that firm, should any desired book not be in
the Association’s Library.

The following books have recently been added to the Library :

Kraepelin.— Psychiatrie, eighth edition.

Lewandowski.— Funktionen des zentralen Nervenssystems.

Morton-Prince.— The Dissociation of a Personality.

Janet.— The Major Symptoms of Hysteria; Automatisme Psychologique ;
Nevroses et Idees Fixes ; Les Obsessions et la Psychasthenie ; Les Necroses.

Edinger. — Vorlesungen u. d. Bau der nervosen Zentralorgane der Menschen
und der Tiere.

Cornil and Ranvier.— Manuel d’Histologie Pathologique.

Flatau, Jacobsohn, and Minor. — Handbuch d. pathologischen Anatomie des
Nervenssystems.

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White.— Outlines of Psychiatry.

Gierlich and Friedmann.— Studies in Paranoia.

Jung.— The Psychology of Dementia Preecox.

Freud.— Selected Papers on Hysteria and other Psycho-neuroses; Die Traum-
deutung.

Myers.— Text-Book of Experimental Psychology.

McDougall.— Social Psychology.

Drs. Orr and Rows have kindly presented to the Library a copy of Modern
Problems in Psychiatry, by E. Lugaro (translated by Orr and Rows).

H. Devine, 1 Hon. Secretaries,

B. Hart, j Library Committee.

NOTICES BY THE REGISTRAR.

The next examination for the Certificate in Nursing will be held on May 3rd,
1910.

Essays for the Bronze Medal must reach the Registrar before June 15th, 1910.
The next examination for the Certificate in Psychological Medicine will be
held on July 6th, 1910, and that for the Gaskell Prize on July 21st, 1910.

All information may be obtained from the Registrar, Dr. A. Miller, Hatton
Asylum, near Warwick.

NOTICES OF MEETINGS.

Quarterly Meeting. —The next Quarterly Meeting will be held in London on
Tuesday, May 24th, 1910.

South-Eastern Division. —The Spring Meeting will be held, by the courtesy of
Dr. Percy J. Bailey, at the London County Asylum, Hanwell, on Tuesday,
April 26th, 1910.

South-Western Division. —The Spring Meeting will be held, by the courtesy of
Dr. Norman Lavers, at Bailbrook House, Bath, on Friday, April 29th, 1910.

Northern and Midland Division. —The Spring Meeting will be held, by the
courtesy of Dr. C. T. Street, at Haydock Lodge, Newton-le-Willows, on Tuesday,
April 19th, 1910.

Irish Division. —The Spring Meeting will be held on Thursday, April 21st,
1910.

APPOINTMENTS.

Ellis, W. Gilmore, M.D., M.R.C.S., Medical Superintendent, Government
Lunatic Asylum, Singapore, has been appointed Principal Civil Medical Officer,
Straits Settlements, vice Dr. D. K. McDowell, C.M.G.

Bell, J. H., M.D., Third Medical Officer of County Lunatic Asylum, Hatton,
near Warwick.

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THE

JOURNAL OF MENTAL SCIENCE

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

No. 234 [To 8 ""-'] JULY, 1910. VOL. LVI.

The International Committee for the Study of the Causes
and Prophylaxis of Mental Disease.

(Communicated by Dr. R. PERCY Smith.)

In view of the impending meetings of the Fourth Inter¬
national Congress on the Care of the Insane, to be held in
Berlin from October 3rd to 7th, 1910, it seems desirable that
the members of the Medico-Psychological Association and
other readers of the fournal of Mental Science should be able
to have in print a record to the present date of the proceedings
of the International Committee, which was originally appointed
at the Congress held at Milan in 1906 with the object of
studying the causes and prophylaxis of mental disease.

It would seem most convenient to achieve this by publishing
the report on the meetings of the Committee which was made
to the Home Secretary and the Scottish Office by the two
official delegates appointed by the Government to attend the
meetings held in Vienna in 1908. The late Home Secretary
(then the Rt. Hon. Herbert Gladstone), having given per¬
mission for publication, the Report is reproduced here together
with the “ Statute ” or regulations for the working of the
Committee.

Hitherto, as far as is known, no definite promise has been
made by any of the Governments who were officially repre¬
sented as to the contribution of an annual subsidy, the matter
resting at present in the hands of the Italian Government to
approach other Governments with this object. For this reason

LVI. 26

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also the British Committee has not been able to do more than
record the proceedings of the International Committee, and
until the various Governments see their way to make some
subsidy it would seem to be useless to make any appeal for
subscriptions from other bodies or from individuals.

Copy of Report by the Delegates from the United King¬
dom to the International Congress on the Care of the
Mentally Deranged and to the International Com¬
mittee for the Study of the Causes of Mental
Disease , held at Vienna on the 6th to qth October ,
1908.

In accordance with instructions given to us, as contained in
letters of 12th, 14th, 18th and 22nd August, 28th September
and 3rd October last from the Home Office and the Scottish
Office, we have the honour to report as follows :—

(1) We attended the sittings of the International Committee
for the Study of the Causes of Mental Disease held at Vienna
on the 6th and 9th October, 1908, and the various meetings
of the International Congress on the Care of the Mentally
Deranged and the Treatment of the Insane which met in
Vienna on the 7th October, and which held meetings each day
until the 11th October. We visited several institutions for
the care and treatment of the insane, including the psychiatric
clinique of the General Hospital, Vienna, the new asylum for
the insane at Vienna, and the psychiatric clinique of the
University of Munich presided over by Professor Kraepelin.

I. The International Committee.

(a) History of its Formation and Development.

At the Second International Congress for the Care of the
Insane held at Milan in September, 1906, Dr. Ludwig Frank,
of Zurich, made a formal appeal in favour of his proposal to
found an International Institute for the Study of the Causes of
Mental Affections and their Prophylaxis. The proposal was
warmly supported by many distinguished psychiatrists of
various countries, and, when put to a fully attended meeting,
was carried almost unanimously. The Presidential Committee
of the Congress was then empowered to nominate an Inter-

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national Committee, having for its object the co-ordination of
the work of all the various countries interested. At the
closing meeting of the Congress the following members’ names
were proposed and accepted :

Argentine. —Prof. Cabred Domingo, Buenos Ayres ; Prof.
Ingegnieros, Buenos Ayres.

Austria. —Herr Fedor Gerenyi, State Inspector, Vienna;
Prof. Arnold Pick, University of Prague.

Belgium. —Dr. Al. Peeters, Medical Superintendent of the
Colony of Gheel; Dr. Morel, Medical Superintendent of the
State Asylum, Mons.

Brazil. —Prof. Juliano Moreira, Medical Superintendent, The
Asylum, Rio de Janeiro.

Britain. —Prof. Percy Smith, 36, Queen Anne Street, Lon¬
don, W.; Dr. J. H. MacDonald, Govan District Asylum,
Hawkhead, Paisley.

Denmark. —Prof. Friedenreich, Psychiatric Clinique, Copen¬
hagen.

France. —Prof. Jules Voisin, Salpetriere, Paris; Dr. Auguste
Marie, Villejuif Asylum, Seine.

Germany. —Prof. Brunholfer, Psychiatric Clinique, Breslau ;
Prof. Konrad Alt, Uchtspringe, Saxony.

Greece. —Prof. M. Catsaras, Psychiatric Clinique, Athens ;
Prof. Tsirigotis, University of Athens.

Holland. —Prof. Dr. Van Deventer, State Inspector, Amster¬
dam ; Dr. Deknatel, Breda.

Hungary. —Dr. G. de Raisz, Minister of the Interior, Buda¬
pest ; Dr. Von Olah, Medical Superintendent of Anglafold
Asylum, Budapest.

Italy. —Prof. Leonardo Bianchi, Psychiatric Clinique, Naples;
Prof. G. C. Ferrari, Bologna; Prof. Augusto Tamburini,
Psychiatric Clinique, Rome.

Japan. —Dr. Prof. Sakaki, University of Fukuoka.

Luxemburg. —Dr. L. Buffet, Medical Superintendent, Ettel-
briick.

Norway. —Dr. Hans Evensen, Medical Superintendent, Asy¬
lum, Trondjhem ; Prof. Ragnar Vogt, University of Christiania.

Portugal. —Prof. Maghalaes, Lemos, Lisbon.

Roumania. —Prof. Soutra, Psychiatric Clinique, Bucharest.

Russia. —Prof. Van Bechterew, Military Asylum, St. Peters¬
burg ; Prof. Bajenow, Krasuoselskara, 3, Moscow.

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Spain. —Dr. Rodriguez Morini, Barcelona; Dr. Gine y
Marriera, Medical Superintendent, Nueva Belen, Barcelona.

Sweden. —Prof. Th. Nerander, Psychiatric Clinique, Lund;
Dr. Prof. Kimberg, 23, Pridderagaten, Stockholm.

Switzerland. —Prof. Auguste Forel, Geneva; Dr. Ludwig
Frank, Zurich ; Prof. Eugen Bleuler, Psychiatric Clinique
Zurich.

United States of America. —Prof. Adolf Meyer, Pathological
Institute, New York.

The members of the International Committee were requested
to form in their respective countries “ national committees ”
composed of “ persons agreeing to work for the conquest of
such a noble end, and in putting at the disposition of the
Committee all their personal influence and energy.”

In May, 1907, Dr. R. Percy Smith brought the matter
before a meeting of the Medico-Psychological Association held
in London, and the following gentlemen were subsequently
nominated as members of the British National Committee :

Dr. Joseph Lougheed Baskin, Medical Superintendent,
Fisherton House, Salisbury ; Dr. C. Hubert Bond, Medical
Superintendent, London County Asylum, Long Grove, Epsom ;
Dr. F. Stjohn Bullen, 12, Pembroke Road, Clifton, Bristol;
Dr.William Richard Dawson, Medical Superintendent, Farnham
House, Finglas, Dublin ; Dr. Charles C. Easterbrook, Medical
Superintendent, Crichton Royal Institution, Dumfries ; Dr.
Edwin Goodall, Medical Superintendent, City Asylum, Cardiff;
Dr. Theo. B. Hyslop, Resident Physician, Bethlem Royal
Hospital, London, S.E.; Dr. W. W. Ireland, Musselburgh,
Scotland ; Dr. Robert Jones, Medical Superintendent, London
County Asylum, Claybury, Essex ; Dr. Richard John Legge,
Medical Superintendent, Derby County Asylum, Mickleover;
Dr. Hamilton Clelland Marr, Medical Superintendent, District
Asylum, Lenzie, Glasgow ; Dr. Charles Mercier, 34, Wimpole
Street, London, W.; Dr. Frederick Walker Mott, Director of
the Pathological Laboratory, London County Asylum, Clay¬
bury, Essex ; Dr. Michael Nolan, Medical Superintendent,
District Asylum, Downpatrick, Ireland ; Dr. Conolly Norman,
Medical Superintendent, Richmond Asylum, Dublin (since
dead) ; Dr. William Rawes, Medical Superintendent, St. Luke’s
Hospital, London, E.C.: Dr. William Ford Robertson, Patho¬
logist to the Scottish Asylums, 10, Morningsidc Terrace,

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BY DR. R. PERCY SMITH.

393

Edinburgh ; Dr. Geo. M. Robertson, Medical Superintendent,
Royal Edinburgh Asylums, Morningside, Edinburgh; Dr.
Richard Gundry Rows, Pathologist, County Asylum, Lancaster ;
Dr. Alex. Reid Urquhart, Physician Superintendent, Murray’s
Royal Asylum, Perth.

In addition to the above, Dr. R. Percy Smith, 36, Queen
Anne Street, London, and Dr. J. H. Macdonald, Hawkhead
Asylum, Paisley, were nominated as being already on the
International Committee. Dr. John Macpherson has also
been nominated as an ex officio member of the British Com¬
mittee since the meeting of the Congress in Vienna.

The first meeting of the International Committee for the
Study of the Causes and Prevention of Insanity was held in
the University of Amsterdam on 4th September, 1907, at
11 a.m.

There were present : Profs. Alt and Aschaffenberg, Germany ;
Prof. Bajenoff, Russia; Dr. L. Buffet, Luxembourg ; Prof.
Catsaras, Greece ; Professor Van Deventer and Dr. Deknatel,
Holland ; Prof. Ferrari, Italy ; Dr. Frank, Switzerland ; Dr.
Gine y Marriera, Spain ; Dr. J. H. MacDonald, Great Britain ;
Dr. Marie, France ; Dr. Morel, Belgium ; Dr. White, United
States ; Prof. Moreira, Brazil.

In the absence of Prof. Tamburini, the President, Prof. Van
Deventer, was called to the chair.

The following motions were agreed to :

(1) That the Board of Directors consist of five members
and two general secretaries.

(2) That besides Dr. Tamburini, the President, and Drs.
Ferrari and Frank, the two general Secretaries, all of whom
were elected in Milan, Drs. Van Deventer, Marie, Alt, and
Pick, shall be members of the Board of Directors.

The following printed Articles, introduced by Drs. Van
Deventer and Deknatel, were adopted :

Art. I .—That the Directorate of the Committee be requested
to collect all documents relating to the prevention of mental
disease and the degeneration of the human race, with the view
of instructing Governments and peoples as to the general
appropriate measures to be taken for their prevention.

Art. II. —That the Directorate be empowered to complete
the Committee by adding new collaborators as members.

Art. III. —That the different Governments be invited to

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appoint representatives to the Committee, each Government to
appoint one or more delegates.

Art.IV .—That the Committee shall,as a rule,meet once a year.

Art. V .—That the Board of Directors be elected every
three years.

Art. VI .—That during its sittings the Committee shall
introduce new questions for discussion or adoption.

The second session took place the following day, at same
hour and place.

Present. —Drs. Alt, Bajanoff, Buffet, Catsaras, Deknatel, Van
Deventer, Frank, Ferrari, Gine y Marriera, MacDonald, Maris,
Morel, Teeters, White. Professor Alt was called to the Chair.

Arts. VI, VII, and VIII, drawn up by Drs. Van Deventer
and Deknatel, were introduced, and after discussion it was
resolved :

Art. VI .—That the Committee publish in its bulletins:

( a ) The laws and regulations adopted by different Govern¬
ments relative to the care and treatment of the insane,
abnormal persons, drunkards, etc.; as well as all measures
adopted by the Governments and tending towards the suppres¬
sion of nervous or mental affections.

( b ) The projects of the laws on these matters and the
reports preceding them.

(c) The reports on questions discussed or placed on the
programme of the International Congress for the Care of the
Insane.

(d) Original articles and notes on questions falling within
the sphere of the Committee and of general interest.

( c ) The reports from delegates upon the actual state of the
legislation, and the particular measures adopted in each country
to combat the propagation of nervous and mental affections.

Art. VII .—That the Committee prepare the organisation of
international statistics of the insane.

Art. VIII .—That the Committee enter into relationship
with scientific and humanitarian societies whose aims enter
into the sphere of its mission and also communicate with
persons who, by reason of special knowledge, can render it
some service. Each member of the Commission shall impart
to his Government, to societies, and persons mentioned above,
the themes discussed at the meetings of the Congress, and
shall invite them to take part in the preparation of the work.

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BY DR. R. PERCY SMITH.

395

Art. IX .—That in order to meet the necessary expenses,
Governments, scientific and humanitarian societies, wealthy
individuals, and the Press, be appealed to.

The consideration of Art. X was postponed for future
consideration. Art. X read as follows :

“ The bulletin of the Committee shall be sold to the public at
the lowest price possible. If the budget permit, the Committee
shall select some published works and place a certain number
at the disposition of the different Governments, for distribution
to public libraries, reading rooms, college libraries, etc.”

It was announced that His Majesty the King of Italy had
agreed to becoma the Patron of the proposed International
Institute, and that the Italian Government had declared its
willingness to recommend the International Institute to all
Governments of civilised states for their support.

A telegraphic message was sent to His Majesty King Victor
Emmanuel, conveying the thanks and gratitude of the mem¬
bers of the International Committee for his gracious favour.

It was unanimously resolved that the seat of the Board
shall be at Zurich. The seat of the Institute to be created
was not decided.

Dr. Frank was requested to attend to the legal formalities
at Zurich, and to find a public bank in that city to take care
of the financial affairs of the Institute.

It was decided that auditors be chosen annually by the
Committee. Drs. Morel and Bajanoflf were elected auditors
for the current year.

Dr. Frank was requested to procure the necessary assistance
for the business transactions and to find a legal expert who
may be called upon for advice when the affairs of the Institute
should require it.

The Board of Directors was requested to greet the Special
Committee of the German Psychiatric Societies for the investi¬
gation of certain forms of mental diseases, and ask them for
their collaboration.

Secretaries Ferrari and Frank were requested to communicate
with Count Lombard, Lugano, who had offered his chateau for
the meetings of the Committee when the Institute was first
proposed, and to beg him to deposit to the credit of the In¬
stitute from 10,000 to 20,000 francs in the bank decided
upon.

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It was decided that the publications of the Committee
should be printed in English, French, German, Italian.

It was resolved that the next session of the Committee
should take place in Vienna on the 6th October, 1908, the
day before the opening of the third International Congress for
the Care and Treatment of the Insane.

(b) Constitution oj the Committee.

The following is a list of the twenty-seven official delegates
accredited by their respective Governments to the International
Committee, which met at Vienna on the 6th of October,
1908 :—

Great Britain. —Dr. Percy Smith, London ; Dr. John
Macpherson, Edinburgh.

Austria. —Prof. Wagner Von Jauregg, Vienna.

Belgium. —Dr. Peeters, Gheel.

Brazil. —Prof. Moreira, Rio Janeiro.

Bulgaria. —Dr. Donadschiefif, Sofia.

Chili. —Dr. Joaquin Castro, Santiago.

Denmark. —Prof. Friedenreich, Copenhagen ; Dr. Hallager,
Copenhagen.

America. —Prof. Meyer, New York.

France. —Prof. Voisin, Paris ; Prof. Marie, Paris ; Dr. Dubief,
Paris.

Greece. —Prof. Catsaras, Athens; Prof. Tzirigotis, Athens.

Holland. —Dr. Schnurmans, Utrecht.

Hungary. —Dr. de Raisz, Budapest; Dr. Olah, Budapest.

Italy. —Prof. Santoliquido, Rome.

Luxembourg. —Dr. Buffet, Ettelbriich.

Mexico. —Prof. Erdozain Dr. Peon del Vale.

Portugal .—Prof. Bombarda, Lisbon.

Russia. —Prof. Bechterew, St. Petersburg.

Szveden. —Prof. Nerander, Lund.

Switzerland. —Prof. Bleuler, Zurich, and Dr. Frank, Zurich.

The following is a list of the nineteen unofficial members
of the Committee elected at the Milan Congress in 1906 :

Germany. —Prof. Bonhoffer, Professor Alt.

Great Britain. —Dr. J. H. MacDonald.

Argentine Republic. —Prof. Cabred Domingo, Prof. Ingeg-
nieros.

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Belgium. —Dr. Morel.

Brazil. —Prof. Peixoto.

Spain. —Prof. Rodriguez Morini, Dr. Gine y Marriera.

Holland. —Prof. Van Deventer, Dr. Deknatel.

Italy. —Prof. Tamburini, Prof. Bianchi.

Japan. —Prof. Yasaburo Sakaki.

Norway. —Prof. Vogt, Dr. Evensen.

Roumania. —Prof. Soutra.

Russia. —Dr. Bajenoff.

Sweden. —Dr. Kimberg.

It will be seen from the above lists that nineteen nations
sent official delegates, the only European nations unofficially
represented being Germany, Norway, Spain, and Roumania.
On the other hand, these four nations were unofficially
represented by three, two, two, and one elected delegates
repectively. No less than fourteen of the official members
had previously been elected members of the Committee, e.g.,
one of the present reporters (Dr. Percy Smith).

As the Constitution of the Committee at present stands,
the official delegates are in a majority (27 to 19).

At the Milan Congress of 1906, as will be seen from the
preceding pages, the only business done was the election of
members.

At the Amsterdam Congress of 1907 a beginning was
made with the organisation of the Committee, the appointment
of officials, and of an Executive Committee, of which Prof.
Tamburini, of Milan, was appointed President; Drs. Frank
(Zurich), and Ferrari (Bologna), Secretaries; and Drs. Van
Deventer (Holland), Marie (France), Alt (Germany), and Pick
(Austria Hungary), Members of Council. It will be observed
that this Executive Board was appointed prior to the appoint¬
ment of official delegates to the Committee, and that it holds
office for four years, i.e., until 1911. It therefore happens
that only two official delegates (Dr. Marie and Dr. Frank) are
members of the Executive Committee.

(d) The Vienna Meetings of the Committee.

The Committee met in the University Buildings at Vienna
on the afternoon of Tuesday, October 6th, 1908, under the

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presidency of Prof. Tamburini. The British delegates found
themselves at a disadvantage in so far as a number of printed
papers, which they had not previously seen, embodying resolu¬
tions to form the basis of discussion, were placed in their hands
for the first time.

The meeting, which lasted for three hours, was wholly occu¬
pied by a consideration of these proposals, which had for their
purpose a determination of the lines of policy and operation
which the Committee ought to adopt with the view of attaining
its objects—an inquiry into the causes and prevention of mental
and nervous diseases.

Generally speaking, three main questions presented them¬
selves : (i) The important question of the collection of scientific
facts, of special literature, and of the legislative procedures of
various Governments for the care, control, and prevention of
insanity. Depending upon this question was the necessity
of establishing an Institute with a paid staff where the work of
collective investigation could be carried on. The Committee
are at present not in possession of any funds for such a
purpose. The official delegates were earnestly requested to
appeal to their respective Governments for such subsidies as
will enable the Committee to found and carry on such a central
bureau, as well as to enable them to publish an official bulletin
containing the results of their inquiries. In the meantime the
seat of the proposed Institute formed the subject of prolonged
discussion. Zurich, Paris, and Rome were suggested. Ulti¬
mately, on our suggestion, it was resolved that in view of the
great interest manifested by the Italian Government in the
work of the Committee, and in view of the fact that H.M.
the King of Italy had graciously consented to become patron
of the Committee, the Italian members be asked to approach
their Government with the object of ascertaining whether that
Government might be willing to provide suitable accommoda¬
tion for the Institute and its officials.

(2) The question of whether the Committee should directly
undertake investigations into the causes of insanity was raised
by the French delegates, with a proposal that an international
laboratory for research of an elaborate and scientific kind
should be established in Paris. Such a proposal did not com¬
mend itself to the majority of the members, and we gave notice
of a motion to the effect that the Committee should, instead of

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399

undertaking direct research themselves, take means to ascertain
the kind of work bearing on their objects which is being carried
on in various laboratories and institutes throughout the world,
and select for encouragement, material assistance and publica¬
tion the researches of such workers as may appear to them
most useful. This motion was unanimously adopted at the
second session of the Committee on Friday, October 9th. It
will be found embodied in a somewhat amended form in the
appended “ Statut ” resolution 17.

(3) On the question of finance.it was resolved that Govern¬
ments represented on the Committee should be requested to
pay an annual sum towards the expenses of the work of the
Committee and towards the publication of an international
official bulletin. An amendment moved by the British
delegates to the effect that Governments so contributing shoula
have a preponderating voice in the direction of the manner in
which the funds of the Committee were expended was practi¬
cally lost, and now appears only in modified form as.resolution
18 of the “Statut” appended. The manner in which it is
suggested that such Government subsidies should be paid is
detailed in resolution 19 of the “ Statut.”

The foregoing, among others, are the chief projects of the
International Committee on the Causes and Prevention of
Insanity. It will be seen that as yet these projects are only
in a preliminary and rudimentary stage, and it would there¬
fore be premature to criticise them. In the meantime the
Committee requires information, which it proposes to collect,
and suggestions as to action, which will no doubt be forth¬
coming. Above all, it requires money, without which it is
unable to proceed. The amount of money at present needed
is comparatively small, and were each Government represented
to contribute a fixed annual sum for a fixed number of years
—say £200 each—we think that until the Committee
decided upon undertaking some enterprise of greater magni¬
tude than is at present contemplated the working expenses
ought to be fully covered by such a sum. At present, we
understand, the expense of the Committee is being defrayed
by a small grant from the Italian Government, but we have
no official authority for this statement.

Speaking for ourselves, we may say that we went to the
meeting of the Committee with some scepticism as to the possi-

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bility of any real benefit resulting from its deliberations. We
are now, however, inclined to believe that in the following two
or three directions the proposals of the Committee may be of
service :

(1) They may serve by a diligent collection and collature
of fact to establish a scientific knowledge of some of the social
causes of insanity, such as insanitary surroundings, alcoholism,
under-feeding or improper dietary, especially of children, the
inheritance of nervous and mental affections, the influence of
certain bodily diseases, and other problems upon which at
present it is safe to say opinion is merely speculative.

(2) By acquainting themselves with special forms of tech¬
nical work carried on in scientific laboratories throughout
Europe and America, the Committee may be able to stimulate
and co-ordinate certain of these researches and direct them
towards the elucidation of problems in the pathology of
insanity, which for want of such co-ordination are at present
fragmentary and isolated.

(3) By collecting and publishing the methods and regula¬
tions of different nations in regard to the care and treatment
of the insane, the work of the Committee may prove educa¬
tive and instructive to all civilised Governments. We con¬
ceive that in these and, probably, in other directions as well,
the Committee may prove fruitful of good. It it should,
fortunately, lead to a practical knowledge of some of the
proximate causes of insanity among civilised peoples the
expense incurred in its establishment and support would be
well-spent money, considering the enormous sums spent in
every civilised country on the care of the insane. It has
been estimated that in Great Britain alone the cost of
lunacy to the country exceeds three million pounds sterling
per annum. We do not mean to suggest that any measures
are ever likely to be successful in preventing the occurrence
of insanity, for it is not one disease or due to any one set
of causes. We believe that many of the forms of insanity
are originally due to innate germinal variations which cannot
be controlled, and which must always occur from time to
time even in the most healthy human stocks ; but we cannot
doubt that other forms are, if not directly due to, at any rate
promoted by, unfavourable social environments and physical
diseases, the nature of which is at present imperfectly understood.

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401

For the foregoing reasons we respectfully recommend that
His Majesty’s Government should join with other Govern¬
ments in granting such material support to the International
Committee, and for such a period of years as will, at any rate,
afford an opportunity of judging whether any beneficial or
practical results are likely to be attained through its
instrumentality.

We also recommend that the reports of the Commissioners
in Lunacy for the three Kingdoms, as well as other Govern¬
ment publications on the care of the insane, should be sent to
the Institute when it has been established.

The printed “ Statut ” containing the results of the delibera¬
tions of the last meeting of the Committee is appended.

{Signed) John Macpherson.

R. Percy Smith.

Statut.

1. LTnstitut International pour l’^tude des causes des
maladies mentales et leur prophilaxie, projete au Congres
International de 1 ’Assistance des Ali6n6s a Milan (Septembre
1906), et dont S. M. le Roi d’ltalie a daigne accepter le haut
patronage, a pour but de rdunir et coordonner dans les divers
pays toutes les donn^es qui peuvent servir a etablir quelles sont
les causes principals des maladies mentales et,en gdndral de la
degeneration humaine; ainsi que les moyens individuels, ldgis-
latifs et sociaux, les plus utiles pour leur prevention, et suscep-
tibles d’etre diffuses parmi le peuple et sanctionnes par les
Gouvernements.

2. LTnstitut manifeste son action :

(a) Par le travail d’une Commission Internationale, organe
fonctionnel de l’lnstitution, rdgie par un Bureau Directij
Central.

(b) Par l’oeuvre des differents Comites Nationaux, qui ont les
memes buts et qui sont continuellement en rapport avec le
Bureau Directif de la Commission Internationale.

(c) Au moyen de Congres Inter nationaux pour l’dtude des
causes et de la prophilaxie des maladies mentales et de la
d£g6n£ration humaine.

3. La Commission Internationale est composee de Membres

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electifs techniques, nommes par les Congres internationaux et
dc Delegues officiels nommes par les differents Gouvernements.

4. Les Membres de la Commission Internationale restent en
charge pendant 4 ans et peuvent etre reelus.

5. Chaque Nation pourra etre representee dans la Commis¬
sion Internationale par trois membres, au maximum, y compris
les Delegues des Gouvernements.

6. La Commission Internationale choisit dans son sein le
Bureau qui sera compose d’un President, d'un Vice-President,
de trois Conseillers et de deux Secretaires, dont un fonctionne
comme Tresorier. Le Bureau reste en charge quatre ans et
peut etre reelu.

7. Dans chaque Nation qui fait partie de l’lnstitut, les
representants sont charges de former des Comites Nationaux
pour l’etude des causes et de la prophilaxie des maladies
mcntales. Un au moins de ces representants fera partie de
droit du Bureau Directif du Comite National respectif.

8. Les Comites Nationaux doivent contribuer aux travaux de
la Commission Internationale et du Bureau Central, surtout en
rassemblant toutes les donn6es statistiques, cliniques, etc., qui
puissent etre utiles pour la determination des causes de la
degeneration en general, et particulierement de la folie, et aussi
des moyens pour leur prevention. Par les soinsde la Direction
de chaque Comite National ces donnees devront etre transmises
periodiquement au Bureau Central de i’Institut, avec les Rap¬
ports des Delegues sur les progres de la Legislation et sur les
mesures de prevention adoptees dans chaque pays contre la
degeneration et la folie.

9. Les Delegues nommes par le Gouvernement de chaque
Nation chercheront a obtenir de leur Gouvernement toutes les
donnees necessaires aux travaux de l’lnstitut et tacheront de
conserver k ^Institution l’appui moral et materiel des Gou¬
vernements.

10. La Commission Internationale se reunira en assemble
ordinaire une fois par an, de preference en coincidence avec les
Congres Internationaux indiques dans l’Art 2.

11. Le Bureau central se reunit aussi une fois par an et
toujours avant la convocation de la Commission Internationale.

12. Les convocations du Bureau et de la Commission Inter¬
nationale sont faites par le President, au moyen d’un des
Secretaires.

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BY DR. R. PERCY SMITH.

403

13. Dans ses reunions le Bureau :

(«) Collectionne et coordonne les donnees et les propositions
qu’il a re9ues des differents Comites Nationaux et de leurs
Delegues.

(6) Redige les questionnaires qui seront distribues aux
Comites pour des reeherches ulferieures.

(c) Fait la distribution, parmi les membres du Bureau, du
travail de coordination et de synthese des donnees refues, et
etablit quelles propositions devront etre presentees a la Com¬
mission Internationale.

( d) Redige le bilan consomptif de chaque annde, et prepare
le bilan de provision pour 1’annee suivante ; bilans qui devront
etre soumis a l’examen de la Commission Internationale.

( e ) Pourvoit A l’organisation et a la convocation des Congres
Internationaux.

14. Les Congres Internationaux auront lieu tous les deux
ans dans la locality qui sera choisie par le Congres precedent.
Ils coincideront, si possible, avec les Congres Internationaux
pour l’Assistance des Alienas.

15. Le Bureau sera toujours en relation avec les Society
scientifiques et humanitaires qui poursuivent des buts analogues
a ceux de l’lnstitut, et avec les personnes remarquables qui par
leurs etudes ou leurs oeuvres pourront etre utiles aux travaux
de l’lnstitut.

16. Le Bureau pourvoit a la publication d’un * Bulletin
Officiel International,’ dans lequel paraitront:

(a) Les comptes-rendus des seances du Bureau et de la
Commission Internationale;

( b ) Les comptes-rendus des Congres Internationaux et les
resumes des Congres traitant des matieres qui interessent
l’lnstitut;

(d) Les Lois et les Reglements des differents Etats en rapport
avec les buts de l’lnstitut;

(/) Les informations statistiques sur les maladies mentales
dans les differents pays, recueillies d’apres des formulaires
uniformes, et les rapports des Delegues sur les progres de la
legislation et de la prevention dans les differents pays;

( g) Les memoires scientifiques d’un inferet general remar-

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404 CAUSES AND PROPHYLAXIS OF MENTAL DISEASE. [July,

quable relatifsau but de l’lnstitut, les resumes et les indications
bibliographiques et toutes les nouvelles qui peuvent intdresser
et contribuer aux buts de l’lnstitut.

17. La Commission aura soin de se procurer aussitot que
possible tous les rapports et tous les travaux publies par les
differents Laboratoires physiologiques, psychologiques, anthro-
pologiques, etc., afin de pouvoir faire un choix de tous les
travaux sp£ciaux relatifs aux causes et a la prophilaxie de la folie.
La Commission interviendra materiellement pour la publica¬
tion dans le Bulletin de tous les travaux qu’elle aura choisis.

Elle prendra aussi l’initiative de nouvelles recherches sur les
causes et les conditions pathogeniques de la folie dans les
Cliniques et les Laboratoires subventionnds a cet effet; elle
aidera aussi autant que possible les recherches individuelles.

18. La Commission prendra specialement en consideration
les propositions des differents gouvernements faites par l’inter-
mediaire de leurs delegues.

19. Les Gouvernements qui par leurs Delegues Officiels
feront partie de l’lnstitut, seront invites a verser une somme
annuelle pour les frais de son fonctionnement et pour la publi¬
cation du Bulletin Officiel International. Ces sommes seront
versees par la voie des differents Ministeres des Affaires Etran-
g&res, a la “ Caisse des Depots et des Prets ” de la Nation qui
sera elue comme Siege central de l’lnstitut, et seront retirees,
d’apres les besoins, par des ordres d’office du President de la
Commission Internationale. Cela independamment de la
contribution que chaque Gouvernement pourra allouer a son
Comity National.

20. Les finances de l’lnstitut seront sous le controle du
Gouvernement du pays dans lequel se trouvera l’lnstitut.

21. Les finances de l’lnstitut pourront etre augmentees par
les dons des pouvoirs publics et des personnes qui auront la
noble intention de contribuer k l’ceuvre de prevention de la
folie. Les personnes ou les corps constituds qui verseront une
somme d’au moins Frcs. 1,000 m£riteront le titre de Membres
Bienfaiteurs.

22. Le Bulletin Officiel International, qui sera publie tout
les trois mois, sera envoye :

(а) Aux Gouvernements qui auront adhere a l’lnstitution

(б) Aux Membres de la Commission Internationale qui auront
paye une cotisation de 20 francs par an ;

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1910 .] INSANITY AS DISORDER OF CONDUCT. 405

23. Les rapports et les mdmoires seront publies en allemand,
anglais, fran^ais et italien. Les memoires originaires seront
publies dans une des quatre langues, choisie par l’auteur; il en
sera publie un resume dans les autres langues. Les informa-

^ tions seront publiees dans les quatre langues.

24. Le Bureau nommera un personnel retribue pour les travaux
de l’lnstitut, pour la correspondence, la comptabilit6, etc., et
pour la publication du Bulletin. Ce Bureau aura sa residence
dans le Siege central de l’lnstitut.

- -

Part I.—Original Articles.

Insa7iity as Disorder of Conduct. By Charles Mercier,
M.D., F.R.C.P.

It is with considerable diffidence that I bring this subject
before such an Association as this. I should have the same
feeling were I to argue before the Mathematical Society for the
merits of the Multiplication Table, or before the Astronomical
Society in favour of the Law of Gravitation. It is a matter
that I have regarded as an axiom for the last five and twenty
years, and that I fondly thought was established as a funda¬
mental doctrine of alienism. My astonishment was great
therefore, when, at a recent meeting of the Education Com¬
mittee of this Association, my proposal, that the doctrine
should find expression in the syllabus of subjects for the
diploma in Psychiatry did not find a single supporter. The
experience carried me back to the early years of my member¬
ship of this Association, when I constantly found myself in a
minority of one in advocating views which are now become
commonplaces. It seems, therefore, necessary to bring the
matter formally before you, and to argue it out ; and here I
am in the difficulty felt by everyone who tries to prove formally
what seems to him self-evident. I believe that things that are
equal to the same thing are equal to one another. I do not
know whether any of the members present share this belief.

LVI. 27

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If they believe that conduct is of no importance in insanity,
the same cast of mind may very well cause them to believe
that things that are equal to the same thing are greater than
one another, or that two straight lines can enclose a space, or
that things that are unsupported fly upwards. But if they do
believe that things that are equal to the same thing are equal
to one another, they would have considerable difficulty in
giving a reason for the faith that is in them. If I question the
truth of it, and ask what are the grounds of their belief, I
think I should place them in a quandary. I am in a similar
quandary in demonstrating that disorder of Conduct is the
prime element in Insanity.

I think I am correctly stating the doctrine, that I fondly
thought I had exploded five and twenty years ago, when I say
that it regards Insanity and disorder of mind as convertible
terms. Insanity is disorder of mind, and disorder of mind is
Insanity. This I utterly, and totally, and strenuously deny.
Nearly every day I see cases of disorder of mind that it would
be an outrage, and worse, it would be a blunder, to call
Insanity ; and very often I see cases of Insanity in which dis¬
order of mind is neglectable, and does not enter into the con¬
sideration of the case. Let me give a few instances. A man
occupying a high position in the service of the State, the duties
of which he performs with great ability, suffers acutely from
claustrophobia. He dreads a railway journey, and finds it
impossible to travel with the window shut. He always travels
with a railway rug in straps, and in the hottest weather he
covers his legs with the rug, to conceal the fact that he has
strapped his legs together to prevent himself from making a
sudden rush from the carriage. When he is in any small
closed space he is in an unreasonable panic ; but he is as far
removed from insanity as you or I, for he knows as well as you
or I that his panic is unreasonable. He can no more help
feeling the panic in appropriate circumstances than you or
I can help feeling drowsy during a Presidential address in this
room. But—this is the point—his conduct has nothing
abnormal in it. What he does is to take a reasonable, sane,
judicious precaution against the consequences of his disorder,
and in this sane conduct he proves his sanity in spite of the
disorder of his mind.

Some of you may say, erroneously as I think, but you may

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407

say that such a case as this is a borderline case—a little more .
and he would have stepped over the border and become insane
—and that the disorder of mind, if it was not actual insanity,
partook of the nature of insanity. I will therefore take another
case, which will I think put the matter out of doubt. At the
present time I have two patients who are affected by a most
distressing form of giddiness. They feel as if the ground were
constantly swaying about, like the deck of a ship at sea. They
walk with uncertainty and difficulty. One of them has
repeatedly fallen, owing to this apparent movement of the
ground. The other feels it even when sitting down ; and
always holds on to the arms of her chair or to the table, or
some other fixed object, for fear she should sway off her seat
and fall. Now, giddiness, I beg leave to remind you, is a
disorder of mind. It is an abnormal feeling. Oh ! but, you
say, it is due to some nerve lesion. It is an affection of the
ocular muscles, or of the semi-circular canals. No doubt it is
due to the messages sent to the cortex from the retina, or the
ocular muscles, or the semi-circular canals, or elsewhere ; but
the giddiness itself is as distinct from the nerve lesion, or the
molecular nerve current, as mind is distinct from matter. The
giddiness is a feeling of giddiness. It is a misinterpretation of
the relative positions and movements of surrounding objects, or
of oneself with respect to surrounding objects ; and interpreta¬
tion and misinterpretation are purely mental processes. The
disorder is, no doubt, founded on a physical lesion and the
result of a physical lesion, and so, we believe, is insanity, but it
is itself a disorder in the mind. No doubt the mind correctly
interprets the sensations that are received, and it is the sensa¬
tions that are erroneous ; but again, sensations are mental, not
material facts. The mind works correctly on the material
presented to it, and this correct working keeps the disorder
within the range of sanity. But the material presented is
mental material, and this material is erroneous. It is mental
disorder. If there are any who think that giddiness is a bodily
disorder itself, apart from its foundations, I respectfully submit
that until they recognise the limits of the mental and the
physical—the distinction between mind and matter—they have
no locus standi in this discussion.

Now take another case. Shortly after I was qualified, as I
was sitting in my uncle’s surgery reading for my next examina-

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INSANITY AS DISORDER OF CONDUCT,

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tion, a man rushed in, took up a chair, and before I could say
“ knife,” if I had wanted to say it—as a matter of fact it did
not occur to me—but before I could have said “ knife,” he had
smashed with the chair every pane of glass in the window, and
lifted the chair to add my head to the general smash. I had
never seen the man before, nor had he seen me to my know¬
ledge. We were entire strangers. Under these circumstances,
ought I to have examined into the state of my visitor’s mind
before forming an opinion on his sanity ? Was I to find out
whether he had a delusion, and whether that delusion so
influenced his mind as to cause him to act otherwise than he
would have acted if he had not had it ? According to what I
must now suppose to be the prevailing and orthodox view of
insanity, I ought to have done so, but I did not. I went out
of the room—I do not say hurriedly; I may have gone
leisurely—I don’t clearly remember. It was a long time ago.
But I went. I went over to the police-station opposite, and
told the sergeant on duty that there was a madman in the
surgery. Was I justified in making this statement? As I
understand the doctrine of insanity which I must suppose is
prevalent, I was not. Insanity is disorder of mind, and I knew
nothing whatever about this man’s mind. For aught I knew
he might have had the minds of Socrates and Aristotle, of Sir
Isaac Newton and Herbert Spencer all rolled into one. But I
did not concern myself about it. I rested my diagnosis of his
insanity purely and solely on what I had seen him do —in fact,
on his conduct, and in this I submit that I was justified.

Take yet another case. Some year or so ago I certified and
sent to an asylum a gentleman in whom neither I, nor anyone else
could detect the slightest intellectual disorder. In conversation,
in argument, in astuteness, he appeared to be immaculately
sane. I rested my opinion of his insanity entirely upon a long
course of conduct, extending from the age of six down to the
age of thirty. It took several sheets of foolscap to set forth all
the facts indicating insanity that were communicated to me by
others, and in all this narrative no reference whatever was made
to his mind. The whole judgment was based on conduct and
on conduct alone ; and this certificate was accepted by the
magistrate who made the order, and by the Commissioners who
assented to his detention.

One case more, and this a brief one. I was once introduced

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409

to a lady, who immediately spat in my face. I sat down at
once and certified that she was insane. I did not interchange
a word with her. I knew nothing, and to this day I know
nothing of the state of her mind. I regarded that as altogether
beside the question, and I think so still.

Of course, when I say that insanity is disorder of conduct,
I shall be understood to deny that disorder of mind exists in
insanity, and I know by experience that it is very little use to
combat this interpretation of my doctrine. It is due to myself
to try, however. I proclaim, therefore, that disorder of mind
is, as far as we know, always present in insanity—as far as we
know, I say, for our knowledge of other people’s minds is
always more or less conjectural. But the point, the gravamen,
the nucleus, the crux of the matter is this, that unless it is
expressed in conduct, or unless it is a guide to the conduct
that may be expected, the state of a person’s mind does not
matter a straw to the alienist. So long as a man’s conduct is
normal in all the relations of life, it does not matter a straw if
his mind is as full of delusions as an egg is full of meat, or a
beehive of bees, or a herring of bones. For aught you know
to the contrary, my mind may be at the present moment
swarming with delusions. For aught I know to the contrary,
you may all be possessed with the most irrational and pre¬
posterous notions about what is to be expected, for instance,
from Tariff Reform, or from the abolition of the House of
Lords. But if, notwithstanding, he acts capably and with
propriety in all the relations of life, then I say, it does not
matter a straw whether a man’s mind is disordered or not,
he is for all practical purposes sane. He is not to be deprived
of his liberty ; he is not to be sequestered from the manage¬
ment of his estate ; he is not to be deemed incapable of making
a will or a contract, or from transacting other business ; he is
not to be held immune from punishment if he commits a
crime. The question of his insanity does not arise.

For us it is conduct, and conduct alone, that matters. What
we are to investigate, and what we are to treat, is not what is
going on in a man’s mind, but the way he behaves. One of the
elementary lessons that I give to my elementary class, is that the
facts indicating insanity that they are to put into a certificate are
to be facts, and facts observed by themselves ; and this excludes
all the states and processes of mind of every sort, kind and

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description. That a person has a delusion may be a fact, but
if it be, it is a fact that cannot be observed by anyone else.
What a person thinks, or feels, or knows, or believes, or wills, or
desires, or hopes, or fears ; whether he is joyous, or miserable,
or apprehensive, or suspicious, or exalted, or confident, or
hopeful, or despairing, is forever beyond our direct observation.
We cannot observe what is passing in another man’s mind.
We can only infer it from what he says, and what he does, and
how he looks ; and these are all phases of conduct. They are
not states of mind. If a man tells me he is the Emperor of
the Universe or that he is the Awful of Awfuls, does he thereby
enable me to see into his mind and observe what he thinks or
feels ? No ; all that I can observe is that he says so. Whether
he really thinks so, or feels so, I cannot observe. I may infer
from other circumstances, from his looks, acts and demeanour,
that he is speaking the truth ; but he may be lying merely,
and whether he is truthful, or whether he is lying, I can no
more observe what is passing in his mind than I can observe
what is on the other side of the moon. I apologise for inflicting
these truisms upon you ; I should never have done so if I had
not been driven to it, but it is impossible to insist too strongly
that all the knowledge we have of the minds of other people is
conjectural, and is inferred from conduct. And when we have
that knowledge of another person’s mind, it is of no value, it is
of no consequence, it is of no importance, except as it indicates
what his conduct is likely to be. In any case, if we take mind
into consideration, we must infer it from conduct ; and from
mind we infer back to conduct. Why not take conduct, which,
and which alone, is open to direct observation, and rest our
judgment of sanity directly upon that ?

Another whole class of corroboratory facts, if corroboration
were needed, is found in observation of post-epileptic automatism.
I have seen persons in post-epileptic automatism so behave as
to pass muster as normal persons. No one who was present,
except myself, had any reason to suppose that they were other
than normal sane persons, so perfectly did the automatic
conduct mimic normal conduct. Yet, as far as it is possible
to judge, these persons were mere automata without any mind
at all at the time. Suppose this state to be prolonged, as there
is some reason to think it has been prolonged, for days, months,
or years, what reason, what excuse, what occasion, should we

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have for pronouncing such persons insane? Supposing that
they went about their business, bought and sold, married and
were given in marriage, performed all their duties to themselves,
their families and society, in a normal manner, what is it to a
bystander whether they have minds or not ? It would never
occur to any onlooker to raise the question. They would go
to their graves with the reputation of having been sane all their
lives, and yet they would have had no more mind than a
Jacquard loom, which can do things as intelligent as a human
being.

Our interest in other human beings lies in what they say and
do ; and not in what they feel and think, except in as far as
their feelings and thoughts are a guide, or an index, to what
they may say and do. If they say and do insane things, they
are insane, whatever the state of their minds may be. If they
do not say or do anything insane, the question of their insanity
does not arise. It never occurs to us to raise the question.

In a conversation I had the other day with one of the mem¬
bers of the Education Committee who voted against me on the
occasion in question, I learnt that he made no distinction
whatever between mind and conduct; and in the provisional
syllabus that has been distributed, you will find that some
phases of Conduct are included under Psychology. It is diffi¬
cult to treat this opinion with respect. I have a great respect
for the gentleman himself, but if I am asked to treat this opinion
with respect, you must excuse me. I will consent to regard
Conduct as a branch of Psychology when you show me how
to equate the smell of lavender with the Houses of Parliament,
or when you can propel a battleship by a feeling of consterna¬
tion. The universe of matter and motion lies on one side of a
gulf, and the universe of mind lies on the other. The gulf is
bottomless, and its width and length stretch to infinity. When
we can jump from the earth to the pole-star, and from the
pole-star to the Southern Cross, then perhaps we may go into
training for the far more difficult task of equating the move¬
ments of matter with the processes of mind.

But where, it may be said, does all this lead to? It may
or may not be an interesting academical disquisition, but what
is its practical moment? It is this. If Insanity is a dis¬
order of Conduct, surely Conduct is worth study. One heretical
doctrine that I preached five and twenty years ago is now

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become orthodox. I then said, if Insanity is disorder of
mind, surely 7 it is incumbent on us to study that which in
Insanity is disordered. We learn Physiology before we study
Pathology, and surely, in Insanity also, the Science of the
Normal should precede the Science of the Morbid. In that
respect we are happily agreed. We are all Psychologists now,
and I vainly imagined that this second doctrine, that I preached
at the same time, was also accepted. But I have been rudely
wakened from my dream. The Education Committee with
unanimous voice has refused to erect Conduct into a separate
branch of Study, or give it a separate heading in the Syllabus.
It is to be content with two or three widely separted sub-head¬
ings of Psychology.

Well, gentlemen, whether Conduct is worth study or not is a
question that I hope to hear debated this afternoon, but whether
any branch of Conduct can be included in Psychology does
not admit of debate. If you included the construction of the
steam engine in a syllabus of Counterpoint and Harmony, or
if you included the drafting of Parliamentary Bills as a branch
of Astronomy you would not go farther astray. The things
are disparate in nature, and by no effort and by no artifice can
they be brought together. The subject of Psychology is what
goes on in the mind. The subject of Ethology, the Science of
Conduct, is what men do and say. Doubtless, what we do and
say expresses, with what accuracy we can compass, the thoughts
and feelings we have in our minds ; but what we do and say are
no more thoughts than the ink-marks on the paper I am read¬
ing to you are thoughts.

My thesis is that Conduct is not only a proper subject of
study for the alienist, but that it is the subject of study. It
ranks in importance before all else, and should be studied by
the alienist at least as systematically as mind, or as the
anatomy of the brain. But again, it will be objected that there
is no book on the subject—as if things had not to be studied
outside of books before they can be put into books! We have
the subject matter of the study constantly before us all our lives,
in both its normal and its morbid aspects. All we have to do is
to observe what goes on around us ; and for books, every novel
is a study of some phases of conduct, unless it is a so-called
psychological novel, and that, I am glad to hear, is now out of
fashion.

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I wonder whether the members of this Association realise
the meaning and effect of regarding insanity as a disorder of
mind, instead of primarily a disorder of conduct. Some part
of the effect is seen in the proposed syllabus for post
graduate instruction, which is now before the Association.
In this we find that importance is attached to investigating the
reaction time of our patients ; we are to discover their aesthetic
sentiments ; we are to find out their ideation type ; we are to
test them with the ergograph ; we are to inquire into the
synthesis of their consciousness ; we are to discover their
faculty of space perception and time perception : but whether
or not they can earn their living we need not inquire ; whether
they are drunkards, or profligates, or prodigals, are matters
of no importance; we need no information about suicidal
attempts. Whether our patient is a miser, or a spendthrift ;
whether he hoards rubbish or collects stamps ; whether he is
filthy in his habits, or maniacal in his fury ; whether he adorns
himself with tawdry ornaments, or tears up his clothing; whether
he tries to murderhiswife and children,or runs amokin the streets,
shooting unoffending wayfarers, all these are to us, as alienists,
matters of profound indifference. We need pay no attention
to them. They are unworthy of our consideration. To teach
students that persons in acute insanity are apt to commit
suicide is of no importance whatever. What is of importance
is that we should take their reaction time, and test them with
the ergograph. That is what students are to be taught.
Gentlemen, I submit that this doctrine is media;val, crude and
profoundly erroneous ; and I submit, moreover, that no one
who professes or pretends to hold it bases his practice upon it.
You may pay it the lip service of saying that insanity is disorder
of mind, but when you investigate your cases do you confine
your investigation to the state of their thoughts and feelings,
and pay no attention whatever to what they say or do ? I am
sure you do not. You have too much sense. But if conduct
is to be investigated at all, is it not worth while to investigate
it systematically? Can it be investigated systematically? Is
there a science of Conduct ? I say there is. It is not
recognised. It is formulated in no book, but I have drawn up
a syllabus on the subject which is my guide in lecturing to my
students, who are taught that the study of Conduct is the
primary and essential and fundamental study in Alienism, and

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such a syllabus should, I submit, appear in the syllabus of
subjects required of candidates for degrees in Psychiatry.

Discussion,

At the Quarterly Meeting held in London, May 24th, 1910.

Dr. Savage said it had given him great pleasure to listen to what he expected
would be a treat. It was a great thing to encounter Dr. Mercier when he was in a
destructive frame of mind. One could never feel quite sure whether he would not
be extremely materialistic to-day, and immaterialistic to-morrow. But at all
events he had provided food for thought. Dr. Savage assumed that all who were
engaged in treating the insane did recognise the necessity of observing their con¬
duct. Certain certificates which he had signed and which had been accepted had
been very wide of the mark in regard to facts observed by himself. With regard
to Dr. Mercier’s remark that a man might be as mad as possible and yet his
conduct be all right, he remembered getting a man removed from a public asylum,
who had been there more than a year, and who had hallucinations of hearing
of a most marked description. This patient said, “ All the difference between you
and me is, that you have a subjective thought which does not influence your
conduct; I have an objective thought which does not influence my conduct either.”
But take the man who was in Bethlem Hospital; he had a suggestive con¬
sciousness which said, “ Knock somebody down,” and he did it. Both men had
hallucinations of hearing; in one, conduct was not influenced; in the other.it
was. The one, Dr. Savage considered, should not be treated as insane, the other
should. He felt very grateful to Dr. Mercier for having so clearly pointed out the
necessity of looking at insanity from the practical point of view, and not entirely
from the scientific standpoint. He hoped that they were not going to exclude
science, nor to go back to practically classifying by symptoms. Some would say
that was the danger. One must fight against the attitude of regarding conduct
alone as the criterion of a man’s insanity, and one must investigate the process of
reasoning on which the conduct was based.

Dr. W. H. B. Stoddart said he was very pleased to hear that he had gained
the respect of so eminent a man as Dr. Mercier, but sorry to learn that his opinion
did not meet with that respect. He agreed to a large extent with Dr. Mercier
that conduct was a criterion of insanity (Dr. Mercier: The criterion). But the
point was that he, Dr. Stoddart, regarded conduct as a part of mind, and that was
where they parted company. It was a large subject to attack in a meeting of that
kind. The difficulty was that it was necessary to draw the line between conduct
and what Dr. Mercier regarded as mind. Conduct appeared to be something
muscular; but he took it that one could not stop at the muscles and not enter the
nervous system at all. Conduct must be some co-ordinated action, and as long as
muscular action became co-ordinated it took one into the nervous system and inside
the skull. It was very difficult to say where the study of conduct was to leave off
and where the study of psychology was to begin. The only point on which he
differed from Dr. Mercier was that he wished to include conduct in the study of
psychology.

Dr. Steen remarked that Dr. Mercier stated that when conduct was disordered
there was disorder of mind. He wished to ask whether the converse was true.
When conduct was not disordered, was there no disorder of mind? He had in
mind the case of a young girl, the history of whose past life would fill many pages
of foolscap. She was certified as insane and sent to the City of London Asylum.
She was a private patient. At the end of one month from admission she, of
course, had to be certified to the Commissioners as insane. There had been no
disorder of conduct during that month, but her certificate was written. At the
end of a year she had again to be certified as insane, yet during that time there
had been no disorder of conduct, and no other mental disorder that he could
discover. He felt, and knew from her past history, that she was a moral imbecile,
or was morally insane, and yet there was no disorder of conduct. What was the
superintendent of an asylum to do with such a case as that if conduct was to be
the only criterion ?

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Dr. Drapes said he thought that if Dr. Mercier had used the word “certifiable”
before " insanity,” his remarks would have been apt. But surely Dr. Mercier did
not wish to press the point that there was no insanity except that which showed
itself in conduct. One was taught that the mind consisted of three principal
departments—intellect, emotion, and will; and that insanity might show itself as a
disorder of any of those, or of all together. One was also taught that disorders of
will revealed themselves in conduct. But did there not exist, underlying every
action a man committed, whether he was sane or insane, a mental condition which
prompted the act? If Dr. Mercier's views were carried out practically, he, Dr.
Drapes, thought the occupation of the alienist would be gone, because the man in
the street would be as good a judge whether a man was insane as would be a skilled
psychologist. What the alienist had to do was to give some explanation of the
man’s conduct. That could only be done by reference to the man's mental con¬
dition as a whole.

Dr. Urquhart said it was a real pleasure for him to come to London to find Dr.
Mercier so happy in the sunshine that he could afford to go back twenty or thirty
years in his life and to reproduce his old ideas, which were very familiar to alienists
there. He feared that Dr. Mercier had that day rather mistaken his audience ; he
must have meant to address the Medico-Legal Society rather than the Medico-
Psychological. Those who had to endure the rough and tumble of the Courts
would highly value the direct and effective reasoning by which Dr. Mercier
introduced and maintained his thesis. But the trouble was that it was not a
doctor’s paper, and it did not in any way set forth a physician’s opinion. If
insanity was merely disorder of conduct, then it was more of a legal than a medical
question. Of course one had to address oneself to the legal question as well as to
the medical one; but it was comparatively irrelevant to members of that Associa¬
tion what was the legal question in connection with insanity: the insanity which
was a disease of the brain, or the brain affection caused by bodily disorder. Dr.
Mercier resembled a man who gave a minute account of a disordered rheumatoid
arthritic joint, without the slightest consideration of what preceded the condition.
What was the reason of the disability of the joint in conduct? That was the
question which alienists were still face to face with to-day. It was a medical question,
and the question of all questions : What was it which led to the disorder of conduct ?
What terrible catastrophe had befallen the person ? What was to be done to restore
that person ? Or, still more, what was to be done to prevent disorder of conduct,
which was a late symptom, and one of secondary importance to the physician ?
He thought that their standpoint, to be effective, must command far more than
Dr. Mercier said. He did not suspect what Dr. Mercier's thesis was until he
produced it towards the end of his address ; he did not know it was an attack upon
an unfortunate syllabus. How difficult it was to write a synopsis for the Association.
It had no personality about it; the whole work of a Committee was watered down
to the meanest intelligence. Whenever a man serving on a Committee had a good
idea and produced it with fatherly pride, it was of short-lived duration ; he found
he had talked too high or too low, too broad or too narrow, and the consequence
was that the Association got something which was safe. Dr. Mercier had taken
that course on the present occasion : he was the safe man talking to “ mad doctors.”
But had he enlightened them as physicians ? Did they know now more than they
had learnt from Dr. Mercier himself twenty-five years ago ? He did not think so.

Dr. Dixon said he wished to ask Dr. Mercier, if one was to regard insanity as
merely a disorder of conduct, without any reference to the supposed state of the
mind which led to that disordered conduct, how one was to provide accommodation
for all the people in this country whose conduct was found to be disordered from
day to day. At the present time it appeared that if the conduct was disordered,
the policeman or some other guardian of the public came to the rescue of the
community. But if all the people whose conduct was disordered were to be cor.
sidered insane, he feared that the asylum accommodation, if they were to be
incarcerated there, would have to be very much increased.

Dr. Bedford Pierce desired to ask Dr. Mercier a question. He understood
the thesis to be that there was no insanity without disorder of conduct. If that
were true we could have no knowledge of insanity unless we discovered some disorder
of conduct. How would Dr. Mercier speak of the person who was troubled with
obsessions to murder ? He knew a gentleman who came to the Retreat at York

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willingly because he wished to be kept there as a protection against himself ; he
was under the fear that he would murder his children. The conduct, in coming to
that institution, was not insane; he was acting reasonably to prevent himself
doing an evil. Unless the fact of speaking of such things was called conduct, he
would have thought the man was insane although his conduct was correct.

Dr. Langdon Down said conduct was the text by which the mind was
read. It was necessary to go through the process from conduct to mind, and
from mind back again to conduct, because without that connecting link there was
no reason why one act should be succeeded by any other similar act. Therefore it
would be wrong to infer future conduct from past, unless one had that basis, that
there was a connection between conduct and mind, and between mind and conduct
again. It was as if Dr. Mercier were to say they were to read the text which
would be seen in the book when it came to be printed, and that the mental
condition of the writer was an inference which did not matter. The text was
studied with the view to inferring the mental condition. The mental and the
physical formed one series of events, and although philosophically one could not
connect them up, it was a mistake to neglect the connection in practical psychiatry.
Surely the analogy which the author laid before the meeting was incorrect in the
case in which he called giddiness a disorder of mind. The mind of that patient,
for all the observer knew, might be correctly reacting on the impulses submitted
to it; just as Dr. Mercier had held that the man who tied his legs together in a
railway train was not showing disordered conduct, because his conduct was reacting
correctly in interpreting his feelings.

Dr. Rayner said that some years ago Dr. Mercier and he saw together a surgeon
who had performed upon himself a most complex operation, involving elaborate
insanity of conduct. Still, although the act, judged simply as an act, was
absolutely insane, it was concluded that he might have his liberty, and so he was
not sent to an asylum.

The President said he had but few remarks to offer on the paper. In con¬
junction with all present, he was much indebted to Dr. Mercier for his very racy
and enlightening paper. He very closely associated himself with Dr. Mercier's
rendering of the subject. The point of the paper was that Dr. Mercier took the
legal consideration almost apart from the medical. He waived away with the hand
at once the legal fiction of delusion as being the necessary proof of insanity; also
he dismissed all other mental manifestations as proofs of insanity, and went at once,
as a true neurological student, to objective phenomena, and examined the mental
reflexes of conduct—if Dr. Mercier would allow the term—and in that case
one found him so pre-eminently practical. He agreed that conduct should be
taken very widely into consideration; but he had always found a stumbling-block
in his way, and he would like it removed—namely, how to deal with crime. If one
took disorders of conduct into consideration, then, as a speaker had already
remarked, our asylums would soon be over full. If one took into consideration
all forms of disordered conduct which embraced the criminal also he did not see
how one could dissociate the two without going further back to mental phenomena
and investigating for oneself, whether the act so performed was the result of what
was usually called insanity, or was of a criminal nature. Possibly Dr. Mercier might
be going further than himself in his definition of crime. But there was a line to be
drawn, and it would often be most difficult to solve the question in the courts.

Dr. Mercier, in reply, said that he could not understand anybody holding the
opinions which Dr. Stoddart held on that subject. That gentleman said that
conduct took one right up the nervous system into the skull. Dr. Stoddart said
that the only point on which they differed was that one included conduct in psycho¬
logy, whereas the other did not. That was only one of the points on which there
was a difference between them; but it was quite true that it was the point upon
which he laid stress. He had already given reasons why he did not include
conduct in psychology. Therefore they must agree to differ. Dr. Steen had
asked him if the converse was true. But it was not exactly the converse. He
said that when conduct was disordered there was disorder of mind ; and Dr. Steen
asked whether when conduct was not disordered there was no disorder of mind.
He tried to give many instances in which there had been no disorder of conduct,
and yet plenty of disorder of mind. He could have reeled off such instances
by the score and by the hundred. And that was his point, showing that there

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could be disorder of mind and yet no disorder of conduct. Dr. Steen brought
forward a case of moral insanity, and said that that unfortunate young lady was
the subject of moral insanity, but he could not, on the assumption that conduct
was to be the sole criterion of insanity, give a continuation order, because he had
not observed in her any insane conduct. If she evinced no insane conduct he did
not see how she could be certified. If she was not insane in her conduct, then, for
the alienist’s purpose, she was not insane at all. But it was possible she might
not be insane. And he thought it was almost certainly the case that the reason
she did not appear to be insane was because Dr. Steen had given her such excel¬
lent care. But if she were relieved of that care she would probably evince her
insanity once more. (Dr. Steen: “But what ought the superintendent to do ? ”)
Our judges invariably declined to answer hypothetical cases, and they were
celebrated for their wisdom. Dr. Drapes spoke about disorder of will, and
contended that such were the only disorders of mind which issued in conduct. He
did not agree with that. He believed that disorders of all the subdivisions of
mind might have their counterparts in disorders of conduct, not merely disorders of
will. His friend, Dr. Urquhart, said the paper was not a doctor’s paper, and that
it should have been read before the Medico-Legal Society; that if insanity was
merely a disorder of conduct, it was legal only. He did not follow Dr. Urquhart
in that; he did not see why that view should be held. The paper was provoked
by the extraordinnry and reprehensible conduct of the Education Committee,
which refused to support him by a single vote when he desired to introduce the
study of conduct as an element in the syllabus. He was not contending that there
was no disorder of mind in insanity; he was not contending that conduct was the
only thing disordered in insanity ; what he was contending for was the systematic
study of conduct, for its erection into its proper position as the primary but not the
sole element in insanity. Dr. Urquhart had said that he (Dr. Mercier) was only saying
over again what he said twenty-five years ago. That was true, but unfortunately,
twenty-five years ago the seed fell on barren soil ; apparently it was sown on stony
ground, and had never fructified. Therefore, there was surely no harm in sowing
again and expecting a better harvest at some future time. Still, he was glad to
see that opinion had moved a little since those old days. He had been asked
whether disordered conduct did not mean crime, and how one was to distinguish
between disordered conduct which meant insanity, and disordered conduct
which meant crime. It seemed to be assumed that if one regarded insanity as
disorder of conduct, therefore one must include crime as insanity. He repudiated
any such notion. That such a notion could be conceived showed that we had no
proper conception of what disorder of conduct consisted in ; and until conduct and
disorders of it were systematically studied, such a mistake would continue to be
made. He did not believe that anyone had upheld more than he had the doctrine
of the unescapable responsibility of every person for his or her acts; and he had
never regarded insanity and crime as convertible terms. Dr. Bedford Pierce had
put a very difficult case to him, that of obsession to murder; and he asked the
question whether such a person as he mentioned, who came to him and placed
himself under care because he had an obsession to murder his children, was sane
or insane. The answer he would give was, Look at the man’s conduct; what did
he do ? He had that disorder in his mind ; what was his conduct in consequence ?
His conduct was the sanest thing he could do, namely, putting himself under Dr.
Pierce’s care. What more sane thing could he have done ? Surely he proved his
sanity by his conduct. If instead of putting himself under care he had cut his
children’s throats, the situation would have been altogether different. It was Dr.
Langdon Down who had placed his finger on what was apparently the weak point of
the position. Of course, undue neglect of a study of conduct and its disorders had led
him, Dr. Mercier, to place an amount of stress upon it which appeared to give it an
exaggerated importance, to elevate it into too prominent a position. He repudiated
any idea that he believed that mind should be altogether neglected. One must,
and one did, argue from conduct back to mind, and from mind back again to
conduct; and mind formed a bond of union, a link of association between conduct
now and conduct following, and both must be studied. But the study of insanity
was not complete when mind alone was studied ; nor was it complete by the study
of conduct alone. Insanity was only fully studied by the co-ordinated considera¬
tion of mind and conduct. Hitherto the study of insanity had been restricted too

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much to one of those aspects, to the neglect of a systematic study of conduct. He
remembered the case which Dr. Rayner reminded him of, and it was a very
astounding one. It was a case in which the man’s conduct was extraordinarily
disordered, but Dr. Rayner and he could not discover a disorder of mind. The
surgeon was not certified ; they agreed that he should not be, but that was not
because his disorder was one of conduct and not of mind, but because they were
both convinced that there was no prospect of a repetition of that disordered con¬
duct. Dr. Rayner would doubtless bear him out in that. Had it been thought
that there was reasonable ground for believing that such conduct was likely to be
repeated, they would undoubtedly have certified him. (Dr. Rayner signified his
assent.) His point was therefore proved. He had already met the President's
objection that the acceptance of the idea that insanity was disorder of conduct
would lead to confusion between insanity and crime. He was sure it would not.
It was only because conduct had not been systematically studied that the confusion
existed ; and if conduct were studied as such, that confusion would not be increased,
but, on the contrary, would be cleared up.

A Theory of the Toxic and Exhaustion Psychoses.

By W. H. B. Stoddart, M.D., F.R.C.P., Assistant

Physician, Bethlem Royal Hospital.

Mr. President and Gentlemen,— I have had a little
difficulty with my title, because the disease to which I want to
refer is known under so many names. “ Exhaustion psychosis”
is one, and the same disease is also described as “post-febrile
insanity,” “acute confusional insanity” and “acute hallucinatory
insanity ” ; while on the Continent, I think, psychiatrists are
unanimous in applying to it the name “amentia.” But “amentia”
in this country has a different meaning, so that we cannot adopt
that term here. Having, however, given you the list of names
by which the condition is known, you will recognise the disease
to which I refer.

It has several causes, but if you examine the cases you will
find that they all have the same series of symptoms. It arises
as the result of toxaemias of various kinds, mainly those
following acute fevers. It is also caused by such poisons as
alcohol, belladonna and hashish. We find the same disease
following physical and mental exhaustion ; one has seen it in
men who have undergone severe physical strain : for instance,
I saw one case in a man who had run a five mile race and
won it. It also occurs after mental exhaustion. One sees it
perhaps most commonly in people who have been working for
examinations. Lastly, it may be the result of mental shock ;
one sees it in patients who have suddenly lost friends, and it
comes on quite suddenly in some patients. For instance, I

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419

think of one particular case of a girl who woke up one morning
to find herself beside the dead body of her grandmother. In
another case a man was working in his shop when he saw his
mate hauled up by the strap of his machine.

One of the most characteristic symptoms is peripheral
anesthesia, mostly of the arms and legs, in severe cases involv¬
ing the head and chest as far as the epigastrium, and perhaps
from above the knees to the ankles ; leaving sensation in the
feet and in the bathing drawers area, and perhaps occasional
patches of sensation in the hands. I shall refer to this
anaesthesia again presently. The next characteristic symptom
is the disorder of perception. Patients suffer from imperception
in various sense departments ; they cannot recognise common
objects when they see them. They are unable to recognise
sounds ; for example, the sounds with which I usually test
patients are the tearing of paper behind their head and
the sissing of a soda-water syphon. They cannot recognise
the sounds. Often these patients are unable to read or to
take in any complicated sentences expressed to them. Simple
remarks like “Good morning” they can take in, but complex
sentences, such as those telling them to do a series of things,
they cannot understand. They do not know where they are,
they do not recognise people, they suffer from illusions of
recognition, and they are disorientated in time, as well as in
space ; and their memory is defective. In other words they are
completely confused. A special disorder of perception is apraxia
of various kinds, that is to say, the patients are unable to
form the idea of simple movements, such as buttoning the
boots ; and they suffer from catalepsy and catatonia, which I
am disposed to regard as forms of apraxia. All these symptoms
cause disorders of conduct, which for my present thesis do not
matter. The patients always suffer from hallucinations, and
these are constant. There are hallucinations of vision and of
hearing, as well as of other sense departments.

Having defined the disease, no doubt you will remember very
many cases of the kind which have come under your notice.
I will now refer to a theory which I propounded some years ago
here with regard to the hallucinations. I then pointed out
that there were a positive and a negative side to hallucination ;
for example, taking a hallucination of vision, the patient sees
a face or whatever it may be, but he does not see the objects

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in the neighbourhood of the face—that is to say, there is a
positive and a negative factor of the hallucination. I then went
on to show that the negative factor was indicative of dissociation
of the central nervous system from the periphery, that the
peripheral neurons were dissociated from the central nervous
system and that there was disordered associational activity.
The point I make now is that the peripheral neurons are dis¬
sociated from the central nervous system, and the presumption
is that the dissociation can only occur at the synapses. We
now see more clearly that dissociation must occur at the
synapses, and that there is increased synaptic resistance through¬
out the whole of the nervous system. This theory is supported
by the presence of the anaesthesia, on which I have made the
following observations : Taking an anaesthetic arm, the patient
cannot feel a pin-prick in the affected area. It occurred to
me that the anaesthesia was due to increased resistance at
the synapses, and accordingly I adopted an expedient which
Dr. Sherrington used in his investigation of the scratch reflex
in the dog, namely, giving more than one stimulus in a given
area. If you take an insensitive patch somewhere near the
margin of the anaesthetic area—for example, if the patient be
anaesthetic up to the elbow and you stimulate the middle of the
forearm—you can pinch up the skin and put a pin through it,
and yet there is no response. If you take a pin and persist¬
ently stimulate a square inch the patient begins to feel the
stimulus. One can overcome the resistance in this way.

Further, I cut a disc of blotting paper, take four drawing pins
and put them close together through the middle of it, then gum
another disc over the top, so that there is a big drawing pin
with four points to it. If in an anaesthetic area, provided you do
not go too close to the periphery, you use this quadruple point
and press it into a part of the skin where the patient cannot
feel a single point, the patient feels it immediately, show¬
ing that the quadruple point will overcome the resistance,
while a single point will not. The conclusion from this is that
the resistance is at the synapses, and that it is not in the cell
bodies, because if there is a block in the neuron there is no
evidence to show that a strong stimulus will overcome the
block more than a weak one. But if the resistance is increased
at the synapses, a strong impulse will overcome the resistance,
while a weak one will not.

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BY W. H. B. STODDART, M.D.

42 I

Now, it occurred to me to try the effect of some drug which
would diminish the resistance at the synapses in these cases.
There is one drug which stands pre-eminent for such a purpose,
viz., strychnine. One has to try moderate cases of the kind—
patients who suffer from some visual hallucinations, and who
are able to tell you something of what the results are. You
can take a hypodermic needle and inject the strychnine into
the anaesthetic area. I will give you the case of a patient I have
in mind who was anaesthetic to the shoulders, and had a patch of
anaesthesia below the knees. At the first dose of strychnine,
which was iipv of the solution hypodermically, the patient
could not feel the prick of the needle. She was suffering
from hallucinations of vision and of hearing. At the next
injection, four hours later, the patient could feel the prick of
the needle, and all the anaesthesia had disappeared to the
fingers, the whole body being sensitive. The patient was
clearer in her mentation, and the hallucinations had more or
less diminished. By the time the third hypodermic injection
was used the hallucinations had entirely disappeared and in this
case the patient went to sleep. I have repeated this experi¬
ment in about a dozen cases now, and find that the strychnine
invariably has this result of diminishing the loss of sensation
and diminishing the hallucinations. The effect was so definite
that I used it as a routine treatment for patients suffering from
hallucinations of this kind, but not cases of hallucinations of
dementia pnecox, or acute mania, for in those cases it would
increase the hallucinations. In the exhaustion and toxic
psychoses the injection of strychnine diminishes the hallucina¬
tions. One can give it by the mouth, but the result by this
method is not so good.

As a result of these observations I conclude that the symptoms
of acute confusional insanity are due to an increased resistance at
the synapses of the nervous system, and that the chief incidence
of the mischief is at the synapses.

Discussion,

At the Quarterly Meeting in London, May 24th, 1910.

Dr. Seymour Tuke asked how long the improvement lasted after the strychnine
injections.

Dr. Bedford Pierce said that all present must have felt very much indebted
to Dr. Stoddart for his most suggestive paper. The only question he had to ask
was as to why Dr. Stoddart inferred it was the synapses which were altered. He

LYI. 28

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422 TREATMENT OF MELANCHOLIA, [July,

supposed there was no doubt whatever that strychnine quickened the reflex
reaction, but he thought that, theoretically, that quickening might take place in a
number of different parts of the reflex arc rather than at the synapses. Perhaps
the nerve-cells might act more quickly, and his idea of the action of strychnine
was that it stimulated nerve-cells rather than terminations of the nerves.

The President said he understood that it was only by a summation of stimuli
that one judged whether there was a synaptic resistance. He thanked Dr. Stoddart
for his very interesting and suggestive paper, which would remain in their minds
as a definite contribution on obscure confusional insanities.

Dr. Stoddart, in reply, said that there was definite improvement after the
injections, but he did not recommend it as a treatment except when the hallucina¬
tions were such as to cause much mental disturbance. It was not intended as a
cure. For such a purpose one had to improve the general health. He only brought
forward the effect of strychnine as a support to his thesis. He had kept up the
injections for two or three days, and they very much lessened the excitement. The
point was that the anaesthesia was apparently due to increased resistance at the
synapses, because it could be overcome by multiple stimuli of various kinds,
whereas a block due to disease of the neuron itself could not be overcome, so far
as was known, by having a multiple stimulus, or a stronger stimulus. He had
previously come to the same conclusion from a study of the nature of hallucinations.

The Treatment of Melancholia by the Lactic Acid
Bacillus. O By J. George Porter Phillips, M.B., B.S.
(Lond.), M.R.C.S., L.R.C.P., Assistant Physician, Bethlem
Royal Hospital.

Melancholia, with its attendant constipation and faulty
alimentation, lends itself at once to a dietetic form of
treatment.

Whether the constipation is dependent on defective innerva¬
tion and is a direct symptom of melancholia or is the initial
cause of this mental disturbance, it matters not so far as our
endeavours in treatment are concerned.

It is obvious that the melancholiac, in the acute stages of
his illness, struggles against great odds owing to the following
facts: His alimentation is defective, his excretions are diminished,
and, moreover, his whole system is in a state of auto¬
intoxication. In other words there is a general clogging of
the metabolic processes. The disturbance of the alimentary
tract tends to form a vicious cycle hindering the nervous
system from obtaining an efficient and pure food supply.

We have ample evidence of this impaired metabolism with
its toxaemia. The patient has a sallow, muddy complexion,
a dry skin, a parched, furred tongue, a high-tension pulse,
brittle nails and lustreless hair, a scanty high-coloured urine

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containing an excess of ethereal sulphates and faeces deficient
in quantity and moisture and very offensive in odour.

Ranging from a mild attack of depression to a severe case
of melancholia one finds the hub of the disturbance centring
itself in the alimentary canal. For this auto-intoxication free
purgation and administration of chemical antiseptics will afford
relief but are not satisfactory.

An item of treatment which pre-eminently suggests itself
is one which will not only inhibit the growth of the proteolytic
organisms, the common cause of the abnormal putrefaction
and consequent auto-intoxication, but will also obtain a
biological intestinal antisepsis.

By the ingestion of vigorous cultures of the lactic acid
bacillus under suitable conditions of diet one is able to produce
this desired inhibition of these putrefactive processes. That
this takes place is proved experimentally by the diminution of
the daily urinary excretion of the ethereal sulphates and by
alteration in the character and quantity of the stools. There
is also a decrease in the number of the Gram-negative
organisms and a great increase in the Gram-positive. This
process of inhibition is probably due to the lactic acid formed
in the intestine in a nascent state, this being dependent on the
fact that the growth of putrefactive organisms which grow
favourably in an alkaline medium is arrested by an acid-
producing organism in a saccharine medium.

It is not my desire to write a monograph on the lactic
acid organisms, but I think it is desirable cursorily to discuss
the leading varieties.

An exact classification of the true lactic acid forming
organisms has not met with any great degree of success. The
soured milks used in Bulgaria, Egypt, Turkey and other
eastern countries contain bacteria which are peculiar to them¬
selves.

Kern, in 1881, described a milk-curdling organism which
he isolated from the Russian Kefir, but this was found to be a
spurious form of the lactic acid bacillus.

Rist and Khoury later investigated the Egyptian soured
milk called Leben raib and described two kinds of organism—
(1) Bacillus lebetiis , (2) Strepto-bacillus lebenis. Grigoroff,
working in Professor Massol’s laboratory at Geneva, isolated,
three years later, from the Bulgarian yohourth, two varieties of

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424 TREATMENT OF MELANCHOLIA, [July,

the organism, and these he called “Bacillus A” and “Strepto-
bacillus C.” These appear to be identical with the two strains
described by Rist and Khoury, the strepto-bacillus in each case
forming a smaller percentage of the lactic acid than the long
bacillus —lebenis or A. In 1906, the bacillus A, or bacillus of
Massol, was carefully described by Cohendy, who has done much
work on the lactic acid organisms. Duggeli was the first to
demonstrate the granule-staining in certain strains of lactic
organisms. He obtained his cultures from the Armenian
sour milk called Mazun.

The strain we have been using at Bethlem is the long
bacillus of Massol, and we have noticed that this variety at
certain times assumes the strepto-bacillary form, and occasion¬
ally shows this metachromatic staining with methylene blue.

From this observation I have formed an opinion that the
two different varieties described are simply the result of a
temporary deviation in the morphology of one organism. It
is from 2 /t to 50 f* long and 1 n broad. It is non-motile and
does not form spores. Viable bacilli are Gram-positive, whilst
dead are Gram-negative. Cultivation is very difficult on
ordinary media, and at most is feeble. It is both aerobic and
anaerobic, and grows best at 38° C. to 40° C., optimum
temperature being 45 0 C., and minimum about 25°C. On
whey agar the colonies are circular, irregular, a greyish-white
in colour and curled at edges. Gelatine is not liquefied and
potato gives no growth. The lactic acid formed is either
inactive or else laevo-rotary.

No peptonisation of the curd takes place. It is non-patho-
genic, and may be given even to infants.

The following distinctive characters of the two varieties may
be of use :

Type A (long bacillus) : Stains homogeneously with
methylene blue, 27 to 37 per cent, of lactic acid formed, and
is inactive.

Type B (strepto-bacillus) : Metachromatic granules with
methylene blue, 12 to r6 per cent, of lactic formed, and is laevo-
rotary.

It is important that a vigorous strain of bacillus should be
obtained, as weakly ones are easily inhibited and tend to die
out quickly.

Now as to the methods of preparing and administering

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1910 .] BY J. GEORGE PORTER PHILLIPS, M.B. 425

the bacilli, they may be administered («) in solid form—tablets,
powder, and gelatine whey ; ( b ) in liquid form—bouillon of
various kinds and curdled milk. The tablets and powder are
quite unsatisfactory, owing to the small number of living
organisms present in some brands and the total absence of
living organisms in others. The lactic gelatine whey, when
carefully and freshly prepared, is an admirable method of
administration, especially to melancholiacs who refuse the
milk or to other patients who are already well nourished, but
there is no other special advantage in adopting its use.

In the liquid form we have various fluid media at our dis¬
posal : (a) milk, (£) lactose whey, (c) maltose whey, ( d ) malt
extract solution.

In order to prepare the lactose and maltose whey one must
proceed as follows: To each litre of milk add i'5 c.c. of HC 1
and boil carefully for five minutes ; in this way the casein will
clot and separate. The whey may now be filtered through a
piece of fine-mesh muslin. To each 100 c.c. of whey add
two grammes of the sugar, maltose, or lactose. The most
reliable sugars are those manufactured by Messrs. Kahlbaum.

Curdled or soured milk has now become so popular a
panacea that the prescription has found a prominent place in
the pharmacopoeia of convention. Every dairyman has of late
been initiated into the craft of bacteriology, and now claims to
supply a pure sour milk, curdled by means of the real
Bulgarian bacillus, the names of Professor Metchnikoff or
Professor Massol being tacked on to assure the public that the
organism employed is the one advocated and used by these
pioneer scientists respectively. Many dairy companies manu¬
facture and offer for sale a genuine and reliable sour milk, the
whole process being carried out under scientific control. The
chief objections to this source of supply are the expense, and, in
outlying districts, the trouble entailed in obtaining a fresh daily
supply.

For purposes of treatment of a number of hospital patients
it is only necessary to obtain an incubator working at 37°(or a
little higher], and a set of vessels for daily distribution. An
ordinary-sized bacteriological incubator of Hearson’s manu¬
facture is sufficiently large for supplying curdled milk for
twelve patients. Hearson’s have a special form of incubator
for this process, but the ordinary pattern suffices.

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TREATMENT OF MELANCHOLIA,

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There are various kinds of bottles used for the distribution
of the milk, but after practical experience of the different
patterns I have found an Erlenmeyer flask of 300 c.c. capacity
the most useful and serviceable. This holds about half a pint.
The advantages are that, being made of thin glass, it is easily
sterilised in a hot-air oven at high temperature without crack¬
ing, and the tapering neck with its moderately wide mouth
lessens the chances of contamination, the aperture being readily
plugged with cotton-wool.

The preparation of the curdled milk is quite simple, but
good results are only obtained when a strict ritual is observed,
the keynote being efficient sterilisation.

The milk to be perfectly sterile should be brought up to a
temperature of 1 20° C. Not only is it difficult to obtain this
temperature by ordinary means, but also it imparts an un¬
pleasant flavour to the product. For ordinary purposes it is
sufficient to bring the milk up to the boiling-point for five
minutes, as by this method all organisms are destroyed with the
exception of the spores of the Bacillus subtilis and the Bacillus
butyricus.

The flasks, having been washed with warm water and soap,
are drained, plugged with cotton-wool and sterilised at a tem¬
perature of 140° C. for twenty minutes in a hot-air sterilsier.
This procedure should be carried out on the daily return of the
empty flasks from the wards. By having a duplicate set of
flasks for each patient this method of cleansing and sterilisation
can be adopted with ease and advantage. The cotton-wool
plug is removed from each flask and the sterilised milk poured in,
the plug being at once re-inserted. It only remains now for
the cooling to take place and the inoculation to be made.

The most convenient way for perpetuating a healthy and
vigorous culture of the bacillus is to keep a couple of sterile
flasks specially for the stock cultivation of the organism.
These are filled with sterile milk and inoculated with a few c.c.
of the original or initial culture, purchased, or otherwise
obtained from some reliable source. After incubating for twelve
hours we have a stock culture, from which one is able to obtain
a plentiful supply for inoculation purposes. Fresh stock
cultures should be prepared every two or three days. Five to
ten c.c.’s of this culture are taken up in a sterile pipette and
ejected into each flask. The wool-plugged flasks are now

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1910 .] BY J. GEORGE PORTER PHILLIPS, M.B. 427

placed in the incubator for eight or ten hours, at the end of
which the milk in a curdled state is ready for distribution to
the wards.

A daily bacteriological examination should be made to
investigate the growth and purity of the culture.

One meets with various difficulties in the process, and the
following points are useful to be remembered : (1) Failure of
the organism to grow. This may be due to the presence of
antiseptics in the milk (this is likely only in summer), or to a
weak or dead culture being used for purposes of inoculation.
(2) Contamination. This may be due to careless sterilisation
of milk or flasks. These sources of failure should be sought
out and rectified, especially the latter, as pathogenic organisms,
e.g., streptococcus, staphylococcus, Bacillus cnteritidis sporogenes,
Bacillus typhosus , etc., may be present in a sample of milk.
From this fact it is self-evident how important it is to sterilise
the milk efficiently before putting it into an incubator, where
under more favourable conditions multiplication of the harmful
organisms takes place before the inhibiting effect of the lactic
acid can be exerted.

Two flasks, each holding about half a pint of the preparation,
are sent into the ward for each patient, one portion being
taken at 11 a.m., and the other at 4 p.m., or, if preferred, at
breakfast and supper, the milk being whipped up with a little
cream and sugar. In this way the whole contents of each
flask are used up at each separate meal, and there is no fear
of contamination, as the flask is not used again until it has
been washed, drained and sterilised.

During the treatment it is necessary to adopt a strict regimen.
At the onset the patient is placed on—

Diet A. —Suppress all food with the exception of milk, malt
extract and sugar of milk solution. After two days give in
addition gruel, milk puddings, custard, bread-and-butter biscuits.

After three to seven days adopt—

Diet B.—Avoid meat and all soups or gravy. Give yolks
of eggs, milk, cream, bread-and-butter, potatoes, milk puddings,
fruit and vegetables. After one week allow fish every other
day.

By this means the pabulum for the growth of proteolytic
organisms is reduced to a minimum whilst that suitable for the
multiplication and acclimatisation of the lactic acid bacillus

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is increased. Although the lactic organism can be demon¬
strated in the faeces a few days after its regular administration,
it takes at least a week or ten days before it becomes properly
acclimatised. After acclimatisation it continues to thrive for
twelve days longer without another dose being taken, and after
that it tends to disappear.

During the early part of the treatment, in a few cases where
the large intestine is in a state of atony, intestinal spasm may
occur giving rise to colic. I have also noted headache, tinnitus,
itching of the skin and nausea as unpleasant concomitants.

A somewhat marked feature in many of the cases noticeable
at the end of the first week is the aggravation of the constipa¬
tion. Some means has to be taken to combat it. Boiled
vegetables and fruit greatly aid the regular evacuation of the
bowels, and figs, prunes and boiled apples should be given
freely in the dietary until the constipation lessens in severity.
Some cases are so obstinate that medical treatment has to be
resorted to ; for these I have found the morning use of a
glycerine enema or a nightly dose of treacle (1 or 2 table¬
spoonfuls) very efficacious. Even after a few days’ treatment
one is able to notice a difference in the appearance of the
patient. The complexion is clearer and he wears a happier
expression. The dry, furred tongue becomes moist and clean,
and an increasing desire for food gradually appears.

As stated above, the constipation, although obstinate at
first, tends to decrease. The fasces increase in quantity,
become softer, and of regular consistency, and the offensive
smell diminishes. Objectively with these changes the daily
excretion of ethereal sulphates in the urine becomes less.

In order to check the quantity of faeces passed Schmidt’s
method should be adopted. This consists of separating off
the stools of three days by means of a small meal of charcoal
biscuits. In this way it has been found that a healthy person
will pass during the three days a quantity of faeces which when
dried will weigh 60 grm., whereas that passed by a habitually
constipated person will not average more than 30 grm.

For the determination of the amount of ethereal sulphates
excreted in the urine Salkowski’s method is the best. The
inorganic sulphates are precipitated by means of an alkaline
solution of barium chloride. Barium sulphate is formed, which
is filtered off, and the filtrate, after being acidified with HC1

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is heated just up to boiling-point. This results in the decom¬
position of the ethereal sulphates, which immediately combine
with the barium salts present in excess. The precipitate is
now collected on a filter-paper of known weight, ignited and
weighed.

Coincidently with the amelioriation of these symptoms a
marked increase in the patient’s weight takes place. Usually
from about the fourth or fifth day the patient puts on weight
steadily, and I have record of a case in which the weight
increased at the rate of nine pounds in nine days. For the
purpose of control I have had patients weighed in the usual
way on admission, put on ordinary diet, and their weight and
symptoms noted at intervals of a week. In the majority of
these cases only a slight increase, and in others no alteration
in weight was noted, and the symptoms were in no way
amelioriated. After a few weeks, or in some instances much
longer, the patient was put on the lactic acid bacillus treat¬
ment.

In all cases which subsequently proved to be the genuine forms
of melancholia, and not depressed states of other mental con¬
ditions, a decrease of the symptoms and an increase of bodily
weight ensued.

The increase of body-weight was registered weekly and the
results placed on special weight-charts.

The weekly increase varied from 1 to 5 lb., and the total
increase during the whole duration of illness ranged from 12 to
28 lb.

Up to the present we have been discussing chiefly the
physical side of these cases. Now let us view the mental side
of the picture.

As described above, the patients undergoing treatment
gradually lost their depression and accompanying delusions,
and the state of lethargy present in so many cases became one
of activity, the rigidity of the large joints soon disappearing.
The patients suffering from delusions without hallucinations
were the most amenable to treatment. Those cases in which
hallucinations appeared showed slower recovery. Eighteen
male cases were treated ; of these, two who are still on
treatment are returned as improved, the final decision as to
cure or otherwise being unable to be legitimately given.
Of these eighteen cases eleven have recovered : two still on

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430 TREATMENT OF MELANCHOLIA. [July,

treatment have improved ; four un-cured (one of which proved
subsequently to be a general paralytic) ; one died (agitated).
In every case treated the body-weight increased consider¬
ably.

I wish here to acknowledge the valuable assistance which
has been rendered me by Mr. Philip Crowe, our pathological
assistant.

Conclusions.

The lactic acid bacillus has a decided beneficial effect on
cases of true melancholia with disturbance of the alimentary
canal: (a) By diminishing the amount of toxins absorbed

from the intestinal tract ; ( b ) by promoting a rapid and easy
assimilation of food material—a very important factor, as in
the majority of cases the previous history shows there has been
great decrease in body-weight. It certainly shortens the
duration of illness and increases the chance of recovery. The
percentage of recoveries is increased from 46 per cent, to 61
per cent.

From a careful study of numerous cases I am convinced
that a large number of them could be mitigated by early
treatment with the lactic acid bacillus.

Its value in correcting defective alimentation suggests that it
might be used with great advantage in other mental conditions.

(') A paper read at the Spring Meeting of the South-Eastern Division, held at
Hanwell, on April 26th, 1910.

Bibliography.

Benjamin White. —Centralblattfiir Bakteriologie , Part 2, November,

1909.

Stoddart. —Mind and its Disorders , 1908.

Massol. —Revue medicale de la Suisse Romande, 1905.

Cohendy.— Comptes Rendus de la Societe de Biologic , 1906, vol. i.
Schmidt. —Examination of the Functions of the Intestine by means oj
a Test Diet, Philadelphia, 1906.

Macleod. —Practical Physiology , 1905.

Herschell. —Sour Milk and Pure Culture , second edition, Glaisher,

1910.

Combe.— DAuto-Intoxication Intestinale, Lausanne.

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JOURNAL OF MENTAL SCIENCE, JULY, 1910.

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^ hnpr.

PRINCETON UNIVERSITY

To illustrate Mr. J. George Porter Phillips’s paper.

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PRINCETON UNIVERSITY

1910 .] THE PSYCHOLOGY OF FREUD AND HIS SCHOOL. 43 I

The Psychology of Freud and his School* By Bernard
Hart, M.B., Assistant Medical Officer, Long Grove
Asylum, Epsom; Lecturer in Mental Diseases, University
College Hospital.

The present paper endeavours to describe, in a short and
summary form, the principal tenets of the school of psychology
founded by Professor Freud, of Vienna.

The task is one of very considerable difficulty. Freud’s
researches, originally confined to the phenomena of hysteria
have spread and ramified in all directions—every department
of psychology, psychiatry, aesthetics, mythology and folklore,
have been successively invaded. Any attempt to reduce even
the broad outlines of all this mass of material into the limits
of a short paper seems foredoomed to failure. Secondly,
although Freud has extended his work into the sphere of
normal psychology, yet he approaches his subject from the
standpoint of the abnormal. It is possible, therefore, that
theories which are satisfying enough to the psychiatrist may
appear forced and incomprehensible to psychologists more
accustomed to the sane than the insane. I must hence crave
your indulgence for those portions of my paper which seem
confused and unconvincing—and I trust that you will ascribe
the blame rather to the difficulty of presentation than to the
subject itself.

It is obvious that an article of this length cannot hope to
be more than descriptive. No attempt whatever will be made
to demonstrate the accuracy of Freud’s observations, nor to
justify the theories which have been built upon them. My
purpose is merely to set forth the general principles of Freud’s
teaching, with sufficient illustrations to make the meaning of
those principles clear. The illustrations will be taken as far as
possible from normal life, but it must be remembered that the
conceptions we shall describe owe their origin, and much of
their force and utility, to the facts of abnormal psychology.

There are two methods by which it is possible to carry out
the task before us. Freud’s psychology may be described
along the lines of its historical development, pointing out in
order the facts which were originally observed, the theories

* Read before the British Psychological Society, at Oxford, May 7th, 1910.

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which were designed to explain them, and the gradual
alteration and growth which those theories have undergone as
a result of subsequent research and experience. On the
other hand, we may take Freud’s views in their most recent
and completed form, analyse the fundamental conceptions
upon which they are based, and consider the utility which
they now possess as weapons of explanation and therapeutics.

The second course is the only one which can be carried out
satisfactorily in a short paper, and we shall therefore adopt it.
Nevertheless, a few preliminary words concerning Freud’s
historical development will no doubt be of some interest.

Freud was a pupil of Charcot, and therefore early became
acquainted with the French school of psychology. The
keynotes of that school, culminating in the work of Janet,
were its insistence upon the psychological method in the
investigation of the psycho-neuroses, and its development of
the conception of dissociation. These essential first principles
were taken over by Freud, and for some time his researches
and those of Janet could be regarded as two parallel lines of
advance. Later, however, though much remained in common,
they tended to diverge—and at the present day they represent
two clearly differentiated schools of thought.

The starting-point of Freud’s psychological career may be
said to have been the moment when he became acquainted
with certain observations made by Dr. Breuer on a case of
hysteria, and with certain tentative theories which Breuer
proposed as a result of those observations. Realising that the
theories were capable of a great development, Freud became
associated with Breuer in the investigation of other cases along
similar lines, and their combined work led finally to the
publication of the well-known Studien iiber Hysterie in 1895.
Subsequently the partnership was dissolved, and Freud con¬
tinued his researches alone. These were at first confined to
hysteria and the allied psychoneuroses, but he was soon led to
extend them into wider fields. Owing to the fact that during
psycho-analysis, a process we shall subsequently describe,
Freud’s patients constantly related dreams they had expe¬
rienced, his attention was early directed to these phenomena.
He made them the subject of a detailed study, the results of
which were ultimately produced in the Trauvideutung , pub¬
lished in 1900. Certain general theories concerring the role

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played by sex in the genesis of mental abnormalities were
published in the Drei Abhandlungen ziir Sexualtheorie in 1905.
Various other works, such as Der IVitz, Psychopathologie des
Alltagslebens , etc., contain extensions of Freud’s method of
research into departments of normal psychology. Freud’s
followers have developed his work in many directions. The
best known of these followers, Dr. Jung of Zurich, claims to
have confirmed Freud’s fundamental views by the methods of
experimental psychology, mainly by the use of association
experiments.

These somewhat scrappy remarks must suffice so far as
historical development is concerned, and we must now turn to
the detailed consideration of Freud’s theory and practice as
they stand to-day.

The structure of Freud’s work may be regarded as composed
of—(1) the observation of certain facts, (2) the construction of
concepts designed to explain those facts. The facts observed
were primarily the psychological phenomena occurring in
hysteria and the so-called obsession neuroses ; secondly, the
phenomena of the more pronounced psychoses constituting the
insanities ; thirdly, certain facts of normal life bearing a more
or less close resemblance to those found in the abnormal cases.
It is not possible here to do more than enumerate a few
examples of the phenomena included under these headings.
Thus we have the various dissociations of consciousness which
the French school have demonstrated in hysteria—anajsthesias,
paralyses, convulsions, somnambulisms, multiple personalities,
etc. Then the symptoms characterising the insanities proper—
hallucinations, delusions, incoherent speech, etc. And in
normal life—dreams, and a number of other phenomena
obviously to be regarded as minor grades of the disturbances
found in the hysterical and the insane.

Freud strove to achieve a comprehensive explanation of
these facts by the construction of certain theories. The essen¬
tial basis of these theories was the conception of the “ uncon¬
scious,” and a clear idea of what Freud means by the unconscious
is a necessary preliminary to any adequate grasp of his psy¬
chology. Freud’s conception has been frequently misunderstood,
and assailed upon altogether unjustifiable grounds. It has
been confused with the subconscious of Janet and the French
school—and the failure to appreciate its conceptual character

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has led to the production of a great deal of nonsense, mas¬
querading in the guise of criticism.

The conception of the unconscious arises from the adoption
of a purely psychological method in the investigation of psy¬
chical facts. It is assumed that phenomenal consciousness,
comprising everything of which we have immediate experience,
constitutes but a small part of the total psychical universe.
The part which remains is the unconscious. So far there can
be no disagreement, except, perhaps, with regard to the termin¬
ology employed. The next assumption is that all the non-
conscious portion can be treated psychologically, that is to say,
it can be conceived as a play of psychical elements subject to
psychological laws. The processes occurring in the unconscious
are further conceived as exerting a causal action upon the flow
of phenomenal consciousness. Here, of course, is the crux of
the matter. According to the physiologically minded, when
we leave phenomenal consciousness we leave psychology,
and the unconscious is only to be conceived as brain-traces,
brain-dispositions, and so forth. Freud claims, however, that
it is possible to attempt the explanation of phenomenal con¬
sciousness not only by conceptions couched in the terms of
physiology, but also by conceptions couched in the terms of
psychology. The psychological conceptions constructed with
this aim are what Freud means by the unconscious.

The factors which determine the course of phenomenal con¬
sciousness are conceived to be certain psychical systems, gene¬
rally referred to as “ complexes.” A complex is built up of three
elements, or better.it presents three aspects: (i) Intellectual
elements, (2) the emotional or affective tone appertaining to
these elements, (3) certain definite conative tendencies. These
last two elements form the characteristic properties of the
complex, and provide, as it were, the thread on which the
individual parts are strung. They belong, in fact, to the
complex as a whole, and it is only in virtue of these constituents
that we can speak of the complex as a unit.

A simple example will make it clear that, in spite of all this
ponderous language, we are so far treading on very ordinary
ground : When a party politician is called upon to consider a
new measure, his verdict is largely determined by certain
constant systems of ideas and trends of thought. In Freud’s
terminology we should describe this fact by saying that the

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politician’s view on the measure in question is determined by
his “ political complex.” The complex causes him to take up
an attitude towards the proposed policy which is quite inde¬
pendent of any absolute merits that the latter may possess. A
Liberal measure is obvious justice to a Liberal, obvious injustice
to a Conservative. If we argue with our politician we shall
find that the complex will re-enforce in his mind those argu¬
ments which support the view of his party, while it will infallibly
prevent him seeing the arguments propounded by the opposite
side. The complex with its pronounced emotional tone is, in
fact, a far more potent agent in determining the direction of his
thoughts than the cold claims of logic. Now it should be
observed that the subject is probably perfectly unaware of this
mechanism within himself—he fondly imagines that his opinion
is determined solely by the logical pros and cons of the measure
put before him. In other words the individual is himself
ignorant of the forces actually deciding the flow of his con¬
sciousness. In the language of everyday life we should say
that the politician was unconsciously biassed. In the language
of Freud we should say that the direction of his thinking was
the result of an unconcious complex.*

This example will, I think, show what is meant by a complex,
and the type of action it exerts in a normal mind. There is
nothing new in the conception itself—it has much in common
with James’s “seifs” (i) and with Shand and McDougall’s
“sentiments.” Shand (2) defines a “sentiment” as “an or¬
ganised system of emotional tendencies centred about some
object.” Complexes, then, are the forces which determine the
behaviour of the conscious stream ; we do so and so because
we are dominated by such and such complexes. They may be
regarded, in fact, as the psychological analogue of the concep-
f ion of “ forces ” in Physics. It is needless to point out that a

* The above description of the unconscious has been greatly simplified for the
sake of clearness—perhaps to an undue extent. In the final chapter of Die
Traumdeutung, in which Freud discusses the general principles underlying his
conceptions, the psychical field is divided into the Bewusstsein, Vorbewusste, and
Unbewusste. The Bewusstsein corresponds to what is, in this paper, described as
“ phenomenal consciousness.” The Vorbewusste comprises the various mental
elements which, although not at the moment in the Bewusstsein, can be brought
there without any resistance on the part of the Zensur. The Unbewusste com¬
prises the mental elements which cannot be so brought into phenomenal
consciousness, on account of the resistance offered by the Zensur. From the
point of view adopted in this paper there is no intrinsic difference between the
Vorbewusste and the Unbewusste, and both have been therefore included in the
unconscious.

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complex is not a phenomenal constituent of the mind : we
cannot speak of complexes in the sense in which we may speak
of sensations and perceptions; they are not things which we ever
actually experience. On the contrary, we invent the complexes
in order to explain our experience. In other words, they are
purely conceptual in character, and belong to the same cate¬
gory as atoms and ether waves. As McDougall (3) says of his
“ sentiments,” “ such a system of emotional tendencies is not
a fact or mode of experience, but is a feature of the complexly
organised structure of the mind which underlies all our mental
activity.”

Freud conceives complexes as having a permanent existence
in the mind, corresponding to the brain-trace of the physiologist.
They are not, of course, constantly active, but only become so
under certain conditions. They may be said, in fact, to possess
both kinetic and potential energy. A complex only becomes
active when it is “ stimulated ” in some way. This stimulation
occurs whenever one or more of the ideas belonging to the
complex is roused to activity, either by some external event,
or by processes of association occurring within the mind itself.
Thus in the simple example we have taken, the “ political
complex ” might be stimulated by a conversation in which some
political subject was introduced, or by a chain of associations
leading from some indifferent idea to an idea definitely belong¬
ing to the political sphere. So soon as this necessary stimula¬
tion has occurred, the complex immediately tends to exert its
effect upon phenomenal consciousness. The effect consists
normally in the introduction into consciousness of the various
constituent ideas, emotions and conative trends belonging to
the complex. Of the ideas, arguments, etc., presented to the
individual, those which are in harmony with the complex are
re-enforced, whereas those not so in harmony tend to be
inhibited and to lose their force.

The mode of thought produced in this manner by the
activity of a complex is quite different from that occurring in
genuine logical thinking. In the latter case each step is the
logical consequence of the preceding steps, evidence is im¬
partially weighed, and the probability of various solutions is
dispassionately considered. Such genuine logical thinking is
in real life extraordinarily rare—in most cases a “ complex
bias ” is only too obvious. Even in the world of science,

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generally regarded by the ignorant as the peculiar sphere of
dispassionate and cold thought, complexes play a vast part.
The discussions of any learned society provide most instructive
material in this respect.

The effects of a complex are in direct proportion to the
intensity of its affective tone. When this intensity is very
high the complex makes its influence felt almost constantly
upon the flow of thought and action. Consider, for example,
the immensely powerful complex formed in the young man who
has recently fallen in love. Ideas belonging to the complex
incessantly emerge into consciousness, the slightest associative
connections sufficing to arouse them. All his mental energy
is absorbed in weaving trains of thought centred about the
beloved one, or, as it has been expressed, in “ dressing the
complex,” and he cannot divert his mind to the business of
the day. Every event which happens is brought into relation
with his passion, and the whole universe is for him nothing
but a setting for his dominating complex.

The effects of complexes upon the flow of thought have
been experimentally demonstrated by Jung in his well-known
work on associations (4). He found that in the ordinary
association experiment the reaction obtained varied considerably
according as the stimulus word had or had not aroused a
complex into activity. The reactions characteristic of the
activity of a complex were increase of the reaction-time, various
peculiarities in the reaction word, failure to reply with the same
word on repetition of the experiment, and alterations in the
electrical resistance of the body as evidenced by a galvano¬
meter. The following example illustrates some of these

points (5).

Stimulus word.

Reaction word.

Reaction time.

(1) Head

Hair

1-4

(2) Green

Meadow

( 3) Water

Deep

S'°

(4) Stick

Knife *

(5) Long

Table

I '2

(6) Ship

. Sink

3'4

( 7 ) Ask

. Answer

. 16

(8) Wool

. Knit

(9) Spiteful

. Friendly

(10) Lake

Water

4-0

LVI.

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Stimulus word.

Reaction word.

Reaction time.

(11) Sick

Well

(12) Ink

Black

(13) Swim

Can swim .

3-8

The patient from whom this series was obtained had, during
a recent attack of depression, determined to commit suicide
by drowning. This complex has manifested itself in the
associations which are italicised. (3), (6), (10), and (13) are
instances of increased reaction-time; (13) shows also a
peculiarity in the reaction-word itself.

As a result of his researches, Jung maintained that by
means of the association experiment it was possible to obtain
information concerning the principal complexes in the mind of
a given subject. This method is, as a matter of fact, now
generally adopted by Freud’s followers as a preliminary to a
detailed psycho-analysis.

I hope that sufficient has now been said to indicate what is
meant by the conception of complexes, and the part which
they play in normal life. We must now examine how far
their functions become modified under abnormal conditions,
and the manner in which they produce the symptoms of the
psychoneuroses and insanities. As a preliminary measure it
will be necessary to describe two further conceptions of Freud
—“ repression ” and “ censure.”

Suppose that a complex is for some reason out of harmony
with the remainder of the personality. This may be because
its emotional tone or conative trends are opposed to those of
the personality as a whole, or perhaps because they are incom¬
patible with reality. In this case the personality may endeavour
to rid itself of the complex as of a foreign body, to throw the
complex out of action, and as far as possible to banish it from
the mind and forget its very existence. This is the process of
“repression.” In its minor degrees repression is common
enough in everyday life ; to find its more marked manifesta¬
tions one must enter the sphere of the abnormal. It is gene¬
rally seen whenever some emotional event of an intensely
painful nature has occurred. Under such circumstances the
individual will endeavour to repress the offending complex—or,
more simply expressed, to put it out of his mind. Such a
mechanism would probably occur in the case of our young
man in love, should his suit be unsuccessful. He would be

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generally recommended to “ forget his disappointment,” “ to
“ think of something else,” “ to do so and so with a view to
distracting his mind from the painful thoughts.” All these
phrases, translated into the language of Freud, mean that he
would endeavour to repress the painful complex.

The effect of repression is to prevent the complex exerting
its normal action upon the flow of consciousness, that is to say,
the complex can no longer cause its constituent ideas to emerge
without resistance into consciousness, and it can no longer
cause the flow of thought and action to proceed in the direction
of its own conative trends. Repression means, therefore, that
a certain resistance is opposed to the complex which prevents
the latter affecting consciousness in its normal manner. To
this resistance Freud has given the name of “ censure ”
( Zensur ).

In spite of repression and the censure, however, the complex
preserves an autonomous existence, and continues to influence
the flow of phenomenal consciousness, but the influence is now
distorted and indirect. The character of this distorted influence
is dependent upon many factors—the intensity of the complex,
the degree of repression, the power of the censure, and those
unknown forces vaguely termed “ constitutional predisposi¬
tions.”

Under certain circumstances the resistance offered by the
censure may be sufficiently great to produce the complete dis¬
sociation or splitting of consciousness found in hysteria. As
an example of this mechanism we may cite the case of Prof.
Janet’s patient Irene (6). Irene had nursed her mother
through a prolonged illness culminating in death. The circum¬
stances connected with the death were peculiarly painful, and
the event produced a profound shock upon Irene’s mind. A
definite hysterical condition developed, characterised by frequent
prolonged somnambulisms. During the somnambulisms she
lived over again the scene of her mother’s death, carrying out
every detail with all the power of an accomplished actress.
While this drama was in progress she was perfectly uncon¬
scious of the actual events happening in her environment,
heard nothing that was said to her, and saw nothing but the
imaginary scene in which she was living at the moment.
Suddenly the somnambulism would cease, and Irene would
return to her former occupation, absolutely unaware of the fact

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that it had ever been interrupted. If she were then interrogated
it would be found that in the apparently normal intervals she
had not only entirely forgotten everything which had happened
during the somnambulism, but that the whole system of ideas
connected with her mother’s death had completely disappeared
from her mind. She remembered nothing of the illness or its
tragic end, discussed her mother without emotion, and w r as
reproached by her relatives for her callous indifference to the
whole subject. Translating all this into the language of Freud,
we should say that the system of ideas connected with the
mother’s illness and death formed a complex of excessively
painful emotional tone. It was therefore altogether repressed,
and the censure prevented its making any entrance into con¬
sciousness along the ordinary channels. Hence her complete
loss of memory for all the events in question. The complex
nevertheless preserved an autonomous existence, and at inter¬
vals the censure was broken down and the complex burst into
consciousness, leading to the production of the somnambulisms
we have described. The censure ensured, however, that the
painful complex should remain dissociated from the personality,
and its appearance upon the stage could only be accomplished
by the temporary annihilation of the normal waking conscious¬
ness.

In this case the censure, during the periods intervening
between the somnambulisms, altogether prevents the complex
coming to the surface of consciousness. But a quantity of the
available psychical energy, if one may employ this somewhat
metaphorical expression, is used up in achieving the repression.
Hence the amount at the disposal of the personality is lessened,
and we have those persistent hysterical symptoms generally
grouped under the names of aboulia and abaissement du niveau
mentale —listless indifference, an inability to carry out any con¬
tinuous train of thought or action, and a lack of all efficient
reaction upon reality.

The same mechanism, though in a higher degree, is to be found
in cases of multiple personality. Morton-Prince’s famous “ Miss
Beauchamp” (7) may be cited as an illustration, especially with
reference to the group of conative trends forming the delightful
personality of Sally.

In other cases of repression, the censure, although preventing
the complex from manifesting itself normally, allows it to

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influence phenomenal consciousness, provided that the effect is
so distorted that its real significance is concealed from the
personality. Thus, in the case of Lucy R—, described by
Freud in 1895 (8), the patient was constantly troubled by a
subjective sensation of smell, together with various aboulic
symptoms of the kind we have already mentioned. She stated
that the smell sensation resembled the odour of burning pastry.
Analysis revealed that, two months previously, an important
event had occurred, connected with a complex of great
emotional force. At the moment when this episode happened,
some pastry then being cooked was neglected and became
burnt. The complex in question was subsequently, after a
severe mental conflict, repressed, and apparently disappeared
from the patient’s mind. It manifested its continued existence,
however, by the constant presence in phenomenal consciousness
of an element only connected with the real traumatic ideas by
a chance contiguity—the subjective sensation of smell.

In many cases the symptom appearing in consciousness has
a symbolical relation to the content of the repressed complex.
Examples of this mechanism in minor degrees are frequently
met with in everyday life, especially in connection with the sex
complexes, which are subject in every individual to a consider¬
able degree of repression by the education and conventions of
society. Thus the well-known enthusiasm which certain elderly
unmarried women devote to the keeping of dogs and cats, and
their intense interest in births, marriages, and scandals—these
are all explainable as symbolic effects of a sex complex whose
normal manifestation has been repressed.

Or, again, the repression of a complex may be evidenced by
the presence in phenomenal consciousness of directly opposite
ideas in an abnormally intense form. The offending complex
is thereby, of course, efficiently concealed. This mechanism is
likewise common enough in normal life. Thus, an acquaint¬
ance of mine had, in his early youth, an intense desire to go to
a public school and subsequently to enter the Army. Both these
ambitions were frustrated, and now my friend has a bitter
dislike for the public school system and a sovereign contempt
for the Army. He is not even aware that his views on these
subjects were ever different from those he holds now, or, rather, it
is an unpleasant fact which he will not acknowledge to himself.
Similarly the repressed sex complex frequently manifests itself

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by an abnormal prudery—witness once more certain elderly un¬
married women. In general we may say that whenever we
encounter an intense prejudice we should at once suspect the
existence of the opposite complex in a repressed form. Turn¬
ing now to the definitely abnormal cases, it will be found that
this mechanism is at the bottom of many obsessional symptoms.
An obsession, of course, is an idea or action which haunts the
individual in spite of all his efforts to rid himself of the incubus,
although he may be perfectly aware of its absurdity and lack
of all logical justification. Thus a patient may be obsessed with
the idea that he is about to die, or that he will injure someone
peculiarly dear to him ; or, again, he may have an irresistible
impulse to perform some action, to touch every lamp-post, or
to carry out some complicated ceremonial before embarking
upon the simplest business of the day. In all these cases we
have an idea in consciousness which is, as it were, overweighted,
and the explanation is usually to be found in a mechanism
similar to that we have just described. The obsession repre¬
sents, often in a symbolic form, the opposite of some complex
whose presence is a constant offence to the personality.* One
often finds, for example, obsessions such as “ washing mania,”
an irresistible desire to wash the hands at every moment of the
day, when some morally objectionable, but unconquerable, habit
is present which arouses constant remorse in the mind of the
patient.

Certain hallucinations may be similarly explained as distorted
manifestations of a repressed complex. Thus a patient is
tormented by “ voices,” which reproach him with various crimes
he has not committed. The crimes in question, however, bear
a symbolical relation to portions of his past, formerly the occa¬
sion of an intense remorse. Such cases may be regarded as
literal examples of the “ small voice of conscience,” distorted by
repression.

While we are engaged upon these questions of repression and
the censure it will, perhaps, be of interest to say a few words
concerning Freud’s theory of dreams, which has played such an
important part in the development of his psychology. Accord¬
ing to Freud dreams are the expression—generally in symbolic

* Here, again, Freud's view has been described in a somewhat unduly simplified
form. Strictly speaking, the obsession is an idea in consciousness to which the
affect properly belonging to a repressed idea has become attached—the conscious
idea is not necessarily the opposite of the one which is repressed.

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form—of complexes which are subject to a more or less degree
of repression. During the waking state the censure is sufficiently
strong to prevent these complexes effecting an entry into con¬
sciousness, but during sleep the resistance is so weakened that
the complex is enabled to manifest itself. The censure, how¬
ever, preserves enough power to ensure that the complex can
only make its appearance in a distorted and symbolic form. A
simple example from my own experience will perhaps make
the meaning of this rough statement clear. A colleague who
occupies a post senior to me upon the staff of Long Grove
Asylum recently applied for an appointment at another institu¬
tion. His success would have meant my promotion—but he
happens to be one of my greatest friends, and I should certainly
resent the suggestion that his departure could occasion me any¬
thing but genuine sorrow. Nevertheless I dreamt this dream :
He and I were endeavouring to write in an inconceivably small
room. The space was so cramped that the movements of one
constantly interfered with those of the other. A quarrel
resulted, and I had the satisfaction of finally pushing my col¬
league and friend outside the door. In other words the
complex whose existence I would not acknowledge in the
waking state managed to express itself in a symbolical form
during sleep.

The distortion effected by the censure is often, however, far
greater than in this very transparent instance, and the task of
interpreting the dream then becomes one of extreme complica¬
tion and difficulty. A character figuring in the dream may be
a “ condensation,” as it is termed, of two or more real individuals
—that is to say, the dream character combines in himself attri¬
butes belonging to several quite distinct persons. Or again,
two or more complexes may combine in their action, so that
the dream drama symbolises two or more independent trends of
thought. As Freud would say, the individual elements of the
dream are “ constellated ” by a multiplicity of complexes.

Space does not permit of our entering further into this
subject, or of our offering any criticism of the vast structure
which Freud has built up in this field. We may perhaps be
allowed, however, to touch upon a misconception which has
arisen from a certain inadequacy in Freud’s terminology. He
has laid down the axiom that every dream is to be regarded as
the fulfilment, in a symbolic or distorted form, of some wish.

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This statement has aroused considerable opposition, and it
cannot be denied, I think, that the word “ wish ” is singularly
unsatisfactory. It tends to arouse the notion of a definitely
realised end, which the mind deliberately strives to achieve.
So far as I understand him, Freud’s meaning would be better
expressed by the term “ conative trend.” We should then say
that every dream permits the conative trend of some complex
to manifest itself against the resistance of the censure. If
Freud’s general theory is admitted, and the significance of com¬
plexes has been clearly understood, the statement under con¬
sideration then becomes almost a truism.

In all those cases of repression of a complex which we have
hitherto described, it will be seen that the process actually to
be observed is a mental conflict. Two opposing or incom¬
patible trends are simultaneously present, and the mind is, as it
were, divided against itself. The conflict is solved, not by a
fight to a finish, but by a process of compromise. One of the
opposing trends is repressed, its existence is ignored by the
personality as a whole. But the repression can be effected
only at a certain cost. This cost is represented by the sym¬
ptoms we have already described—obsessions, somnambulisms,
aboulia, prejudices, and a multitude of other manifestations,
comprising in their major forms the symptomatology of hysteria
and other psychoses, and in their minor forms many of the
anomalies of everyday life. It must be carefully observed that
it is not the mere conflict which is morbid, but the method by
which the conflict is assuaged—the compromise,and the injury to
the efficiency of the individual which this compromise inevitably
brings in its train.

In these emotional conflicts and their avoidance by processes
of compromise formation, Freud sees the essential mechanism
of the psycho-neuroses. In a paper which recently appeared
in the Sociological Review , Mr. W. Trotter (9) has shown that a
similar mechanism may be observed in the sphere of social
psychology—a conflict between, on the one hand, the primary
instincts of the individual and the facts of his experience, and
on the other hand, the conventions of education and civilisation
acting upon him by means of the “ herd instinct.” Between
these two frequently incompatible factors every individual must
find a compromise of one kind or another.

Returning to our main subject we must say a few words

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concerning the methods of investigation and therapeutics
employed by Freud in the analysis and treatment of the
psycho-neuroses. These are based upon certain empirical facts
discovered in the course of his researches. He found that if a
repressed complex were brought to the light of day, so that
the individual was forced to recognise its existence, and to
face once more the conflict which he had previously avoided
by the process of repression, then the complex was deprived of
its morbid powers, and the symptoms of the psycho-neuroses
disappeared. Such a procedure enables the individual to
acquire an objective attitude towards the opposing trends in
his mind, and the formation of compromises is stopped. In
order to obtain this end Freud contrived his well-known
method of “ psycho-analysis.” The aim of the method is the
discovery of the various complexes underlying the symptoms
in any given case. It will be remembered that, owing to the
operation of the censure, the individual is himself ignorant of
the real nature of the pathogenic complex. The latter can
only manifest itself to consciousness in the various distorted
forms we have previously mentioned. The problem was,
therefore, to circumvent the censure in some way. Freud
achieved this originally by the employment of hypnotism.
By hypnotising the patient he succeeded in temporarily
weakening the force of the censure, and unearthing the
complexes of which he was in search. Later, however, he
found hypnotism to be often inapplicable or ineffective, and he
gradually replaced it by his present procedure of psycho¬
analysis. The patient is encouraged to unburden his mind
fully to the physician. He is asked to relate every idea or
memory which occurs to him, but to make no attempt to
direct or control the flow of his thoughts (Zwatigsloses
Assoziiereri). It is necessary that he should adopt an entirely
non-critical attitude, recording everything which passes through
his mind, however trifling or irrelevant it may seem to be.
The ideas thus recorded will be almost all conditioned by the
complex, and the more successfully the non-critical attitude is
achieved, the more nearly will these ideas indicate the real
nature of the complex. Various peculiarities in the character
and mode of production of the images and memories described
by the patient enable the physician to estimate their signifi¬
cance ( Deutungsverfahren ). By persisting in this procedure

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the underlying complex will be finally unearthed with a rapidity
varying directly with the skill and experience of the physician.
Its nature and bearings are then fully explained to the patient.

It must be realised that the method of psycho-analysis and
its claims to therapeutic efficiency rest almost altogether upon
an empirical basis—its theoretical justification is by no means
perfectly clear. Freud’s primary assumption is, of course,
that the actual consciousness of the moment is rigidly deter¬
mined by the past, and in particular by the affective past, or
rather by the forces in which this affective past is conceived to
be now embodied, namely, the complexes. In his method of
psycho-analysis he further assumes that this process may, as it
were, be made to retrace its steps, to proceed in the reverse
direction ; that, provided the censure be inhibited by the adop¬
tion of a non-critical attitude, it is possible to start from the
morbid symptom and proceed along a chain of associations
leading ever nearer to the pathogenic complex. The complex
thus found is then assumed to have been the primary cause
whose active functioning produced both the chain of asso¬
ciations and the morbid symptom itself. It is true, of course,
that we are not called upon to imagine that during psycho¬
analysis links of a chain which actually led from the complex
to the symptom are successively reproduced in inverse order,
but merely that the two end terms, the complex and the
symptom, will be identical in the two processes. Nevertheless,
we cannot pretend that the theoretical aspect of psycho-analysis
is entirely satisfactory, and we must reiterate our statement
that at the present time it can only be justified empirically.
Freud claims that the empirical justification is very strong.
He asserts that the coherent picture of the whole disease
process obtained at the end of an analysis, the discovery of a
satisfying explanation for almost every symptom, and the
power of profoundly influencing the course of the disease, are
proofs of great cogency. Almost everyone who has taken the
time and trouble to master Freud’s technique—a task, by the
way, of no mean difficulty—has confirmed his results in all
their essential details. But, even if all this be admitted, there
is still room for doubt. The initial method of non-critical
associations might be reasonably established by proofs of this
kind, but the Dcutuvgsverfahre?i introduces a conveniently
mobile factor which inevitably arouses some distrust.

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Freud’s methods have been carried by his followers into
many fields. Perhaps the most important of these extensions
has been the work of Dr. Jung in the sphere of the definite
insanities. In his Psychologie der Dementia Prcecox , published
in 1907, Dr. Jung showed that in the large group of insanities
included under the name of dementia praecox it was possible
to trace psychological mechanisms identical with those demon¬
strated by Freud in the psychoneuroses. The emotional
conflicts, the repression of complexes, and the development of
compromise formations were all to be met with. He found,
moreover, that the extraordinarily fantastic and apparently
incomprehensible symptoms which make up the clinical picture
of dementia praecox could all be regarded as exaggerations
of the mechanisms which were known to play a part in the
phenomena of normal life—more particularly, of course, the
phenomena of dreams. We can make no attempt here to
follow him into this field, but perhaps the description of a
simple case will give an idea of the way in which these
conceptions illuminate some of the problems of insanity. The
case is taken from a paper of Dr. Jung’s, entitled Der Inhalt
der Psychose (10). A man of between thirty and forty
years of age, of exceptional intelligence, and an archaeologist
of note, was brought to the asylum in a condition of acute
maniacal excitement. He was of short stature, thin, and
weakly, and he stuttered abominably. His history was as
follows: He had been an intellectually precocious boy, and
had early devoted himself to the study of archaeology, finishing
his education at the University of B—. At the conclusion
of his university career he buried himself altogether in the
pursuit of his science, cut himself off more and more from the
world and from his friends, and finally led the life of a
complete hermit. Some years later, while on a holiday tour,
he returned to B—, where he spent most of his days in long
walks among the outskirts of the town. After one of these
excursions he complained of feeling nervous and restless. A
state of excitement developed, passing rapidly into the acute
delirium which led to his removal to the asylum. On admission
he was intensely confused, had no idea where he was, and
spoke only in short sentences which nobody understood.
Periods of violent excitement were often present, during which
he attacked all those about him, and could only be restrained

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by the united efforts of several attendants. Gradually the
delirium abated, and one day the patient suddenly awoke as if
from a long dream. He rapidly returned to his normal con¬
dition and was discharged from the institution. He immedi¬
ately resumed his former life, and in the following year produced
several works of the first rank. His acquaintances only observed
that he seemed more of a misanthrope and more of a hermit
than ever. Then once again he came to B—, and again
occupied his days in long walks. A fainting attack in the
street was followed by an outbreak of delirium, and for the
second time he was brought to the asylum. On this occasion,
however, the symptoms were different from those noted during
his former illness. He performed complicated gymnastics all
over the room, spoke of his marvellous muscular power and
bodily beauty, announced himself to be a great singer, and con¬
tinually sang love ditties of his own composition. After a
time the delirium lessened, he became more accessible, and it
was possible for Dr. Jung to undertake an analysis of the case.
The final result of his investigations was as follows : While the
patient was a student in B— he fell in love with a certain
lady, and they were in the habit of taking long walks in the
neighbourhood of the town. The shyness and feeling of shame
of the stutterer prevented him from declaring his passion, and,
moreover, marriage was at that time a financial impossibility.
At the end of his university career he left B—, and never again
saw the lady. Shortly afterwards he heard that she had married
somebody else. Then he buried himself in his hermit’s life, and
strove to forget ; in other words, the complex, painful through
its incompatibility with reality, was repressed. Then came his
journey to B—, and the first outbreak of delirium—the repressed
complex burst on to the surface. He found himself in the chaos
of a mighty dream ; great battles were in progress, and he was
always in the centre of the fight, performing prodigies of valour
and leading the armies with marvellous skill, while the lady
watched and awaited him as the prize of victory. This was
the period when he blindly attacked all those about him and
struggled furiously with his attendants. Then came the final
victory—the bride approached and he awoke once more to
reality and the dull routine of his life. The complex was again
repressed. It will be observed how closely the content of this
delirium resembles the ordinary day-dreaming of the adolescent

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—which is likewise, of course, a symbolised expression of the
sex complex. The difference consists merely in a degree of
dissociation which permits the complex to manifest itself in a
definitely hallucinatory form, altogether cut loose from the
control of the personality. In the second attack, which, like
the first, was preceded by a visit to B—, the course of events
was somewhat different. The complexes which then mani¬
fested themselves, although obviously closely allied to the sex
complex, were rather those which had arisen as a result of his
bodily infirmities. It will be remembered that he was stunted
and unattractive, his muscles atrophied and weak, and that he
stuttered abominably. He was entirely unmusical, his voice
was harsh, and he was incapable of singing a note in tune.
All this formed part of a complex of bodily shame, which we
saw in action at the time he was courting his lady. Coupled
with it, of course, was the intense secret desire that the defects
could be removed. During the second attack of delirium this
was the complex which emerged to the surface, with all its
conative trends fictitiously fulfilled. He was immensely strong,
and a gymnast of the first rank—hence the complicated antics
he performed around the room. He was the greatest singer
in the world, and a prodigious orator. He possessed, in fact,
the corresponding virtue for every defect which reality had
inflicted upon him. This type of hallucinatory fulfilment is
extremely common, and is the mechanism producing the kings
and queens to be found in every asylum. Freud has referred
to it as a flight into the disease to obtain a refuge from reality.

The similarity between this case and the dreams of normal
life will be obvious to everyone. The parallel may, indeed,
extend much further. In the more advanced cases of dementia
praecox we find all those mechanisms—condensations, sym¬
bolisms, distortions of speech, etc.—which Freud has demon¬
strated in the ordinary dream. As Jung expresses it: “ Let
the dreamer walk about, and act like one awakened, and we
have the clinical picture of dementia praecox/’

Those who have some acquaintance with Freud’s work will
be surprised that I have so far made no mention of his sex
theories. The omission has been partly the result of want of
space, but to some extent it has been deliberate. To the
majority of Freud’s critics the sex theories form the essence of
his work, and it is these they have seized and rended. To me,

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however, the sex theories are not the whole of Freud’s work—
they are not even its most important part. Freud’s great con¬
tribution to science has been his demonstration of the mechan¬
isms underlying so much of normal and abnormal life, and I
hoped to emphasise this fact by deliberately neglecting his
other aspect. I propose, however, to indicate roughly the
relation which these two aspects bear to one another.

We have seen that the various mechanisms described were
all regarded as the result of a mental conflict, the existence of
simultaneous opposing trends in the mind—and as the methods
by which the conflict was avoided. Now Freud found, as the
result of experience, that the complexes which tended to be
repressed were in most cases of a sexual nature. This is also
what we should have expected a priori. The enormous power
of the sex complexes, the equally powerful repressions imposed
by education and all the conditions of civilisation—in these
forces we have all the factors necessary for an intense mental
conflict. Freud, however, has gone further than this purely
empirical statement. In his endeavour to find wide-reaching
generalisations he has constructed elaborate theories of the
essential nature of the sex complexes, their biological develop¬
ment, and their axiological significance in the causation of the
various types of psychical abnormality. These theories have
undoubtedly a great body of evidence in their favour. On the
other hand, Freud has, during his long career, altered them to
a considerable extent, and one cannot feel assured that a
similiar fate will not await them in the future. They are
entitled to impartial consideration and to every investigation—
but a sceptical attitude is, for the present, certainly justifiable.
In any case, however, the sex theories and the mechanisms form
two independent structures, which must be criticised and esti¬
mated altogether apart. The former may be regarded as still
unproven ; the latter have, I think, already justified themselves
in many of their essential points.

Genuine criticism of Freud’s work hardly exists—we are
badly in need of it. That which has been attempted has
generally foundered upon one of two rocks. Many critics have
totally failed to realise that Freud’s views deal largely with
conceptual constructions. They have imagined that his com¬
plexes and unconscious mental processes were phenomena on
the plane of sensations and perceptions, and have asked how

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their existence can possibly be demonstrated. This is com¬
parable to asking a Mendelian to produce his recessives and
dominants for general inspection. It is surely obvious that
Freud’s conceptions can only be established or disproved by
the process of applying them, and determining whether or not
they suffice to explain the phenomena observed, and to predict
the occurrence of future phenomena. Other critics—the
majority — confuse the categories in the most lamentable
manner. They attack Freud on the really astounding ground
that his theories are ethically objectionable, that it would not
be desirable for such things to be true, and that therefore they
are not true. On the other hand, certain of Freud’s followers
are, perhaps, too enthusiastic, and tend to convert his school
into something dangerously like a religious sect.

There can be no question that Freud’s works contain some
of the most valuable and stimulating contributions ever made
to the progress of psychiatry. He has carried psychological
determinism and the psychology of the individual to an extent
never previously attempted. His demonstration of the fact that
the flow of phenomenal consciousness is conditioned by psycho¬
logical causes of whose existence the individual is altogether un¬
aware—a fact known implicitly to every competent novelist
and historian—opens up a fascinating vista for future research.
We owe to Freud, again, the first clear formulation of the prin¬
ciple that mind can be treated as a phenomenon, capableof psycho¬
logical explanation, and the first systematic attempt to construct
a conceptual psychology—certainly a notable departure in the
history of science. He has, moreover, established a firm basis
for the oft-repeated phrase that the mental processes of the
insane are only exaggerations of those found in the sane.
Most important of all, he has shown the vast role which
mental conflicts play in the psychology of both sane and insane.

On the other hand, some of Freud’s work has been carried
out by methods which do not altogether harmonise with the
requirements of modern science. He has built up enormous
structures upon bases which have not been adequately estab¬
lished, and formulated wide-reaching generalisations from a
comparatively small number of facts. l ie may be said to have
the genius rather of the poet than of the scientist. In all his
books are ideas which astonish by the intensity of their illu¬
mination, and which inevitably arouse an answering thrill of

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conviction. But when he attempts to demonstrate their validity,
the facts often seem insufficient, and the deductions
unconvincing.

The need of the moment is—not the enthusiasm of the
disciple who builds the structure ever higher, not the undis¬
criminating attack of the a priori opponent—but the cold
criticism of the impartial investigator, who will examine the
foundations with every care, and estimate the justification with
which each stone has been laid upon another.

References.

(1) W. James.— Principles of Psychology, vol. i, p. 292.

(2) A. F. Shand.—“Character and the Emotions,” Mind, N.s., vol. v

(3) W. McDougall.— Social Psychology, p. 122.

(4) C. G. Jung.— Diagnostische Associationsstudien, Leipzig, 1906.

(5) C. G. Jung and F. Peterson.—“Psychological Investigations
with the Galvanometer and Pneumograph in Normal and Insane
Patients,” Brain, July, 1907.

(6) P. Janet.— The Major Symptoms of Hysteria, Londpn, 1907,
p. 27; “L’Amnesie et la Dissociation des Souvenirs par l’Emotion,”
journal de Psychologic normale etpathologique, 1904, p. 417.

(7) Morton Prince.— The Dissociation of a Personality, New York,
1906.

(8) Breuer and Freud.— Sludien iiber Hysteric, Leipzig, 2nd edition,
1909, p. 90.

(9) W. Trotter.—“ Sociological Application of the Psychology of
Herd Instinct,” Sociological Review, January, 1909.

(10) C. G. Jung.— Der Inhalt der Psychcse, Leipzig, 1908.

On the Functions of the Optic Thalamus and the Corpus
Striatumf ) By Jas. V. Blachford, M.D., Medical

Superintendent City and County Asylum, Bristol, and
Clinical Lecturer on Insanity, University College, Bristol.

Suggestions have from time to time been made as to the
probable functions of the basal ganglia, but so far none of
them appear to have been very satisfactory.

It seems to be generally accepted that the optic thalami
are not merely sensory centres for every or any special kind
of sensation, but are large association ganglia, and it is the
endeavour here to point out from anatomical, pathological, and

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other reasons the kind of associations with which they are
probably concerned, and the very important part they play in
the life of all animals possessing them.

It may be objected that the conclusions arrived at are not
in any way the result of experimental investigation, but when
dealing with structures such as these, which in the higher
animals are so deeply seated that considerable damage, or, at
least, disturbance, must be caused to surrounding and very
important nervous centres if they are operated upon ; this
method of inquiry seems to be not only useless, but often
misleading, for by whatever method they may be extirpated,
it is impossible to estimate the damage done to surrounding
parts, and if the experiments consist of attempts at stimula¬
tion it is impossible to prevent the diffusion of the stimulant
beyond the area under experiment, added to which in both
cases we have to take into consideration the effect of the shock
of the operation on the animal itself. In these circum¬
stances, a better way of arriving at a correct conclusion as to
the functions of such deeply seated and important nervous
ganglia seems to be by reference to their development, their
anatomical relations and the symptoms which are manifested
when in disease of the central nervous system they appear
to be chiefly affected, and by discussing how far this patho¬
logical condition interferes with that association of sensations
which makes an intelligent appreciation of our surroundings
possible.

First let us consider the developmental relations of the
optic thalami. They are developed as thickenings of the
postero-lateral aspects of the anterior cerebral vesicle. From
the same vesicle we have the optic vesicle budding out
giving rise to the optic tracts and retinas, and from its fore
parts the buds which are destined to become the cerebral
hemispheres.

We thus see that from the outset the parts which are
about to develop into the optic thalami are very intimately
associated with the cerebral hemispheres.

We next come to the consideration of their anatomical rela¬
tions. To commence with, the optic tracts are to a great
extent connected directly with them. The main fillet-fibres
are said to end in the ventro-lateral or main sensory nucleus
of Cajal; those of the central tract of the cerebral nerves,

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and of the fifth, in the anterior semilunar nucleus, which is
in close proximity to the main sensory nucleus. Axons from
the corpus mamillare reach the anterior part of the thalamus
through the bundle of Vicq d’Azyr, and so bring it into
communication with the fornix and hippocampal region, and
so probably with the osmatic centre. By the optic radia¬
tions of Gratiolet they are brought into direct communication
with the cortical visual centre in the occipital lobe.

By their anterior peduncles they communicate with the
fronto-parietal part of the cortex or sensori-motor area, and by
their inferior peduncles with the temporal region, and so, no
doubt, with the cortical centre of hearing. There are numerous
other connections with various parts of the central nervous
system, but for the present purpose it will be sufficient to
enumerate these. In studying the connections of the thalamus,
one curious and significant point arises, viz., that, although it
is intimately connected with the various parts of the cerebral
cortex and with the corpus striatum, by both afferent and
efferent fibres, those connecting it with the lower centres appear
to be mainly, if not entirely afferent. In the section devoted to
neurology in the last edition of Quain's Anatomy the following
statement appears: “From the thalamic nuclei the afferent
or sensory path is continued to most parts of the cerebral
cortex by fibres which arise as axons of the thalamic cells.
On the other hand, the thalamus receives fibres from cells of
most parts of the cortex. How the nervous impulses, which
descend along these fibres are continued to the lower centres
is not certainly known.”

As to the pathological symptoms the present discussion was
suggested by a case which died in the Bristol Asylum some
years ago and was the subject of a short paper. It was briefly
as follows: “ A man of middle age had been ailing for some
three and a half months, the symptoms being very rapid loss of
sight with oncoming dementia, the latter being out of all pro¬
portion to what one would expect from the loss of sight only,
and the condition of dementia arrived at in a few weeks being
far deeper than that occurring even in advanced general
paralysis. At the same time, as far as could be ascertained
(before this advanced condition was reached), there ,was no
corresponding loss of sensation.

“ On post-mortem examination no tumour or hsemorrhage could

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1910 .]

be discovered, and there were no signs of general paralysis,
but both the optic thalami and anterior corpora quadrigemina
were mottled, and on section being made the cells were found
to be degenerated.” In this case there was a history of syphilis.

In the same paper two other cases were reported, each
with a history of syphilis, with exactly similar symptoms, but
in each there was a marked improvement upon the administra¬
tion of pot. iod. in large doses, reaching as much as 3j three
times a day.

I think we are justified in assuming that these two were
similar in nature to the one which was post-mortemed , but
that the treatment at any rate delayed the fatal result.

In looking up records of cases of lesion of the optic
thalami (and these are few and far between), the chief
symptom mentioned is invariably that of dementia.

Can we in any way explain the above symptoms, if, as it
appears, we are dealing with a lesion of a basal ganglion and
not one of the cortex ?

Let us for a moment consider the nature of a simple per¬
ception : take that of a rough surface ; such a surface to
one who had vision only, but not the tactile sense, would
mean nothing except that it differed in appearance from a
smooth surface. Add the sense of touch, then, and whenever
the surface is seen and felt at the same time, two distinct
stimuli arrive at the central nervous system by different paths,
—one by the optic tract, the other by the fillet. After
a sufficient number of similar experiences, whenever one
sensation occurs it gives rise to a faint sensation or idea of
the other and vicc-vcrsa. How is this brought about ? There
must be a common link somewhere, otherwise a faint sensa¬
tion of the one would not follow a vivid sensation of the
other.

We have seen before that the part which is centrally
situated and most intimately connected with the cortical
centres for these sensations is the optic thalamus. We have
also seen that the most profound dementia occurs in lesions of
that body.

Seeing that the two most relational senses are those of sight
and touch, and that consequently anything which would inter¬
fere with their association would be most likely to bring about
the symptom we are discussing, I think we may reasonably

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infer that the association of the sensations of sight and touch
occurs in the optic thalamus.

Take next the sense of hearing: if, whenever a rough surface
is seen or touched, or both, the word “ rough 5 ’ is mentioned, then
on this sound being again heard, although there is no surface
to examine, the faint sensation of a rough surface, both in its
appearance and feel, will occur to the individual, and will con¬
stitute the idea of roughness.

The optic thalamus has been shown to be in intimate
connection with the cortical centre for hearing, so that in all
probability it is the association medium between these three
sensations.

What is the probable explanation of this. We must suppose
that fibres from the optic tracts arborise round cells in the optic
thalamus and anterior corpora quadrigemina bodies; from
these, axons pass to the occipital cortex and arborise round
visual cells, giving rise to the sensation of sight. Thence other
axons pass back to the optic thalamus to arborise round other
cells there. In like manner axons arise from cells in the
tactile cortex and pass to the optic thalamus, and there
arborise round the same cells; hence, whenever an object is
seen and at the same time examined by the sense of touch,
a certain kind of stimulus reaches these cells from the visual
cortex, and is immediately followed by a certain kind of
stimulus from the tactile cortex or vice-versa, and when
these changes have followed each other sufficiently frequently,
upon the production of the one the other will invariably
follow, though with less intensity.

The axons arising from the thalamic cells will convey the
result of these changes to the corresponding cells in the cere¬
bral cortex, where they will give rise to sensations consti¬
tuting the perception of the object observed.

The same will apply to sounds which can in any way be
associated with sight or touch.

If it be admitted that all our sensations are cortical—and
this seems to be generally accepted—and that our perceptions
are the result of the association of two or more sensations,
then there must be some centre in which they are associated,
and we have seen that from a developmental and anatomical
point of view the optic thalamus appears to be most suitable.
If we add to this the fact that in disease of this body we have

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a very pronounced dementia, which might be easily accounted
for by a loss of perceptive power, we have gone a great way
towards localising these association functions in the optic
thalamus. If this is so, the optic thalamus may be looked
upon as the centre for that association of the primary sensa¬
tions of sight, touch, and hearing, which, when registered on
the cortex, gives rise to the perception of things around us.

Let us go a step further; these cortical cells, which represent
the association cells in the optic thalamus, if stimulated from
some other source, will give rise to similar sensations, as if
the stimulus arrived from the optic thalamus itself; hence,
when in trains of thought arising in other parts of the cortex
they are affected, faint perceptions will arise in the mind, much
like those which would have originated had the stimulus
arrived from the optic thalamus, the only difference being that
whereas a stimulus arising in the optic thalamus necessarily
entails stimulation of the sensory cortex, from which the
afferent fibres to the optic thalamus arise, and so a vivid
impression as well ; in this case the faint impression arises
without any vivid impression, is therefore still more faint, and
forms what may be termed an idea. This being so, the
optic thalamus is indirectly responsible through its registered
impressions in the cortex for our ideas of the primary attributes
of things around us.

The senses of smell and taste have not been mentioned, as
they are so unrelational, and so form very few associations, but
in those cases in which associations are formed between these
senses and those of sight or touch these probably take place
in the optic thalamus, so that to summarise briefly the functions
of the optic thalamus :

(1) It appears to be concerned directly in the sensation of
sight, some of the cells, especially those in the pulvinar and
lateral geniculate body, forming relay cells between the retinae
and the cells in the visual cortex.

(2) It is the centre of association between sight and touch
themselves, and between these senses and all others, including,
perhaps, the muscular sense.

(3) Indirectly through its representative cells in the cortex,
in which these associations are permanently registered, it
makes possible those ideas of the qualities of things without
which thought, as we know it, would be impossible.

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Concerning the muscular sense, of which mention has been
made, it is very difficult even to speculate, but in those asso¬
ciations in which it is concerned it seems possible that there
is some other centre involved primarily, and that the optic
thalamus plays a secondary part; and more than that, seeing
how intimately it is associated with the internal capsule, with
its pyramidal and geniculate fibres, it seems not unlikely that
the other or primary centre for the association of muscle sen¬
sation is the corpus striatum. Should this prove to be so, then,
as the optic thalamus is responsible to the cortex for Supplying
it with associated material from which our primary ideas of
attributes arise, so the corpus striatum is responsible for supply¬
ing it with the associated material for the recognition of our
space and numerous muscle-sense relations, and so, ultimately,
for the material for all the higher and more abstract thoughts.

In the paragraph dealing with the probable anatomical expla¬
nation of the association of sight with the other senses in the
optic thalamus, it will be noticed that the new fibres reaching
the thalamic cells are mentioned as arising in the cortical
visual cells, and not as being collaterals from the fibres in the
optic tracts as they pass through or near the thalamus. Proof
that the association is not due to collaterals is derived from
the fact that in blindness caused by tumours in the occipital
region, although the retinal and corresponding tractal fibres
are not impaired, stimulation of the retina has not been men¬
tioned as giving rise to any other perception, such as one of
roughness, smoothness, etc., which one would expect to get if
the association were brought about by collaterals which arose
from healthy nerve-fibres before they reached the seat of
injury.

Another fact in favour of the optic thalamus being a purely
association centre connected with the various parts of the
cortex was mentioned in the paragraph dealing with its ana¬
tomical relations, namely, that the path along which nervous
impulses descend from it to the lower centres is not
certainly known; for if its function be to associate the various
cortical sensations these paths would be unnecessary, and,
therefore, non-existent.

(*) A paper read at the Spring Meeting of the South-Western Division held at
Bailbrook House, Bath, on April 29th, 1910.

In the discussion which followed, Dr. Aveline asked if the optic thalamus had

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459

been found diseased in many other cases of dementia. Dr. Blachford pointed
out that as far as he could ascertain it had not been so, and that in those cases
following acute insanities, epilepsy and general paralysis, there apparently never
occurred the very profound dementia arrived at in the cases here mentioned, and it
was this fact which made him suspect that the change giving rise to it must take
place at the very centre, where the association of the sensations, more especially
the more relational, occur. '

Some Points concerning the Diagnosis and General
Treatment of the Feeble-Minded. By W. R. Dawson,
M.D., F.R.C.P.I., Medical Superintendent, Farnham House,
P'inglas, Dublin ; late Medical Investigator to the Royal
'Commission on the Feeble-Minded.

The class of defectives with which I propose to deal briefly
in certain of its aspects consists of those persons over school
age who are capable of earning a living in favourable circum¬
stances, but are incapable, from mental defect existing from
birth or from an early age, (a) of competing on equal terms
with their normal fellows, or (b) of managing themselves and
their affairs with ordinary prudence—a definition which, though
rather rough, may be accepted as of some value in practice.
Such persons have been found by the Royal Commission on
the Feeble-Minded to constitute about 40 per cent, of all
aments in the United Kingdom ; and it has been estimated (')
that their numbers in England and Wales amount to between
50,000 and 60,000. In my investigation, in the City of Dublin
I found 365, or 30 per cent, of all aments. Thus they deserve
separate study from their numbers alone, apart from the fact
that, owing to their relatively high intelligence, they at once are
more dangerous socially, and repay help better, than any other
class of aments.

As regards detection, these cases naturally range themselves
in two classes, viz., those who, as defective children, have been
at special schools, and are therefore already recognised, and
those who have had no such advantage, a large proportion of
the latter (three-fourths in the Dublin investigation) being
found in workhouses and prisons. The balance of numbers
will incline more and more in favour of the former class with

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the development of special schools and institutions, until
eventually it may be hoped that the numbers of the undetected
and undealt-with feeble-minded will become insignificant. In
passing, the curious discrepancy in numbers between the adult
feeble-minded and the defective children may be noted, which
was conspicuous in my investigation as in those of others. It
has been thought that in urban districts this may be due to the
known tendency of the mentally feeble to drift into the country,
where the conditions of life are less strenuous and employment
requiring little intelligence is more readily found. On referring,
however, to the report of Dr. Mills, who investigated a rural
district in Connaught, I find precisely the same discrepancy,
and must therefore conclude that the difference in numbers is
partly due to the dying off of very many defective children
before they reach adult years, while some cases become insane
at the dangerous period of early adolescence, and pass into the
asylums; and lastly, it is probable that a considerable number
of apparently defective children in the schools are merely
backward, and that these will have overtaken their fellows
before reaching the age of 16. However this may be, it is in
the case of those who have not come under special observation
in their school years that difficulties of detection and diagnosis
will chiefly arise.

The difficulty of detection varies very much, and is, roughly
speaking, inversely as the degree of mental deficiency. Thus
there will, as a rule, be little trouble involved in learning of
and recognising the severer cases, just as with cases of idiocy
and imbecility, while those who are epileptic will usually be
discovered with ease. As regards even these last, however,
this is not necessarily always the case, since my experience in
Dublin was that, amongst the lower orders, epilepsy is regarded
as casting a greater slur on a family than mental infirmity;
and moreover, in the case of those at all able to earn their
living, the occurrence of even an occasional seizure would
be a bar to employment, although seizures, if infrequent, do
not necessarily prevent the winning of a livelihood.

The distinction between idiots, imbeciles and feeble-minded,
being one of degree and not of kind, is somewhat arbitrary, but
is necessitated by practical considerations; and the definitions
given by the Royal Commission are, from this point of view,
perhaps as good as any. Thus the criterion employed to

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distinguish the “ feeble-minded ” from those on the next
lowest stage, i.e., imbeciles, is capability, in favourable
circumstances, of earning a livelihood; while on the other hand,
as has been stated, the feeble-minded are distinguished from
the normal by their incapacity from birth or early age to
compete with others on equal terms, or to manage themselves
or their affairs with ordinary prudence. From the extremely
wide scope of the definition of feeble-mindedness, it is evident
that the degrees of deviation from the normal will differ greatly
in different cases; but difficulties in classification will be
chiefly encountered in dealing with cases on the borders of the
normal, and with those on the borders of imbecility. In most
others it is in practice sufficient for the examiner to ask him¬
self: Could the individual under any conditions earn a living,
and, if so, has he as good a chance as an ordinary person ?
In the more difficult cases, however, these questions can only
be answered after a thorough inquiry, the chief points of which
may be shortly touched on.

Of great importance is the patient’s history, both family and
personal. Mental abnormality in the family of an individual
affords presumptive evidence against his mental status in
proportion to the propinquity of the relatives so affected.
Personal history will yield important information on such
points as late and faulty development of the physical and
mental powers in childhood ; nervous symptoms in childhood ;
the amount of school education which has been attained ; the
patient’s habits, i.e., whether social or unsocial; his ability in
the direction of muscular acquisitions, such as games; and his
moral development. The last is of great importance, as most,
if not all, cases of “ moral imbecility ” ought to be included
under the heading of feeble-mindedness; and the points to be
sought for are such as indicate a tendency to objectless lying,
stealing, cruelty and mischief generally, in early youth, passing
into graver obliquities, often of a sexual kind, with advancing
years.

Taking next the bodily signs, the most useful may be briefly
alluded to without going minutely into the subject of stig¬
mata. A general survey of the individual in the first place
will usually yield a valuable impression as to his mental
status. Although many of the cases which are most deformed
and of lowest vitality never reach adult years, still smallness

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of size, malnutrition, defects of shape and unevenness of
development, with awkwardness of movement, and sometimes
tricks, such as lurching to one side in walking, betray the
faults of growth and function that go with mental defect.
Of the individual details, the size and shape of the head are
the most useful, and may alone be sufficient to determine
the existence of mental weakness. Thus a head with a cir¬
cumference of 18 in., with receding chin and forehead and
prominent nose, cannot be that of a mentally normal person;
and largeness of cranium, with projecting forehead and occiput,
of course points in the same direction, though with less certainty.
Of the smaller details, malformations of the ear, Assuring of the
tongue, a high narrow or deformed palate, and irregularity in
the arrangement of the teeth, are all useful points easily
observed, and of the greater weight when two or three of them
occur together. But on the other hand some feeble-minded
persons are perfectly well formed and even comely.

Peculiarities of speech are often present, and lead us
naturally to the consideration of the most important abnor¬
malities of all, those of mind, with which speech is so closely
bound up. One of the commonest of these, and, when very
marked, one of the most fatal to any chance of earning a live¬
lihood, is defect of the power of attention. Those in whom this
power is wanting are unable to concentrate their minds upon
anything for long. They cannot stick at a piece of work, or
read a few pages of a book, or keep up a sustained conversation
on one subject—the least thing withdraws their attention else¬
where, while the lethargic cases, wearied by the effort, lapse
into their usual state of listlessness. Such individuals often
seem to remember badly, but rather as a result of inattention
than from any real fault of memory, which in some feeble¬
minded is not only not defective, but is developed to an extra¬
ordinary degree. I have in mind a man who can give, per¬
fectly accurately, details and dates in the lives of prominent
persons, and knows their pedigrees unerringly ; yet he is so
weak mentally that on one occasion he tried to shave with a
cardboard razor, which he then handed back to the giver with
the remark that it was not strong enough! Perhaps, however,
the most useful faculty to test is the power of reasoning, which
may be investigated by simple devices such as that mentioned
by Tredgold, viz., sending the individual to fetch something

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from a room, the door of which was locked, but the key hung
in full view. Tests with money, such as the number of half¬
pence in two or three half-crowns, arithmetical tests, and com¬
parison of the sizes and shapes of objects, are all useful.
Many of the feeble-minded are emotionally unstable, easily
pleased or grieved, frightened or made angry, and as easily
calmed again, but others are lethargic. Lack of will-power
may be shown not only by inability to decide, but also by
deficient self-control; and lastly, the most recent acquirement,
the moral sense, may be wanting, but to decide on this the
history affords the most important indications. Before leaving
this part of the subject there is a practical point to which
attention may be called. The persons regarding whose mental
state a decision is required will be mainly of two classes, viz.,
those for whom aid is sought by parents and guardians, and
inmates of public institutions. We have seen that the majority
of the feeble-minded met with in Dublin have been found in
the workhouses and the prisons; and with reference to these it
may be worth while to note a peculiar difficulty which has been
encountered, viz., to make due allowance for the lingering effects
of alcoholic indulgence in those recently admitted. It was
found that “ a prolonged and frequently repeated debauch will
often leave a degree of mental hebetude, indistinguishable
from that of permanent mental weakness, which may last for a
week or more.”( 2 ) Such cases require a second visit after an
interval if a right decision is to be arrived at.

The difficulty in determining whether persons are capable of
earning a livelihood naturally arises chiefly in the case of those
on the border-line of imbecility. It is precisely here that educa¬
tion often turns the scale: and if it appears that such persons
have reasonable self-control and obedience, and a certain power
of attention, even should their intelligence be but small, a chance
may be given them amongst those who are feeble-minded only.
This, however, is a simple matter, practically, compared with
the forming of a decision regarding those at the other end of
the scale; and although it is perfectly true that there is a
difference in kind, and not only in degree, between the high-
grade feeble-minded and the normal, still the transition from
one to the other is by no means abrupt, but often exceedingly
gradual, and, moreover, it may affect the various “ faculties ”
of mind very unequally. It is amongst cases of this class that

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examples of so-called “ moral imbecility” are mostly to be found,
and they form some of the most difficult and troublesome cases
therein. The Royal Commission on the Feeble-Minded has
seen fit to classify these cases separately, though they do not
consider it “ scientifically correct ” to group cases of acquired
moral defect into a category apart from other “ persons of un¬
sound mind.” Their definition of moral imbeciles as “ persons
who from an early age display some mental defect coupled with
strong vicious or criminal propensities on which punishment
has little or no deterrent effect,” seems to me to render this
position inconsistent and untenable. The moral faculty is one
of the latest phylogenetic acquirements, and to a greater or less
degree is probably impaired in all mentally defective persons.
In most of these, however, this impairment is completely over¬
shadowed by the intellectual defects, and only in a compara¬
tively few is the opposite state of affairs to be found. But the
difference is relative only, and I submit that these cases should
be included amongst the feeble-minded. In practice they are
very troublesome cases, not only to diagnosticate but to deal
with, owing to the abnormal amount of intellectual develop¬
ment which they sometimes show, and which, in existing
circumstances, renders it impossible in many cases to send them
to an institution for detention. Amongst the lower orders, it
is true, alcohol and general debauchery are likely to develop
acquired intellectual defect in such persons, but this is not
always the case, and in the higher classes of society is frequently
not so. In the mildest cases the individual may merely be
exceptionally self-centred, incapable of appreciating the rights
and feelings of others, with little regard for time or money, and
governing his conduct entirely by his own likes and dislikes, to
which everything has to give way. Such an individual is
obviously not detainable; yet to a person of this character,
lying, drinking, sexual immorality and other vice come naturally;
and in more marked cases, where also the accompanying intel¬
lectual defect is more pronounced, the latter prevents him from
seeing beyond the moment’s gratification to the unpleasant
consequences which will follow, even if he has sufficient will¬
power to control himself if he did see. Apart from the pro¬
nounced moral imbeciles, there are two other classes of feeble¬
minded, as Tredgold points out, who are specially prone to
criminal acts, viz., the extremely facile who are unable to resist

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any suggestion, good or bad, and those who are liable on the
smallest provocation to outbreaks of violence resembling those
to which epileptics are prone. All three classes require to be
dealt with in very special ways, which brings us to the subject
of treatment.

Medical treatment, except in the case of cretins, can do
nothing directly for the feeble-minded, and it is now generally
agreed that surgical treatment is equally powerless, though
indirectly each serves a most important purpose in building up
general health and correcting physical abnormalities. Further
than this, all dealing with such cases must be by influences
which affect their whole environment.

The feeble-minded who have been educated in special
schools and classes up to the extent of their capability are
never, even in the most favourable cases, quite on a par with
normal folk. Even if, as now and then happens, they no
longer show overt signs of mental weakness, and are able to
earn fair wages, the brain weakness is still there, and the stress
and worry of ordinary life, of the critical epochs of life, or any
unusual shock, are always liable to cause a mental breakdown ;
and much more is this the case where development has been
less, and the permanent defect more pronounced. It is here
that “ after-care ” becomes a necessity for the purpose of look¬
ing after such cases generally, and seeing that they are placed
in the most favourable surroundings possible and provided with
employment securing some remuneration. But even amongst
those who have received every advantage there will always be
a large proportion of persons who cannot be left at large, while
naturally those who have reached adult years without any such
special training will show a still greater percentage. The feeble¬
minded not only develop late and slowly, but cease to develop
early, so that few are susceptible of much improvement after the
age of sixteen, though some may still be taught a little, and some
are capable of doing useful work of an unskilled sort. A large
proportion, however, will by this time have joined the ranks of
the criminal classes and gone to swell the population of gaols
and workhouses. I have already mentioned that, in Dublin,
the great majority of the feeble-minded were encountered in
institutions belonging to these two classes. The numbers in the
prisons were especially striking, and as they so vividly illustrate
the utter futility of merely punitive measures in dealing with

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offenders of this class, I may perhaps be allowed to mention a
few details. In the two Dublin prisons I found 12*21 per cent.
of defectives, of whom 17*72 per cent, were committed more than
once during the period of investigation, as against 8 per cent, of
the total committals, and less than 14 per cent, were first com¬
mittals. Two women were committed four times within a
month. The average number of previous convictions for the
male defectives was 17*76, and 15 of them had had over 50 convic¬
tions each,the highest being 70,82,85 (two),and 170. Even these
numbers, however, are insignificant compared with those shown
by the females, who had an average of 44*13 previous convic¬
tions each, while 19 showed 50 and over, and 14, 70 and over,
the highest individual numbers being 101,120,127,171,181, 214,
and 236. Of these, a lad, aet. 17, had had eight convictions ; a
man, aet. 23, 63 convictions; while the woman who heads the
list with 236 previous convictions was only 29 years old !
Surely this is a reductio ad absurdum of our present methods
of dealing with feeble-minded delinquents, or, indeed, with any
class of habitual offenders. To such, short periods of imprison¬
ment are no deterrent, and merely serve to restore their health
and strength in preparation for another outbreak on their
discharge. In this country such persons are practically always
alcoholic; and as, moreover, their immediate admission to
institutions inhabited by the better-behaved defectives is not to
be thought of, in the interests of the latter, the simplest and
most effective method of dealing with such would seem to be
the development of the inebriate reformatory system, a system
which, even in the comparatively small way in which it has
been tried, has already yielded promising results. To be really
efficient, however, the system should be extended by further
facilitating the committal of recognised inebriates to such
institutions for periods of not less than two years, to be
followed by a longer or shorter period of probation under
surveillance. Even with the existing law, however, more
might be done if magistrates could be induced to make further
use of the facilities at their disposal. A sojourn in such a
reformatory would have an improving influence in other
respects than alcoholic indulgence, by breaking the habit of
petty crime, separation from criminal associations and the
gradual development of habits of thrift and industry.

Apart altogether from the delinquents, however, a large

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class of feeble-minded will be left who cannot be allowed to
enter the rough-and-tumble of life for the purpose of earning
their living without much supervision, or who have unsuitable
homes, or no friends to look after them. This group will also
include almost all the younger women, whose mental weakness
continually exposes them to the risk of becoming mothers and
so perpetuating their own infirmity. And with all these, we
may note in passing, may be taken imbeciles, and the class of
so-called “harmless insane,” as the same kind of provision is
suitable for them all. The worst cases will undoubtedly
require to be kept in institutions, under constant supervision,
and epileptic cases would require special institutions for them¬
selves. Such as are liable to fits of uncontrollable violence, or
(pending the establishment of special institutions) are epileptic,
ought to be detained in public asylums or in annexes imme¬
diately connected with them. An absolute essential for such
institutions is abundance of land for farming purposes. Work
is necessary for the well-being of defectives, and outdoor work,
such as is afforded by gardening or farming operations, not
only is healthier, but requires little skill when carried out under
supervision. Indeed, in all cases this is desirable, and for the
bulk of such persons there can be little question that institu¬
tions on the colony system are best. Institutions of any sort
are, however, costly, and in view of the numbers to be provided
for, finance is a most important matter. For this reason, and
also because of the inherent value of the method, it was a
matter of disappointment that the recommendations of the
Royal Commission did not lay more stress on the system of
family care—a point which has been animadverted on by one
of the Commissioners themselves, Dr. Dunlop. Yet it seems
probable that, for financial reasons, some such method of
dealing with defectives, at once cheap and (for suitable cases)
efficient, affords the only chance that the recommendations of
the Royal Commission will be carried into effect within any
reasonable time. The saving effected in Scotland by the
boarding-out system has been estimated at between £40,000
and £50,000 a year.

To sum up : There will be required for the best class of the
feeble-minded a certain amount of supervision and friendly care
in their own homes, to be exercised—if the recommendations
of the Royal Commission be adopted—by regular officials in

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the case of registered and certified persons, in the case of
others by after-care associations; for those a little lower in the
scale, or much lower provided they are healthy and at the same
time quiet, harmless and manageable, some system of family
care—and here it may be noted in passing that such cases
form 35 per cent, of the patients at Gheel, and 45 per cent, of
those at Jerichow. For special classes special institutions will
be wanted—colonies for epileptics, reformatories for inebriates,
mental hospitals for those subject to attacks of insanity, and
closed institutions of a less expensive class for such as need
much supervision without the highly specialised treatment of
a hospital.

Amongst the latter would be included female defectives of
child-bearing age, even when comparatively high in the intel¬
lectual scale, as experience unfortunately shows that it is not
altogether safe to treat these on the “ family care ” system.
And before concluding I should like to add a few words on
this, which may be called the preventive aspect of the treat¬
ment of defect. No fact has been brought out.more clearly by
the valuable inquiries of the Royal Commission than the
hereditary nature of mental defect, thus reinforcing the views
previously held by most; and therefore it is clear, as has been
pointed out by them in other words, that measures desirable
for the safeguarding of the individual defective have the
further advantage of checking the propagation of defect. But
there is another factor of the importance of which the Royal
Commission are not so assured, viz., the influence of parental
alcoholism. Yet in addition to the a priori probability that
alcohol circulating in the blood of the parents must have a
prejudicial effect upon the germs of the offspring’s nervous
system, there is a considerable body of evidence tending to
show that it does so. To mention only a few facts; it has been
shown in the case of dogs and fowl that alcohol causes them to
produce abnormal offspring; in human beings, out of 1,000
cases of mental defect parental alcoholism was found in the
father in 471 cases, in the mother in 84, and in both in 65. In
another series it was found in 46'5 per cent, of 150 idiots and
imbeciles. Galton found a case where a man who was the
father of several normal children became a drunkard and had
imbecile offspring. Again, in 10 sober families, of 61 children
born, 50 survived infancy and were normal, whereas in 10

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families where one or both parents were alcoholic, out of 56
children born only nine surviving infancy were normal. Such
examples might be multiplied indefinitely, and are at least
highly suggestive, and Dr. W. A. Potts, who has gone into
this subject at considerable length, arrived at the conclusion
that although paternal alcoholism alone has not been clearly
proved to produce mental defect, it is plainly a most unfavour¬
able element, “while maternal drinking, and drinking con¬
tinued through more than one generation, are potent influences
in mental degeneracy.” If this be so, clearly it will not be
sufficient to seclude merely the feeble-minded inebriates, but it
ought to be possible to detain other chronic inebriates also
compulsorily. A Committee of the British Medical Association
long since recommended on somewhat different grounds that
compulsory detention should be legalised, with proper safe¬
guards, in the case of persons who, by reason of addiction to
alcohol or other drug, are at times dangerous to themselves or
others, or at times incapable of managing themselves or their
affairs; and the Departmental Committee on the Inebriates
Acts has more recently endorsed this view, which will command
the assent of most sensible people. But under this heading it
ought also to be made possible to transfer inebriate lunatics, on
their mental recovery, to inebriate reformatories or homes for
a prolonged period, as it is notorious that these cases recover
mentally long before there has been time for the eradication of
the drink habit, and being discharged, are a source of infinite
mischief and expense, constituting as they do probably the
largest class of recurring cases of insanity.

If some such stringent treatment of all inebriates be adopted,
in addition to the effective supervision of the existing feeble¬
minded, I am convinced that the problem of dealing not
only with mental defect, but also with acquired insanity and
with crime, will be one of rapidly diminishing importance for
future generations.

(>) A. F. Tredgold, Mental Deficiency, p. 147.—( a ) “ Report on the City of
Dublin,” Royal Commission Report, vol. vi, Appendix, p. 413.

Discussion,

At the Autumn Meeting of the Irish Division, on November 6th, 1909.

Dr. Greene said that the percentage of defectives in the Ennis Inebriate Re¬
formatory was not so high as that found by Dr. Dawson, but one of the inmates, a
female, had had 366 convictions, and was now in the asylum. Magistrates could
not send patients to inebriate homes unless their County Councils contributed,

LVI. 31

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and in the case of the reformatory at Ennis there must be conviction of an
indictable offence at quarter sessions, together with habitual inebriety. Sixty
per cent, of the discharges from Ennis did well. If the inebriate relapsed within
eighteen months he might be sent back to complete his sentence. Only three
cases had come to the asylum from the reformatory in eleven years out of some
three hundred cases.

Dr. Mills emphasised the necessity of providing for feeble-minded persons as
they grew up, since they were commonly the worst treated members of the family,
being made to do all the heaviest work, and worst fed. Such persons were very
susceptible to alcohol, and publicans often employed them and paid them in porter.
Most typical village drunkards were distinctly feeble-minded and deficient in the
power of providing for themselves.

Dr. Fitzgerald expressed himself as in general agreement with the views ex¬
pressed in the paper, and cited, as showing the influence of parental alcoholism,
two cases of first children who were idiots, the fathers having been drunk on the
marriage night. He regarded extreme mobility of the phalangeal joints as an im¬
portant stigma. A woman in the Cork gaol had had 440 convictions.

Dr. Nolan quoted Dr. Shuttleworth as to the great percentage of deaths from
tuberculosis at an early age amongst Mongolian imbeciles. He had himself main¬
tained the importance of maternal alcoholism. Mr. Fagan had urged the desirability
of training feeble-minded and normal children together, but his own knowledge of
institutions for children did not bear out this view', and he thought the imbecile
child had a bad effect on other children.

Dr. Leeper pointed out that the duty of providing for epileptics had not yet
been undertaken in this country, and he thought that the condition of this class
should be first taken in hand. Alcoholism was not always productive of alcoholic
insanity.

After a few remarks from the Chairman, Dr. Dawson briefly replied, mention¬
ing, amongst other things, that in alluding to the committal of inebriates he was
referring to the Ennis Reformatory.

Observations on Epileptics—Illustrating their Reaction
to the Purin hi Diet. (’) By Leonard D. H. Baugh,
M.B., Ch.B.Edin., Senior Assistant Medical Officer,
Gartloch Mental Hospital.

In a former paper (i) diet was referred to as a part of the
management of the epileptics under care in a mental hospital,
and the opinion expressed that, on a diet mainly purin-free{z\
tendencies to serial fits, confused states and dream states
appear less marked.

Further investigations tend to confirm the accuracy of the
statement then made, and as the subject is one of interest, and
one not as yet fully explored, summaries of some of the
observations are submitted.

The first is a synopsis of three and a quarter years’ study of
the effect on epileptics of diets of different purin standards
Three diets have been used, and are termed “ poor," “ moderate’’
and “average,” according to their purin content. Seven chronic
epileptic women, illustrating different degrees of mental evolve-

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igio.]

BY LEONARD D. H. BAUGH, M.B.

471

ment and phases of epilepsy, were selected, from those who
had been for some time under care, and in whom there was
no reason to expect new developments.

To exclude other factors and to minimise the margin for
error, all were chosen from patients who lived, and if workers,
worked, in the epileptic ward, and were thus least likely to
have their lives affected by environmental changes. With the
exception of C. L—, who needed for a few hours daily a rest in
bed, the cases, apart from their epilepsy, enjoyed average health.
At times during the three and a quarter years, on account of
epileptic manifestations, milk was given for a few days instead
of the prescribed diet. In the case of M. B—, owing to an
attack of scarlet fever observation was interrupted and was
not resumed.

The existence of a period of variation resultant from change
of diet is generally acknowledged. Although the extent of this
variation can be only approximately estimated, it should probably
be taken more into account than it often is.

In these chronic cases, I have decided to consider the first
three months on each diet as a period of variation and adapta¬
tion. The six months following the arbitrarily fixed period of
adaptation is regarded and studied as typical of the diet.
The adaptation periods themselves appear worthy of some con¬
sideration, and are incorporated in the table alongside of the
tabulations of diet periods.

Before giving tabulated results, one would like finally to
mention that precautions were taken to guard against autotoxic
absorption from the alimentary canal throughout the course of
the observations.

It is noteworthy that these chronic cases, placed as far as
possible, to react to dietetic changes alone, do not show the rapid
response to change of diet to which some writers have drawn
attention.

In J.M.D—,M.D—,and H.G—, all of energetic types, as might
have been expected, an increase in nitrogenous food appeared
at first to exercise a favourable influence; this lasted as long as
the purin standard was not raised too high, or the high pro¬
portion of purin was not too long continued.

If weight rose and then fell slightly, it appeared that it
might be interpreted as an indication that the higher purin
standard had been continued for as long as was beneficial.

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As these cases, on purin-moderate diet, got five or six meat
meals in a fortnight (thirty-five in three months), as well as cod
and tripe, it suggests that some might do very well with such a
purin-containing meal, say, twice a week (twenty-six in three
months), over considerable periods of time.

It would appear that purin-poor diet, although often the

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best for good general health, does not always mean fewer fits ;
some seem to have more fits on such diet.

In connection with the incidence of fits, from the study of
the table it is strikingly noticeable how an erroneous con¬
clusion regarding the patient’s state can be arrived at by noting
the number of fits alone; e.g., M. D—, who has very few fits at
any time, had fewer than usual when on purin-average, but as

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i 9 io.]

BY LEONARD D. H. BAUGH, M.B.

473

against that lost a little weight, and more often passed into the
phase which, for want of a better descriptive term, I refer
to as “hypochondriacal dream states.”

Further,on purin-average diet.M.M.G— and M.S—.while they
showed diminution in number of fits, showed no improvement
in general condition; both lost weight. M. M. G— culminated
in a series, and M. B— developed serial manifestations as a new
feature in her case.

That, when on purin-average diet, serial epilepsy manifested
itself for the first time in M. B— and J. McD— is deserving of
mention.

That auto-intoxication from the bowel could be excluded in
both M. B— and J. McD— suggests strongly that the strain
on metabolism played an important part in the production of
the serial fits. The vexed question, the toxaemic cause of
serial epilepsy, is outside the present purpose, but the intensi¬
fication in the two mentioned and in C. L—, plus, in her, marked
depreciation in health, may be noted as significant of a
toxaemia.

Second Summary .

Here we deal with a male who was never employed at any¬
thing beyond light ward-work. The period considered is two
years and ten months, and during the greater portion of the
time he got bromide.

J. G—, aet. 13, feeble-minded, stated to have fits frequently,
was admitted in May, 1907.

As there was no prospect of mental recovery he was regarded
as a suitable case to watch for some time without taking any
steps to ameliorate his condition.

He was allowed to go about whenever his attacks permitted,
and was given purin-average (ordinary asylum) diet.

From May 7th to June 30th he had 193 fits, was lethargic
and lost three pounds in weight.

In July he was put on potassium bromide, gr. xxx, thrice
daily. His attacks diminished in number (169 in six months),
he gained a stone in weight, but mentally he continued much
the same.

During this six months he took purin-average diet, except
for about three weeks in October, when, owing to a succession

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of serial attacks (eight-six fits), he was kept in bed, lost weight,
needed chloral as well as bromide and was on milk alone.

The year 1908 was on the whole uneventful. He had
bromide regularly.

Except during a breakdown (seventy-one fits) in May, he
had purin-average diet.

At the end of December he weighed 7 st. 12 lb.—an increase
of 16 lb. since corresponding time in 1907.

He had 249 seizures during the twelve months, and was not
any more alert.

In 1909 purin-poor food was given instead of purin-average
diet.

Bromide was continued until June 14th. He had forty-six
seizures (twenty-nine in March) in five and a half months,
weight remained stationary, and mentally he was much the
same.

Bromide was discontinued on June 14th, and he became
more active in his habits, and more alert mentally.

His weight rose from 7 st. 1lb. to 8 st. 5 lb. by January
13th, 1910.

There was no increase in fits on cessation of bromide : he
had fifty-nine (twenty-four in September) in seven months.

This year, on January 12th, he was replaced on purin-average
diet: he had seventeen fits in the last eighteen days of
January.

During the first eight days of February he was very lethargic,
and after fits (seventeen in number) his confusion became very
marked.

On the 6th it was feared a serial attack would pass into
status epilepticus, and for two days he got milk alone.

Purin-poor diet was resumed on the 9th.

From the 9th to the 16th he had eighteen fits, and remained
silly.

Between the 17th and the 24th, six attacks occurred, and he
was a little more alert.

On the 26th and 27th he had a fit each day.

Three seizures on the 28th were separated by hours and
there was no post-confusion ; this is best shown by quoting
written report of charge nurse : “ Five minutes after each fit he
was quite clear. I asked him to rise, lift the pillow, and put it
back on the bed. He did all asked in his usual way.”

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i 9 io.]

BY LEONARD D. H. BAUGH, M.B.

475

It may be, that the time during which a richer purin diet
was again exhibited coincided with one of his “ fit ” states, but
in number of attacks and presence of serial epilepsy, lethargy
and post-confusional states, this attack, which occurred during
and immediately following the administration of purin-average
diet, is only paralleled by the condition seen on three previous
occasions while on similar diet.

Third Summary.

In this case the patient was employed in the laundry
during most of the two years reviewed ; the factors of work
and extra food have thus to be taken into account.

J. S—, a good worker, usually contented and sensible, a little
over io st. in weight, had been on purin-average diet for about
twelve months, and had averaged about twelve fits a month.
After a fit she showed confusion, frequently less than one hour
in duration, always less than one day.

In February, 1908, she went to the laundry to iron and
work in the sorting-room ; there she had extra purin in the
form of soup, given as lunch to laundry workers.

There was a period of gain in weight, during which well¬
being and capacity for work were maintained. This lasted
until June 22nd (nearly four months), when she became con¬
fused, had to go to bed and take milk for a couple of days
before confusion cleared up; she then rallied, and resumed
work on the 27th.

From June 27th she remained at her normal for two
months ; then a severe serial attack necessitated her being in
the ward for over a fortnight until middle of September.

Before this attack she lost weight slightly, just as she had
done previous to the breakdown in June.

She next worked at laundry for one month ; again becoming
confused, she was kept in the ward over a fortnight.

As it was considered that diet and hours of work might
combine as causative factors of confusion, on November 4th was
put on purin-poor diet, and only sent to the laundry in the fore¬
noon. Under these conditions she did well for three months,
up to a serial attack on January 30th, 1909. She soon returned
to the laundry, only to break down again on February 16th,
and had to undergo bed-treatment until the 28th. All March,

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and first part of April, she showed a lot of confusion. Although
well in latter portion of month, she was kept in the ward. In
May, she was sent to work in the laundry the second part
of the day, so as to miss lunch, and continued to get purin-
poor diet at meal-time. Working under these conditions she
maintained her normal, for six months.

In November, a promise not to take soup for lunch having
been obtained from her, she started to work all day in
the laundry, and maintained capacity for work and freedom
from confusion (save of the transitory type usual to her), but
showed more irritability than her wont. On January 8th she
had a breakdown, and was off until the 14th, when she
resumed and worked until the end of month, thus doing nine
months with only one breakdown of six days’ duration during
the ninth month.

Fourth Summary.

Here the factor of extra food imposes greater strain, there¬
fore the reaction is more striking.

Epileptics, employed as kitchen workers, gave the general
impression that they tended to break down and show confusion
oftener than others. In order to investigate this, four cases so
employed were selected for observation.

The notes on two are withheld, as close investigation
revealed the facts that in one constipation, along with
frequent alimentary upsets, introduced complicating factors; and
that in the other, fits and breakdown were associated, or, at
any rate, coincident with menstruation.

In this connection, a question of such interest is reached
that it is worthy of digression to point out that, of eleven
menstrually active cases utilised for this paper, this ruled-out
case (C. K—) is the only one in which there was a definite
association between epileptic and menstrual manifestations.
Attention is drawn specially to this, as it is at variance with
the usual statement found in books, and it can unhesitatingly
be said that, in the eleven cases referred to here, the periods at
which menstruation occurred were very carefully noted.

The two whose charts are shown were, as far as could be
judged, free from complicating factors.

Observation in M. M— extended over two and three quarter

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i9io.]

BY LEONARD D. H. BAUGH, M.B.

477

years ; it was discontinued when she was selected as a subject
for investigation on another point not entered into in this paper.
In F. G— it was carried on for three years and two months.

nSQGSSBSSISEOISDSBQQSHQEOSIEOSEIQElEllBI-IElIZlIElCj

Case of M. M—, 2 years 9 mos. — indicates at kitchen work. - - - indicates
not at kitchen. | indicates a serial manifestation.

The longer period enables me to mention that, since the
breakdown over nine months ago, she has been kept from
kitchen work ; next, that, after emerging from past confusion
etc., six months ago, she has enjoyed a comparative state of

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mental and physical well-being. During this six months the

Years

1907

1908

1909

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Case of F. G—, 3 years 2 mos. — indicates at kitchen work. - - - indicates
1 not at kitchen. | indicates a serial manifestation.

fit rise is not appreciable. This period, by comparison with rest
of chart, discounts strongly any suggestion that might be

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i9io.]

BY LEONARD D. H. BAUGH, M.B.

479

advanced, as to the state developed while at kitchen work
being coincident with periodicity of fit state.

The charts show graphically the investigation. Attention is
arrested by one or two points particularly.

The fall in body-weight, increase of fits and mental collapse,
subsequent to employment that is steadier and more active,
and where purin-containing extra food, such as stews, soups,
etc., are liberally partaken of, all seem to support the conten¬
tion advanced (after the study of the table dealing with the
seven chronics), that purin standards should not be raised
high, or, if raised, that this high standard must not be too long
continued.

The persistence of fit state and confusion after a complete
breakdown emphasises the slow response to treatment of the
metabolism in epileptics, particularly when it is borne in
mind that, at such periods, the patient was given only purin-
free liquids.

The fit rise and accompanying loss of weight in F. G—,
in January, 1909, when diet was increased after treatment of
a breakdown, 1 regard as due to added stress being pro tern.
too much for metabolism, and as a further illustration of the
epileptic’s tardy return to the normal metabolic standard.

Before conclusion, I desire to thank Dr. Parker, the Medical
Superintendent, for having granted me free permission to use
material ; also other members of the staff who have aided me
by the careful keeping of books, records, etc.

In conclusion, although I do not suggest that diets in which
purin is low are the best for all epileptics, I do say without
hesitation :

First, that observations point to such diets being suitable to
the major number of epileptics.

Secondly, that the slow recuperation seen after a breakdown
when on a purin-average diet, a feature shown by all the
summaries submitted, supports the hypothesis that, when
taxed with a diet average or rich in purin, failure of the
organism to carry out metabolic functions plays a considerable
part in the production of the symptoms.

(') A paper read at the Spring Meeting of the Scottish Division, held on March
18th, igio, at Gartloch.

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480 COMMUNICATED INSANITY, [July,

References.

(1) The Writer.—“Observations on Insane Epileptics, treated under
Hospital Principles ,"Journal of Mental Science , July, 1908.

(2) I. Walker Hall.—‘The Purin Bodies of Food Stuffs,’ (published
i9°3)-

Communicated Insanity, by Arthur W. Wilcox, M.D.
Edin., Senior Assistant Medical Officer, County Asylum,
Hatton.

But why the term communicated? Is insanity catching?
Such was the question asked by this Journal some five years
ago referring to a case of so-called communicated insanity
mentioned in a county asylum report. In this article I shall
endeavour to bring evidence to show that in some few cases
apparently it may be so.

Hack Tuke ( L ), writing on “ Folie a Deux” some twenty
years ago, accepted communicated insanity as the best English
equivalent known to him for this French term.

His classification was as follows :

(1) Cases in which an insane patient distinctly infects
another person with the same mental disorder.

(2) Cases in which a person becomes insane from com¬
panionship, not in consequence of the direct transference of
morbid ideas, but in consequence of the shock arising out of
the painful impressions caused by witnessing the attack or by
the strain of nursing a patient.

(3) Cases in which two or more persons become insane
simultaneously from the same cause.

(4) Cases in which one lunatic infects another lunatic with
his special delusions.

(5) Twins.

The last two divisions I shall not again refer to, as it is not
uncommon to find in asylums patients who copy the actions
and suffer from the same delusions and hallucinations as other
patients with whom they are brought into daily contact, but as
these persons are already insane they can hardly come under
the category of cases of communicated insanity in its strict
sense ; while la folie gcmellaire is now generally recognised as
being quite distinct from folie a deux.

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1910.] BY ARTHUR W. WILCOX, M.D. 481

Hack Tuke admits that if we restrict ourselves to the idea
of contagion or communication of mental disease to another
we must dismiss from the above divisions the second and third
categories, but he found it convenient to use the term folie d
deux in a wider sense and to include them as did the French
writers. The term folie simultanJe given us by R^gis accurately
describes the third division, although he himself used it as a
synonym for folie d deux.

Communicated insanity affecting large numbers of people,
sometimes religion and sometimes politics being the exciting
cause, has occurred throughout all ages. Lombroso declared
that there are mental epidemics as well as physical, and he
attributed the frequent outbreaks of anti-Semitism, by which
his own race was afflicted, to this cause.

The latest example of an epidemic of contagious political
insanity in our own times is seen in the unlawful and in every
way extraordinary conduct of the suffragettes. Whatever the
justice of their cause may be, most people will agree with the
stipendiary magistrate who, with a pleasing alliteration, charac¬
terised their conduct as “ neither polite, politic nor political.”
It has been pointed out that should the hunger strike have
been allowed to continue and any one of this misguided band
of females been permitted to commit suicide by starvation, the
verdict of the coroner’s jury would undoubtedly have been to
the effect that she committed the act “ whilst temporarily
insane.”

The first case recorded by Tuke in the above-mentioned
article comes under his first division. Neither of the patients,
a gentleman and his wife, had an insane inheritance. The
wife was an Irvingite, who was induced to try some experi¬
ments with the planchette. She was the more strong-minded
of the two, and in the author’s opinion it was she who drew
her husband into the same path rather than the planchette.
She became a demonomaniac (Esquirol), was deluded and
suffered from auditory, visual and olfactory hallucinations.
She then infected her husband, who became the victim of
exactly the same distressing delusions and hallucinations as his
wife. Both patients ultimately recovered, although they utterly
refused to be separated during their period of alienation. The
husband, however, admitted some time after he had been able
to return to his business that he still heard voices when

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tired, but that he did not listen to them or tell anyone about
them.

Ten years ago E. W. Griffin reported in this Journal an
interesting case, which falls under the second division of Tuke’s
classification.

Two sisters were admitted to the asylum (one four days after
the other) suffering from acute mania. No family history of
insanity could be ascertained. Both had been nursing a third
sister suffering from mental aberration, and became insane, not
from any direct transference of morbid ideas, but from shock
arising from the powerful impression caused by witnessing the
attack and the strain of nursing the patient. Four years later
J. R. Lord added another to the recorded cases of true folie a
deux.

It is that of a mother, who in a very short time infected her
daughter, their mental disorder taking the form of paranoia
chronica.

This infection was probably helped, the author thinks, by a
similarity of mentalisation and temperament, the network of
delusions, which was a prominent symptom in both cases, being
probably elaborated between them—a double contagion, each
infecting the other. Both complained of persistent annoyance
for the last twelve years by a Salvation Army officer, who, as
a matter of fact, had been abroad for the last nine years.
They constantly saw this person running in front or walking
behind them in the street and looking through the window at
them when they entered a shop. This took place both when
they went out together or separately. They blamed this poor
man apparently for all the evils, real and imaginary, which had
befallen them during these years.

Within another year Goodall mentions a case of a father and
two daughters admitted to the same asylum at the same time.

In this case there existed neurotic degeneration in the family,
lonely surroundings, unusual anxiety, stress of mind amongst
those attacked, and a terrifying suddenness of onset in the first
case. Another curious feature was that death occurred in the
same way and from the same cause in two of the cases.

Urquhart refers in his Morison Lectures, published some two
years later, to the case of two sisters, the younger of whom
brought the elder to the asylum possessed of the necessary
papers for her detention. Both presented the same pronounced

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i9io.]

BY ARTHUR W. WILCOX, M.D.

483

delusions of persecution, both had experienced the same
mysterious influences, both had to obey simultaneously com¬
mands issued to them at the same moment, and both had seen
the same visions. The elder sister, who dominated the younger
and was the suggester of every morbid idea, had been insane
for a considerably longer time than had the latter. The two
cases were not by any means simultaneous in inception or
development or symptomatic phenomena, and the author thinks
that in this particular instance the occurrence of two cases of
insanity in the family was only what might have been pre¬
dicted. A history of heredity was ascertained, although at
first denied, and he says (the italics are his), I do not believe
that any case of this kind could be traced to a family other than
neuropathic.

He points out that the incidence of folie a deux is more
common in France and Ireland than in Scotland, and, I would
add, than in England also.

A typical case of folie a deux in which the wife infected her husband
has recently been under my own observation. The wife on admission
was suffering from paranoia. She was a steady, hard-working
woman, ret. 49, who had been married to her present husband for
the last seven years. She had two children by a former husband,
as had also her present husband by a former w'ife. No hereditary
history of insanity could be obtained. Her father died at the age of
forty-two of bronchitis and asthma, and her mother at the age of
seventy-one of the like diseases. Two brothers and one sister were
alive, and healthy mentally and physically. She had been confined in
an asylum for a short time a few years ago, but I did not obtain this
information until some time after her admission.

Her medical certificate was to the effect that she saw and heard
certain people, generally two men and a girl, about the house at night,
and also following her about during the day. She described them as
“ show-people,” and said that they wanted her head to put in their
show. Her husband’s daughter and her own daughter by her former
marriage she believed were bringing these people to take her away, and
that her only neighbour was lodging them. Her husband corroborated
these statements, which he believed to be true in every detail. After
her admission she quickly lost her hallucinations, but continued to be a
paranoic with systematised delusions of suspicion and persecution
against her own and her husband’s daughter. She would describe how
these show-people would throw stones at the window, and if this did not
annoy them sufficiently would climb up a ladder and blow foul gases,
smelling of sulphur, into the bedroom. They also, by means of electric
batteries she thought, would make her hands twitch and her mouth be
drawn to one side, or she would find that she was rocking to and fro on

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her chair, or in the night time that she was being dragged out of bed.
She assured me that her husband when he came to see her would
confirm all that she had told me, and that he also endured similar
sufferings During her residence in the asylum she was industrious and
well conducted and gave no trouble. She was ultra-polite, dropping a
curtsey when addressed, and evidently prided herself on her manners.
She was loquacious, and fond of bragging how well she had brought up
her daughter (who she said had married beneath her), and what a good
education she had given her. She would also mention the names of
numerous gentry who would speak as to her own good character and
respectability, although these were never in question.

I had an interview with the husband when he visited his wife about
a month after her admission. I found that he also was the subject of
paranoia, with exactly the same delusion as that under which his wife
laboured, and that he had suffered from many of her hallucinations also.
He was a steady, hard-working farm labourer, in a good situation and well
thought of by his employer. No family history of insanity was obtain¬
able. He stated that he regularly got up at five o’clock in the morning,
milked fifty cows, and then occupied the rest of the day in working on
the land. He was very comfortable and happy with his present wife
fot some time after their marriage. She then began to complain of
constant annoyance during the day and night by some show-people.
It was a month or two before he also became one of their victims, and
not until his wife had often wondered why he, too, could not see and
hear them. He first noticed that during the evening, when his wife
was sitting reading or sewing, she would be pulled forward or backward
and nearly fall off her chair, or her hand would twitch and her mouth
be drawn to one side. She would also almost nightly waken him and
say, “ They’ve come,” and then nearly fall out of bed. He then found
that he began to have exactly the same experiences. When his wife now
began to suffer, he, too, would find that he was being pulled off his chair,
that his hand would twitch, or his mouth be drawn to one side. Now,
when she woke him in the night and asked him if he heard them, he
would hear a noise like the winding-up of a clock, and also a “fizzing”
noise, and then both he and his wife felt that they were being pulled
out of bed. He never saw anyone, but had no doubt but that it was
the show-people who did it, having been “ put up ” to annoy them by
their respective step-daughters. His own daughter did not wish him to
marry again, but to give up his cottage and go to live with her and her
husband. When asked if he really believed that these show-people
wanted his wife’s head to put in their show, he said that it seemed a
funny thing to say, but that he was quite sure that there was something
in it. He had slept soundly and had not been worried in any way
since his wife left him, but he was very fond of her and anxious to have
her back again at home. A month later I again saw him. He had
suffered no annoyance of any kind since his wife was taken away, but
said he felt very lonely. He was still convinced that his own daughter
and his wife’s daughter were “ at the bottom ” of all the annoyance he
and his wife had suffered when together. He said that if people
annoyed them again when his wife returned he would do anything to
stop them, even if he had to get his gun and shoot at them.

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1910 .] EXAMINATION OF CEREBROSPINAL FLUID. 485

The authorities were notified of this threat, but as he continued to
pursue the even tenor of his ways, no steps were taken for his certifica¬
tion as a lunatic.

Four months after her admission the wife was sent out on trial, and
three months later finally discharged as relieved.

A few weeks after she left the asylum she wrote me a letter, which
clearly showed that she was still the subject of persecutory delusions.

Since then I have been unable to glean any further tidings of her, or
to learn whether her hallucinations returned and were again communi¬
cated by her to her husband when she rejoined him.

In my opinion he would most probably never have suffered from
delusions or hallucinations had he not been infected by his wife. Here
we have the case of a simple unimaginative yokel married to a woman
(in spite of the opposition of their respective families) to whom he was
extremely attached, and whom he evidently regarded as both his
intellectual and social superior.

It is not surprising that when she developed these delusions of
suspicion against her own daughter and his, she should after some time
have impressed him with their truth, or that by constant reiteration of
her aural hallucinations by day and night after some months she should
have succeeded in convincing him of their actuality.

Had not fate proved unkind in his second matrimonial venture,
would not this ploughman have been content after his hard day’s work
to homeward plod his weary way and to leave the world, material and
spiritual, to darkness and to—the poet ?

(*) Brain, vol. x, 1888, p. 408.

Examination of the Cerebro-spinal Fluid as an Aid to
Diagnosis in Certain Cases of Insanity, with Special
Reference to the Protein Reaction described by Ross
and fones.Q ) By John Turner, M.B., Essex County
Asylum, Brentwood.

The value of Wassermann's reaction in the diagnosis of
syphilitic and the so-called para-syphilitic diseases is now
generally conceded, but, apart from the technical difficulties in
carrying out the test, which places it beyond the means of all
except those working in well-equipped laboratories specially
licensed, the fact that it merely enables one to diagnose a
previous syphilitic infection in nearly all its stages, detracts
somewhat from its value as a means for the special diagnosis
of general paralysis or tabes. Wassermann’s reaction tells us
what nearly every patient is able, if willing, to tell us ; whereas
the protein reactions, especially that described by Ross and

LVI. 3 2

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4S6 EXAMINATION OF CEREBRO-SPINAL FLUID, [July,

Jones, appear, so far at any rate as my observations go, to be
much more specific in the information they yield. The Ross-
Jones test in my hands only gave a positive result in general
paralysis and cerebral syphilis.

1. Protein Reactions.

In 1909 Drs. G. W. Ross and E. Jones (1) described a very'
simple protein reaction, which consists in the addition of clear
cerebro-spinal fluid to a saturated solution of ammonia sulphate,
in such a manner that the fluid lies on the reagent without
blending with it. In the case (according to these authors) of
general paralysis, tabes, tertiary syphilis, and syphilis of the
nervous system, at the junction of the two fluids a definite,
sharply defined, thin white film, which has very much the
appearance, when looked at against a dark background, of a
cobweb, forms immediately or almost immediately. They
believe that this reaction depends merely on the amount of
globulin present in the fluid. Globulin, as we know, is present
in normal cerebro-spinal fluid, but apparently in insufficient
amount to give the reaction. I have carried out this test in the
fluid from ninety-five cases of insanity, and my results would
seem to show that it, especially in conjunction with a cell-count,
affords most valuable help in making a diagnosis in early cases
of general paralysis, and in differentiating certain early cases of
alcoholic insanity from general paralysis. Although several of
my cases had a history of recent or active syphilis, in only one
case, syphilis of the nervous system, did I get a positive result
except in general paralysis.

J. Henderson Smith and J. P. Chandler (2), writing of the
Wassermann reaction, state that unfortunately in the early
cases of general paralysis the reaction most often fails, and that
even in the most advanced cases it is sometimes negative. In
my experience the Ross-Jones reaction has never failed to give
a positive result in early cases ; agreeing to a large extent in
this respect with the cell-count, which is usually most abundant
in early cases, and which may be slight or even absent in older.
In forty-eight cases of general paralysis, or suspected general
paralysis, I only got a decided negative result twice: one was a
case of seven years’ standing, and from the clinical standpoint
possessing no diagnostic difficulties; the other was a recent

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iqio.]

BY JOHN TURNER, M.B.

487

case, set. 2, of the real nature of which I am still in doubt. An
advanced case of tabes with Charcot joints also gave a
negative result.

All the cases (twelve) of dementia praecox, all the cases
(eight) of alcoholic insanity, all the cases (eight) of epilepsy
and all but one of seventeen cases not classified, including
seven of secondary or organic dementia, gave a negative result.
The exception gave a doubtful positive after twenty minutes.
In ambiguous cases it frequently enables one to give with con¬
fidence a positive diagnosis which would without its aid be
impossible. Three of the general paralytics were not diagnosed
until after an examination of the fluid, although one of them
had been an inmate five years, and another two years. On the
other hand, three had been diagnosed as general paralytics, but
the examination of the fluid indicated that this was incorrect.
Two of these proved to be cases of polyneuritic psychosis,
and the other a case of delusional insanity with paraplegic
symptoms.

In the majority of the cases Noguchi’s butyric acid test was
employed also. This is somewhat more troublesome to carry
out, and, so far as my experience goes, not quite so trustworthy
as Ross and Jones, or perhaps one should say, not so specific,
as it sometimes gives a positive reaction in cases of tertiary
syphilis, and in three cases of general paralysis it gave a
negative result, whereas the Ross-Jones test was only negative
in one. This experience seems to coincide with Dr. G. S.
Amsden’s (3), who tested thirty-six cases at the Bloomingdale
Hospital with Noguchi’s, Ross and Jones’s, and Nonne’s phase
1 tests, and he found that the Ross and Jones method gave
more definite and clear-cut results than Noguchi’s, and that
both were more sharp and delicate than Nonne’s.

2. Cell-count.

The value of a cell-count for diagnostic purposes is scarcely,
if at all, inferior to the protein reaction, and is especially useful,
inasmuch as the number of cells is generally greater in early
cases.

Joffroy and Mercier (4) state that the cytosis precedes the
speech and pupil symptoms in general paralysis, and Frenkel
(5) finds the same as regards the pupillary symptoms in tabes.

This aid to diagnosis, although largely used on the continent

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and in America, has had far too little attention given to it in
England.

I have followed E. Jones’s (6) method, in which 3 c.c. of the
fluid is centrifugalised for ten minutes and the supernatant
fluid drawn off until only a fifth of the original bulk is left. As
often with the clearest fluid erythrocytes are present, although
quite invisible to the naked eye even after centrifugalisation,
and, as these cannot be distinguished with certainty in counting,
I add to the remaining portion of the fluid two small platinum
loopfuls of a 1 per cent, solution of methl violet, which, after
standing a few minutes, colours the leucocytes a pale blue, but
does not stain the erythrocytes. The deposit is well stirred up
and a few drops transferred to the Thoma-Zeiss counting-
chamber in the usual way, and the field of the microscope is
adjusted so that its diameter corresponds to 7*5 of the small
squares in the counting-chamber, the area of the field being
then ^ mm. Three chambers are filled and thirty fields
connected from each, and the total (ninety) represents the
contents of 1 c.mm, but this has to be divided by five, as only
one-fifth of the fluid was taken.

In fifty cases of general paralysis only six failed to show a
cytosis (any number of cells below 5 per c.mm. being looked
upon as negative). Three of these were chronic cases present¬
ing well-marked clinical symptoms, two were recent cases and
also well marked clinically; the remaining one was an acute
case, in which several epileptiform seizures occurred the day
before the puncture. In this case the diagnosis was confirmed
by post-mortem and microscopical examination of the brain and
cord four days later.

In forty-five cases of other forms of insanity only three
showed a slight lymphocytosis. In one case of organic
dementia with apopletic attacks the lymphocytosis was 8 - 8, in
another it was 7* 2, and in the third, a case of dementia przecox,
g*9 per c.mm.

As regards the differential count, the means were not at hand
for carrying out Alzheimer’s method, which involves centri¬
fugalisation for one hour, and which is stated to give satis¬
factory results, and I must admit that the method I employed
did not give entirely satisfactory results in all cases; occasionally
there was some difficulty in differentiating between endothelial
and plasma-cells.

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BY JOHN TURNER, M.B.

489

Some of the deposit, after centrifugalising for ten minutes
and drawing off all but a drop or so of the supernatant fluid,
was spread on slides, dried and stained in Pappenheim’s stain
or else Leishmann’s. But if the fluid is not treated before
centrifugalisation, a very large number of pale, irregularly
contoured bodies with badly defined or invisible nuclei are
found in the deposit. They have the appearance of cells
underlying a partial digestion or disintegration, and Pappen-
heim (7) found that especially in general paralysis the fluid
does exert a very deleterious action on leucocytes, but this
action can be destroyed by heating the fluid to 56° C. I found
this to be the case, but eventually discarded the heating, which
was troublesome, for the addition of two to three drops of 1
in 1,000 formalin. This entirely stops the disintegration of the
cells, but produces a slight shrinking in them.

The total number of cells per c.mm. varies between very wide
limits in general paralysis, generally somewhere between twenty
and sixty. In three it was over a hundred.

The lymphocytes form the great bulk of all the cells present
—from 80 to 95 per cent. In only a few cases were polymorphs
noticed, and these were in fluids contaminated by blood at the
time of puncture. I frequently, however, noticed quite large
numbers of erythrocytes under the microscope from fluid
which, even after centrifugalisation, appeared quite colourless to
the naked eye.

The presence of plasma-cells from a perfectly clear fluid
justifies a diagnosis of either general paralysis, tabes or cerebral
syphilis.

Films were also stained in Unna’s polychrome blue and
examined for micro-organisms, which were found in seven
cases, as follows:

Case i. —Male, general paralytic. Swarms of diplococci
(? pneumococci) occur in dense clusters, small groups, and
singly. Also some slightly elongated diplo-organisms and a
few longer and more slender diplo-organisms. This man was
in fairly good health, and is still alive.

Case 2.—Male, general paralytic. An acute case. Death
occurred a month or so after. No post-mortem. Numerous
short, rod-like, beaded bacilli in clusters and short chains.

Case 3. —Male, cerebral syphilis; gummata of pons. Film
crowded with diphtheroid organisms, similar to the preceding

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490 EXAMINATION OF CEREBRO-SPINAL FLUID, [July,

case, and also pneumococci. Death a few months later.
Autopsy.

Case 4.—Female, epileptic imbecile. Film showed numerous
tubercle bacilli and some streptococci. Patient still living.

Case 5.—Female; alcoholic insanity (polyneuritic psychosis).
Film crowded with diphtheroid organisms similar to those
seen in the two general paralytics. Patient died five months
later. Autopsy.

Case 6.—Female, secondary dementia. Numerous diph¬
theroid organisms. Patient still living.

Case 7. —Female; acute delirium. Film crowded with
pneumococci. This last case was interesting. She was
admitted April 23rd, 1909, in a state of low muttering delirium,
and on October 22nd a blood-count was made, showing 8140
leucocytes per c.mm.; polymorphs, 63’25 per cent .; lymphocytes,
33'00 per cent.) hyalines 375 per cent. No eosinophiles. No
organisms detected in blood. She died four days later from
pneumonia and enteric. Some blood taken with aseptic
precautions from the left ventricle sixteen hours after death
was spread on serum and on agar tubes, and put into the
incubator at 30° C.; the serum tubes remained sterile; the
agar, after thirty-six to forty hours, grew two small round,
yellow colonies of Micrococcus tetragenus, and one small, dull
greyish-white colony of pneumococci.

In two only out of twenty-one general paralytics were
organisms similar to those described by Ford Robertson found,
and they were found also in two cases not general paralytics.

3. Total Protein Contents.

A somewhat rough quantitative examination for the total
protein contents was made by mixing 5 c.c. of the fluid with a
like quantity of absolute alcohol, allowing the flocculent preci¬
pitate which forms to settle for two or three hours, centrifugalis-
ing for two minutes, again after the lapse of four or five hours,
and again the next morning; by this time the supernatant
fluid should be quite clear, and the precipitate forms a solid¬
looking mass at the bottom of the tube, and its height can be
read off against the c.c. divisions marked on the tube.( 2 )

A glance at the table shows that a protein content over
i’5 on the tube is almost as characteristic of general paralysis
as either the protein reaction described or the lymphocytosis.

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Positive reaction to Ammonium Sulphate. I B. Negative reaction to Ammonium Sulphate.

1910.]

BY JOHN TURNER, M.B

49 I

All except two of the cases in this table reacting positively
to ammonium sulphate had a protein content higher than i’5.

These results lend considerable support to Ross and Jones’s
contention that the ring test depends merely on the amount of
the protein contents. If this reaction, however, entirely

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the negative except two were general paralytics. Although individual variations between the amount of protein
and number of cells are very great, yet, with four exceptions, all the cases which show a high protein content also
show a lymphocytosis, and all with a low content (below 15 degrees) show no, or a very slight, lymphocytosis.

492

EXAMINATION OF CEREBRO-SPINAL FLUID, [July,

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depended on the amount of globulin in the fluid, it is difficult
to account for a positive reaction in a few of the cases in which
there was less protein than was found in two cases giving a
negative reaction. According to my (8) experience, which I
believe is borne out by most later investigators, practically the
whole of the protein contents in the fluid of general paralytics
is serum globulin. In twelve fluids which I tested fifteen years
ago, after saturation with magnesium sulphate, no less than
eight showed no trace of serum albumen on heating the clear
filtrate, and only the very faintest trace in the other four.
Purves Stewart (9), however, quotes two French observers
(Guillam and Parant) as having found in sixteen cases of
general paralysis that the clear filtrate, after saturation with
magnesium sulphate, showed on boiling a characteristic precipi¬
tate (? serum albumen).

It might be supposed that organic brain lesions would be
associated with an excess of protein in the fluid, and although
to a very slight extent this was so in two out of four cases I
examined, yet only one of these gave a (doubtful) positive
reaction with ammonium sulphate.

J. Froude Flashman and A. Graham Butler (10) refer to
this question; they found in three cases with extensive
vascular cerebral lesions no evidence either of complement
fixation or of increase in the total protein contents, which was
only one-tenth the amount of that in the fluid of a general
paralytic taken at the same time. They state that “ there is
no room for doubt that, apart from acute or subacute diseases,
a heavy flocculent precipitate occurring in a cerebro-spinal
fluid on the addition of a general albumen precipitant is very
strong evidence that the fluid was derived from a case of
general paralysis or tabes.” This entirely coincides with my
opinion.

4. Reaction (Alkaline or Acid).

In all the cases of this series, and in twenty examined fifteen
years ago, I have obtained an alkaline reaction (and not
amphoteric) to litmus paper, but with phenolphthaleine the great
majority gave an acid reaction. The degree of acidity, how¬
ever, is in many cases very slight. A very faint pink solution
of phenolphthaleine was poured into two small beakers, so that
the tint in both was similar in looking down at them as they

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BY JOHN TURNER, M.B.

493

stood upon a porcelain slab. A little of the fluid was then
added to one beaker, and generally the pink colour was imme¬
diately discharged. I found that fluid left unstoppered in my
room, where gas is constantly burning, rapidly became alka¬
line, whereas similar fluid in stoppered bottles retained its
acidity, and that in my later examinations where this source of
fallacy was recognised and excluded, the results tend more and
more to be uniformly acid with phenolphthaleine, but the degree
of acidity varies greatly, and is most marked in case of general
paralysis.

Dr. A. Connal (n), testing the reaction to phenolphthaleine
of the fluid in infective diseases of the meninges, found an
alkaline reaction in all. He states that normal fluid possessed
the highest and turbid fluid the lowest degree, and lessened
alkalinity was found to coincide with disappearance of the
dextrose (copper-reducing substance) normally present. Boil¬
ing a turbid fluid with Fehling invariably failed to reduce the
copper, and this absence of reduction was further associated
with the presence of lactates as tested for by Uffelmann’s
reagent.

I tested some of my cases for lactic acid by Uffelmann’s
reagent, using 5 c.c. and counting the number of drops of fluid
required to decolourise it, and I found in four cases of general
paralysis from 30 to 45 drops were needed, in two epileptics 40
and 42 respectively, in one case of acute delirium (with enteric)
only 25 and in one alcoholic case no less than go drops. After
death the decolourising power rapidly increases, so that 12 or 13
drops are sufficient. And also after death, as I pointed out
fifteen years ago, the copper-reducing substance rapidly dis¬
appears from the fluid.

5. Copper-reducing Substance.

This substance, which at different times has been asserted to
be sugar, pyro-catechin, dextrose, one of the purin bases, and
recently, by Dr. G. S. Williamson (12), glucosamine, the
reducing body of mucus, was tested for with Fehling’s solution
in 73 cases (58 in this series and 15 in my first series fifteen
years ago). During life it was only found to be absent on two
occasions, and both of these were in advanced general para¬
lytics.

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These results do not coincide very closely with Williamson’s,
who found it to be absent in 14 out of 22 general paralytics, and
he stated that the reaction is as constantly absent in the early
as in the late stages.

In 51 cases the amount of copper reduced was estimated
quantitatively, and it was found that the amount was least in
general paralysis and greatest in alcoholic insanity.

Thus in 21 general paralytics it averaged i 6 - 4 (in 10 c.c. of
fluid) ; in 7 epileptics, 19*0 ; in 10 (unclassified), ig - 8 ; in 6 cases
of dementia pnecox, 2i’3 ; in 5 of alcoholic insanity, 22’2 mgrm.

The rapid disappearance of this substance after death is
striking, and, so far as my experience goes, constant; for
example, in a male general paralytic in whom during life it was
abundant, it was entirely absent eight and a half hours after
death, which occurred sixteen days after it had been tested for
during life. In another, where during life 10 c.c. of fluid reduced
22 mgrm. of copper, it was absent thirteen and a half hours
after death, which occurred fourteen days after the first
examination.

In another, where during life 10 c.c. reduced 15 mgrm. of
copper, it was absent seventeen hours after death, seven weeks
later. In two cases of dementia prsecox of the katatonic form,
where during life it was present, it was found to be absent
after death, which occurred eight days later in one case and
five days in the other.

In one case where the fluid was tested only four hours after
death a slight amount was present; probably in this case a long
enough time after death had not elapsed for all of it to be got
rid of.

J. H. Coriat (13) found it in 9 out of 29 cases in the post¬
mortem fluid, but in the account from which I take this
information no mention is made of the time after death that
the fluid was tested. Probably, as A. Connal points out, this
disappearance of reducing substance is due to, or at least
associated with, the presence of lactates in the fluid, for after
death, if one may trust the Uffelmann reagent, the amount of
lactic acid rapidly increases. To give an example, one case in
which during life thirty drops of fluid were required to decolorise
5 c.c. of the reagent only required thirteen drops one hour after
death, which occurred two days later ( s ).

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BY JOHN TURNER, M.B.

495

6 .

I will just briefly touch upon some of the interesting features
noticed in the cases other than general paralysis or cerebral
syphilis which were examined.

a. Dementia Prcecox.

The fluid was examined in 12 cases (4 hebephrenics, 7 kata-
tonics and 1 paranoidal), and all gave a negative result with
the Ross and Jones test. Two gave a slight lymphocytosis,
4'5 per c.mm. and 9*9 respectively. Two of the subjects had had
syphilis. In one of these, infected two years ago and under treat¬
ment in the asylum, but not during the last nine or ten months,
the Noguchi reaction was positive; in the other, infected six
years ago and treated for a year (according to her own account),
the Noguchi reaction was not tried.

In several of the cases the fluid came away rapidly, in nearly
confluent drops, and in one of these cases, a woman in a
stuporose condition, there was a marked mental improvement
a few hours after the puncture. She had been subject to
stuporose attacks with lucid intervals for some years, but
latterly the attacks had become much longer and the lucid
intervals very short. The improvement after the tapping,
however, lasted for six months. She then again relapsed and
was again tapped and 13 c.c. of fluid removed (on the previous
occasion 20 c.c. were taken). Two days later she emerged from
her stuporose state and became cheerful and communicative,
but this improvement coincided with a short attack of subacute
rheumatism and only lasted tw'o days.

In another case which had been persistently stuporose for
nearly two years no improvement followed the withdrawal of
20 c.c. of fluid. In this case the fluid came away slowly.

B. Epilepsy.

Four men and four women were punctured; all the women
and at least three of the men were imbeciles. The only points
to which notice need be directed are that in one case suffering
from tertiary syphilis with destruction of soft palate (not under
treatment) a positive reaction was obtained with Noguchi’s

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reagent, a negative with ammonium sulphate ; and in two cases
there was a rather high protein content, 15 degrees in one
(the syphilitic case) and 17 in the other.

C. Alcoholic Insanity.

The fluid from seven women (all examples of polyneuritic
psychosis) and one man (a doubtful or impure case) was
examined. Beyond the fact that the copper-reducing substance
in two was present in large amount (and it is worth noting that
in both of these the reaction to phenolphthaleine was alkaline) it
presented normal characters, gave negative protein reactions
and contained no excess of cells.

In six of the women the puncture was made shortly after
admission to the asylum, and during an early stage of the
disease; the remaining case had been an inmate for three
years.

In early stages it is often impossible, apart from an exa¬
mination of the cerebro-spinal fluid, to make a positive
diagnosis between this disease and general paralysis. In these
doubtful cases the information obained from the examination of
the spinal fluid is invaluable, and permits a positive diagnosis
being given—a matter often of the greatest practical utility.

It should, however, be noted that Nissl (14) cites two cases
of chronic alcoholism with positive cytological result.

After-Effects of Lumbar Puncture.

Nissl (14), in 1904, pointed out that even after the withdrawal
of only a few c.c. of the fluid, symptoms similar to sea-sickness
were frequently met with—headache, nausea, vomiting, pains
in back and neck, and a feeling of apathy—which occurred only
after five to six hours, and were not experienced in the recum¬
bent position. They lasted from one to eight days, but no
permanent damage, according to him, resulted.

Several of my cases complained of similar symptoms, together
with a feeling of constriction about the chest, but in all these
symptoms were slight and transient, and no permanent ill-effects
have followed the operation.

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BY JOHN TURNER, M.B.

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Summary.

The main points of practical interest in the examination of
the cerebro-spinal fluid are the protein reactions and the cell-
count. Both are of great value for the early diagnosis of general
paralysis, tabes, or cerebral syphilis.

The simplicity of the Ross and Jones test brings it within the
reach of any qualified man, and it would appear to be the most
delicate of all the protein reactions.

So far as I know this series is the largest in which the re¬
action has been tested. Ross and Jones only tested 27, and
Amsden 36 cases.

At the present time the other characters noted, the acidity or
alkalinity and the presence of copper-reducing substance, are
mainly of academic interest. It is probable, however, that the
degree of acidity to phenolphthaleine may coincide with the
development of lactic acid in the fluid during life, and this
with the disappearance or lessening of the copper reducing
substance ; so that inasmuch as lactic acid is rapidly formed in
dying nervous tissue, we may have here the means of establish¬
ing a test as to the extent of the organic nervous changes in any
given case.

Writings on the subj’ect of the spinal fluid are now so
numerous that some apology is almost needed for adding to
their number, especially when, as in my case, nothing new is
recorded. Still, I felt it was worth while further testing the
trustworthiness of such a simple reaction as that described by
Ross and Jones, by its application to a larger number of cases
than has hitherto been done, and from my results it appears to
come successfully out of the ordeal.

Note Concerning Cadaveric Cerebro-spinal Fluid.

Smith and Chandler (2) state that fluid from bodies kept in
the cold room (at Claybury) is as clear and limpid as in life. I
have, however, always found that when the corpse remains at
ordinary temperature, even in winter, the fluid becomes turbid
and quite'unsuitable for the Ross-Jones test a very few hours after
death, and at the same time it is found to contain very many
large, ill-defined cells—as many as four hundred or more per
c.mm. For example, in two cases of dementia praecox, in

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neither of which the fluid contained any cells during life, they
were found in very large numbers after death, which occurred
six and eight days later respectively.

(') A paper read at the Quarterly Meeting, held in London May 24th, 1910.—
( s ) Care should be taken to ascertain by a standard 1 c.c. pipette that the mark¬
ings on the tube are correct. I had to discard several of my findings in earlier
cases from not paying attention to this point, for very considerable inaccuracies
were found in the markings on the tubes which had been used.—(*) This only
applies to fluid removed from a cadaver. Fluid taken during life does not alter in
respect to its decolourising power on Uffelmann's reagent however long it is kept,
provided it remains undecomposed.

References.

(1) Ross, S. W., and Jones, E.— Brit. Med. Journ., May 8th, 1909.

(2) Henderson Smith, J., and Chandler, J. P.— Idem., July 24th,
1909.

(3) Amsden, G. S.— New York Med. Journ ., February 26th, 1910.

(4) Joffroy and Mercier .—Journ. of Ment. Path., 1902.

(5) Frenkel, H. S.— Monats. f. Psych, u. Nerv., 1904.

(6) Jones, E.— Review of Neur. and Psych., 1907.

(7) Pappenheim.— Zeitschr. f. Heilk., 1907.

(8) Turner, J.— Brit. Med. Journ. 1896.

(9) Purves Stewart.— Edin. Med. Journ., 1906.

(10) Flashman, J. Froude, and Butler, A. Graham.— Brit. Med.
Journ., October 9th, 1909.

(n) Connal, A.— Quart. Journ. of Med., iii, 1910.

(12) Williamson, G. S.— Journal of Mental Science, October, 1909.

(13) Coriat, J. H.— A/ner. Journ. of Insanity, 1904.

(14) Nissl.— Centralbl. f. Nerv. u. Psychol., 1904.

Discussion,

At the Quarterly Meeting held in London on May 24th, 1910.

The President thanked Dr. Turner on behalf of the meeting for his paper,
which he regarded as of extreme value.

Dr. Hubert Bond said he could quite corroborate the statement with regard to
the ease with which the test was applied. At Long Grove Asylum they had
recently been using it. He hoped to hear of some equally ready test to reveal
cases which at some period of their lives had had syphilis. The Wassermann test
was difficult, could only be done in certain laboratories, and by those trained in the
technique. While the test described by Dr. Turner was easy and within the scope
of all asylums, it would seem that it yielded information only with regard to
syphilis of the nervous system. Whereas, bearing in mind the vitiating power of
syphilis on the system generally, it becomes more and more of importance to be
able to say definitely how many of our asylum cases have at some time contracted
the disorder.

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CLINICAL NOTES AND CASES.

499

Clinical Notes and Cases.

A Clinical Note.i}) By Norman Lavers, M.D., Medical
Superintendent, Bailbrook House, Bath.

This is a note of a somewhat unusual case which seems to
me of sufficient interest to be described in some detail.

The early history is of importance in its bearing on the later mental
phases shown by the patient. The lady, Mrs. K—, was left an orphan
(the youngest of four) at an early age, her father dying of some chronic
form of nervous disease and her mother of phthisis; a sister and two
brothers have strong neurotic tendencies, and are rather flighty and
unstable mentally. She was looked upon by her brothers and sister as
the strong one of the family, and hence if any unpleasant duty cropped
up, it fell as a matter of course upon her shoulders, and being shy and
reserved she preferred to support it rather than cause any fuss. At
school she was under a lady whose only fault was that her active
mentality, her strong and vivid personality did not allow much initiative
to her pupils and assistant. From school the patient went to a well-
known ladies’ college, where she held a teaching post for some years,
under another eminent educationalist, who was essentially the ruler of
her own domain and kept a remarkably firm hand on the reins of office,
exercising a powerful influence on the members of her staff, which
caused them to merge to some extent their individuality in hers and to
defer to her in an unusually thorough manner.

Whilst at college the patient had to get through an enormous amount
of work in preparing various subjects for teaching, and was also respon¬
sible for a nephew whose parents were abroad. The strain proved too
much and a break-down followed, characterised by listlessness and
apathy, and inability to concentrate the attention except for short
intervals, when a feverish mental activity took place without much
tangible result.

There was also considerable loss of memory for recent events, and
inability to perform everyday actions such as writing, needlework, etc.
Under treatment a certain amount of improvement set in, and she went
abroad with the idea of taking a year’s quiet travelling and rest. The
improvement was maintained, and shortly afterwards she married and
settled down abroad.

Shortly after her marriage she had what was diagnosed as a heat¬
stroke, and after six weeks’ complete unconsciousness suddenly came
to herself, when she was found to be hemiplegic on the right side, with
loss of control of her bladder and rectum, and an exaggeration of her
former mental symptoms. Speech was not affected. Since then her
mental and physical condition has remained about the same, with some
very brief intervals of comparative improvement, for occasionally she
has walked fairly well and taken an interest in her daily life for a few brief
hours, but generally has been very helpless, without ability to do more

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than shuffle along at a snail’s pace by the aid of a stick and the articles
of furniture, and has displayed considerable apparent dementia.

During about five years she has had many doctors and a great variety
of treatment, including rest, over-feeding, massage, electricity, etc., sepa¬
rately and in combination. Her husband has endeavoured to save her
all mental and physical effort, and, living abroad, she has been sur¬
rounded by native servants who have relieved her of all necessity for
doing anything.

When I saw her a few weeks ago, the patient complained of general
weakness, inability to walk or to balance herself, incapacity for work or
occupation, however light, a feeling of heaviness in the right leg and foot,
the necessity for attending to the calls of nature immediately the desire
was felt and difficulty in remembering things cf ordinary occurrence.

Her age was 35, the stature short, the body poorly developed but fairly
nourished, some slight spinal curvature of long standing ; glasses were
worn for myopic astigmatism. The gait was slow and unsteady with
feet wide apart, the right foot being swung outwards as it was brought
forward, and usually there was no progress without support.

There was no facial paralysis or inequality; the tongue was protruded
medially and was steady.

The respiratory system was normal.

The cardiac rhythm was good and there were no adventitious sounds:
the pulse in the right upper and lower extremities was not quite so strong
as on the left side, and these were distinctly colder to the touch.

With regard to the alimentary system there was occasional vomiting,
generally traceable to dietetic error, and there was precipitate defaecation.

The renal system showed no abnormality other than precipitate
micturation.

The menstrual epochs were normal.

The muscular system generally was soft and flabby, but there was no
wasting anywhere which could not be accounted for by dis-use; there
was some rigidity of right lower leg, which practically disappeared when
the patient’s attention was occupied elsewhere; the action of the right
leg muscles was feeble, but could with care be elicited. The grip of the
two hands was good and practically equal. I am not satisfied with the
electrical tests so far made, which show a weak response generally but
no reaction of degeneration.

The knee-jerks were decidedly brisk, the left greater than the right;
ankle clonus was easily elicited on the right side but could not be
obtained on the left; no planter reflex, either flexor or extensor, could
be obtained on either side. Common sensation and pain and temperature
sense were normal, except that response was somewhat slow on both
sides; there was impairment of muscle sense in both lower extremities
and patient was unable to stand with eyes shut. Co-ordination was very
fair in upper extremities but the movements were rather hesitating in
character; there was no intention or other tremor. There were no
trophic changes.

An operation for strabismus had been performed in childhood on the
right side : the pupils were equal and reacted briskly to light and accom¬
modation ; there was no nystagmus. The right fundus was pale and the
vessels small, the condition being suggestive of old neuritis, but as suit-

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able glasses gave £ vision in that eye and £ in the left, it would seem
scarcely proper to condemn the eye in view of the very fair vision
persisting.

There were no hysterical points.

The mental condition varies: at her best the patient is bright and
cheerful and will converse readily and freely, but shows a lack of will¬
power and initiative, some confusion of ideas, impairment of memory
for recent events, considerable morbid self-consciousness, little self-
reliance, inability to fix her attention for any length of time, and is
unduly sensitive as to what she imagines other people may be thinking
of her. At her worst all these phases are much accentuated ; her atten¬
tion cannot be fixed at all, there is great confusion of ideas, almost
complete loss of memory for recent and marked impairment of that for
long past events. She cannot find her way about the house, and so far
as her thoughts can be gauged appears to be entirely occupied with
herself and other people’s opinion of her. There are no apparent
delusions, hallucinations, or illusions.

Her physical condition varies with the mental: at times she can walk
fairly briskly for a few steps without assistance until she begins to think
how well she is doing, when her powers suddenly fail, and for a time
she has fair control of her sphincters; at other times she can but hobble
slowly with assistance, and at her worst she seems incapable of conscious
effort or movement, and will pass urine and faeces under her. Physical
fatigue markedly accentuates the symptoms.

Her history during the past five years appears to have been a series
of these undulations, and, according to those who know her, her con¬
dition, since the so-called heat stroke, has not become progressively
worse or better, but the general level has remained about the same.

It is noteworthy that if she can be interested in conversation or
otherwise she appears to be better physically, to walk better, etc., but
as soon as her attention wanders it becomes concentrated on herself,
and her symptoms are exaggerated.

This necessarily brief and sketchy description will not in all proba¬
bility convey a very definite picture, but that is just my difficulty.
The signs and symptoms are so vague and contradictory that I am
unable to weld them into a clinical entity, and therefore, without taking
up your time in a discussion of the differential diagnosis, I will confess
that I am forced to relegate them, in my own mind, to that limbo of
the imperfectly understood—the functional disorders. There is, no
doubt, a certain amount of organic mischief, but it seems to me that
on this somewhat slender foundation a great superstructure of func¬
tional trouble has been raised. It would appear that many actions
whose boundaries should normally be within the subconscious area
have, by continued introspection and self-centred concentration, been
raised until they can be carried out only by the aid of conscious
attention, with the natural result that they are performed less well, and
at a greater cost of fatigue and strain.

Her history shows that from childhood the patient has had an
environment which tended in any direction rather than towards
strengthening her will-power, self-reliance and initiative, whilst her life
abroad removed all necessity for active mental effort, even that usually
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called for in household management. There, too, she was at frequent
intervals left alone with nobody about her but native servants, and with
little to occupy her thoughts.

Treatment has been intermittent and various, and most methods
have been tried at one time or another. The lines I am following at
present aim at improving the general physical tone by graduated exer¬
cises and tonics, and seek to restore a proper balance by repeated
systemised suggestions directed towards improving the patient’s will¬
power, diverting her attention into extraneous channels and relegating
the disordered functions to their proper sphere. A case of so chronic
a nature is not the most favourable for treatment by suggestive
methods, and I am unable to speak yet of results, but it seems to me
that these methods hold out the only hope of improvement, and it is at
least encouraging that the patient is sleeping much better, that for days at a
time she has no trouble with her sphincters, that she has taken to read¬
ing and needlework with considerable zest, that she has recently written
several long and perfectly connected letters (the first for some years),
that she can join intelligently in conversation and that she walked up
the drive here in eight minutes without assistance, whilst her husband
says that it is quite pleasurable again to see her and be in her society.
This may be a temporary improvement, and I feel the necessity for
caution in expressing an opinion, but at any rate it encourages one to
persevere.

(*) A paper read at the Spring Meeting of the South-Western Division held at
Bailbrook House, Bath, April 29th, 1910.

Notes on a Case of Hysteria. By J. E. Middlemiss,
M.R.C.S.Eng., L.R.C.P.Lond., Assistant Medical Officer,
Gartloch Mental Hospital.

The subject of the following notes was admitted to Gartloch
Hospital on March 19th, 1910. He was set. 18 at that time and
his physical condition on admission was described as follows : “ He was
clean, and in ‘ fair ’ physical condition. There were old scars to be seen
in the right groin and on the inner side of the right thigh, and also a
scar on the scalp, near the crown of the head. The pupils were unequal
and there was an internal strabismus. The pulse was slow (56 per
minute), irregular, and dicrotic. The tendon reflexes were exaggerated.
There were no signs of disease otherwise, except a small sinus in the
right submaxillary region and an enlarged gland behind the right ear.’’
(These have both disappeared in the interval.)

Mentally, he was fairly bright and intelligent, and able to answer
questions and give a rational account of himself. He said that his fits
dated from the time of an accident which occurred about a year and a
half ago, and in which he injured his head. He described all this in
detail—the nature of the accident and the full circumstances of the same.
His memory did not seem to be impaired at all, and although he has
had several fits since admission, they do not seem to have affected him
at all mentally. An interesting fact is that a sister seems to be affected

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by what, from patient’s description, appear to be attacks of “ petit mal.”
He also said that he experienced no aura prior to the onset of the fits.

From now onwards until April 23rd (1909) there is nothing note¬
worthy to record, except that patient had fits which were regarded by
those who saw them as typical “grand mal” seizures. About the date
mentioned, however, Dr. Parker happened to see him during a fit
which struck him as being suspiciously like hysteria in character. About
a week later he began to have fits in a rapid series, having as many
as twenty to forty fits within three hours or so. Altogether from April
30th to May 5th inclusive ( i.e six days) he had 202 fits, having them in
interrupted series, the shortest interval between two successive fits
being about five minutes. He was given various medicaments, including
chloral and digitalis per rectum , morphine hypodermically, and chloro¬
form inhalations, and had intervals of upwards of seven and eight
hours between the different series. Between the series of fits he seemed
to be sometimes in a state of altered consciousness and sometimes fully
conscious; the fits themselves were an excellent imitation of the “grand
mal” type of seizure, except that the stages were shortened and tele¬
scoped into one another, as it were. Moreover, it struck me that they
were influenced in one way or another by the presence of the doctor,
sometimes being started, sometimes inhibited, if the doctor happened
to be near. Most striking of all were the slight after-effects of
the fits, inasmuch as even after six days of them he seemed little the
worse, and recovered consciousness enough to sit up in bed and ask
for something to eat. This, in conjunction with the fact that on exami¬
nation he was found to be anaesthetic all over the body except for two small
areas of skin, led us to conclude that the fits were probably hysterical
in character. Since then and up to the present time (March, 1910) he
has been treated on ordinary hygienic lines, and has had practically no
medicine. For the last ten months he has averaged about eight or nine
fits per month, excepting for one short relapse in February of this year.
About September, 1909, I began a series of experiments with the object
of ascertaining, in the first place, whether I could influence him hypnoti¬
cally at all, and if so, whether, in the second place, it could be used as a
means of cure. From the first I found him very impressionable. My early
experiments were quite simple, and consisted in “sending him to sleep”
and ordering him to waken at a certain time, the time chosen being as
a rule not the hour or the quarter, but such times as 10.35, 11-27,
say, so that he might not be assisted by a clock in the next room.
He was sleeping at the time in a side room off the ward, which room con¬
tained no clock or watch, and the door of which was closed. He was to
get up, go into the ward, and report himself to the nurse in charge, who
noted down the time of rising. The latter, it need hardly be said, was
never informed as to the time of rising. In the great majority of cases
he rose and reported himself exactly to the minute, with an accuracy
which was as amusing as it was astounding. Occasionally he was
wrong in the time, but he never failed to waken, even when he was
incorrect in the time. Later he was given orders during hypnosis
which he was to carry out later. The longest period after which he
carried out such an order was fourteen days. This order he performed
within five minutes of the time arranged, and it is remarkable that the

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nurse who was concerned had herself forgotten all about the order in
the interval. As his memory was ordinarily not at all reliable, it
occurred to me that his daily duties might be more forcibly impressed
upon his mind whilst in the hypnotic state, so I gave him instructions
to carry out certain ward work every day or every week as the case
might be, and he has since performed these duties with uninterrupted
regularity. On several occasions, too, it has been suggested to him
during “sleep” that he would not want his soup or his porridge, etc.,
next day, or would miss a meal altogether. This experiment has
never failed; moreover, he has given a natural explanation for his
abstention, has retained no memory of my share in the business, but
has merely said that he was not hungry, even though the particular
dish omitted was a favourite one. The nurses on these occasions, not
being forewarned, were naturally astonished at his behaviour. More
recently I have tried to induce a deep and prolonged “ sleep,” and on one
occasion he slept sixteen hours continuously, and on another seventeen
and a half hours, with two slight intermissions which were both
according to order. I have remarked that on waking he would
generally have no recollection of an order given during sleep until such
time as he was to carry it out, but if “put to sleep” again in the
interval he was shown to remember it perfectly, the injunction lying
latent, as it were, in his mind until wanted. On the whole, however,
I have tried to avoid giving the patient any commands of a bizarre or
melodramatic nature, partly because I could not do it with conviction,
and partly because it served no obvious good and might quite possibly
even be harmful. Even the fact that he was suggestible at all was a
mere chance discovery, and the ideal to be aimed at in such a case
would seem to be the utilising of this suggestibility as an aid to
recovery. For instance, it would seem advisable to suggest to such a
patient that he would in future control his feelings better, and that he
would not be upset by trifling incidents. Then, after he had attained
a certain degree of control and mental composure his own intelligence
might be enlisted in the service. He might be taught a trade and
shown how to employ his mind in wholesome and salutary ways,
especially of a routine and unexciting nature. In course of time the
excessive emotional reaction to ordinary and every-day stimuli might
become lessened, and the emotions themselves come to occupy a less
important rd/e in the mental life of the patient. In such a treatment
and in such a training it is obvious that a good deal depends upon the
original mental endowment of the patient, and unless he is intelligent
enough to have some insight into his own condition, or, at least, to
understand and appreciate one’s instructions, the degree of improve¬
ment must necessarily be limited.

As bearing upon Freud’s theory that hysteria is generally the outcome
of a suppressed emotion, or an emotional shock which often remains
latent, it is interesting to record that this patient, during his states of
altered consciousness, almost invariably reverts to some painful incidents
which occurred before he came here, and the drama and dialogue of
which he re-enacts before one’s eyes. What bearing these incidents
have upon his present condition I am not in a position to say at present,
but the facts are, at least, suggestive.

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As regards the particular method employed to induce hypnosis in
the case of our patient, on the first occasion he was asked to gaze at
my two fingers held a little in front of and above his eye-level. Soon his
eyes tired and began to water. I then closed his eyes and told him to
think of sleep; I meanwhile continued to stroke the forehead and press
the temples until the breathing became regular and he appeared to be
in a condition resembling sleep. After speaking to him a little I
ordered him to open his eyes and to waken up, which he did, merely
remarking in response to questions that he had felt sleepy and was now
feeling a little dizzy. From this time onwards much the same
method was employed, except that I told him to close his eyes almost
immediately. At this stage of the proceedings he seemed to be merely
in a natural sleep, so much so that if spoken to by name he opened his
eyes and appeared to wake. To prevent this he was told “ to stop
asleep ” and merely to pay attention to what I said. Moreover, before
he could be brought “en rapport'' with me, there was a distinctly per¬
ceptible start, as if he were emerging from one state of consciousness
and passing into another, the first one being more like a natural sleep
and the second being the true hypnoid state, or, at least, state of
heightened suggestibility. As a rule there was complete amnesia
during the “ sleep,” and he was unable to narrate what had occurred
during the time, and this applied whether he had been ordered to forget
or not. Usually, however, he was told that he would not have any
recollection of the events which had taken place during sleep. On the
occasions when he was given a post-hypnotic command to carry out,
he was repeatedly tested in the interim to see whether he had any
recollection of the same, and whereas he could not remember anything
of it in the waking state, he had no difficulty whatever in recalling it
during the hypnotic state. Then, when the time arrived to carry out
such a post-hypnotic command, which was always arranged for some
definite time, there was a perceptible change in his demeanour, and
although he might not at the moment be within reach of a clock, he
would exhibit a certain amount of uneasiness, and in a manner a little
hurried and “ egari" and as though his memory had had a sudden jolt,
he would proceed to carry out the order, as if conscious of an important
commission which must be performed immediately. In order to avoid
as far as possible all voluntary deceit on the part of the patient as well
as complicity on the part of observers I have performed these experi¬
ments over and over again ; I have also employed numerous assistants
whose bona fides were unquestionable, and have purposely laid traps in
order to test whether I was myself being deceived, all this partly
because of the very obvious fallacies which might arise in a case of this
description, and partly in obedience to that principle of scientific
scepticism which should regulate all observations, however matter-of-fact
and plain-sailing they may appear to be. Meanwhile the patient’s mental
health has improved considerably during the last five months, and he
has gradually come to be the most useful and reliable patient in the
ward. His fits are now few and far between and are treated very lightly.
There has, however, been one break-back, referred to above, during
which he had a number of fits and was quite inaccessible for the time
being to any purely mental treatment. This relapse I attribute to a

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public performance which he gave in the asylum recreation hall and
which excited him very much. When he recovered he had no recollec¬
tion of what had transpired during the breakdown, but later on whilst
in the hypnotic state he recalled the circumstances. Finally, I would
like to take this opportunity of thanking Dr. W. G. Parker for permis¬
sion to publish these notes, and for his kindness and help during their
compilation.

Notes on Four Cases of Huntington s Chorea. By Richard
Eager, M.B., Ch.B.Aberd., Senior Assistant Medical
Officer, and J. R. Perdrau, M.B., B.S.Lond., Junior
Assistant Medical Officer, Devon County Asylum.

Owing to the comparative rarity of this disease a short
account of the following cases admitted into the Devon County
Asylum might prove interesting.

Case t.— W. C—, male, set. 35 on admission in 1882. Mother
suffered from chorea accompanied by mental derangement during the
latter part of her life. A brother, who died recently, also showed the
same symptoms for several years before death at the age of 61.

On admission the most prominent symptoms were partial loss of
memory and general mental inactivity with auditory hallucinations. The
speech was slow, and was described as characteristic of general paralysis
of the insane. The pupils were unequal, and he had fibrillary tremors
of tongue and facial muscles. Gait unsteady. Heart-sounds normal.

The notes in the case books until 1892 only record increasing
dementia. In 1892 there is a note to the effect that his facial muscles
were always twitching, and that he was very obstinate. In 1899 t f |e
notes are : “Very demented and obstinate, shows loss of attention and
memory, and is inclined to be very irritable at times.” Four months
before death, which occurred last February, he was found to be always
twisting himself about and constantly passing his hands in front of his
face the movements being involuntary, irregular, slow, of small range
and affecting the whole body. Knee-jerks exaggerated. Mental con¬
dition was one of profound dementia. No other signs or symptoms
beyond those recorded above. He developed lobar pneumonia last
February and died.

A post-mortem examination was held. The skull was thin and soft,
and the membranes much thickened and adherent to each other. The
pia was firmly adherent to the cortex, especially along the upper and
anterior part of the margins of the great longitudinal fissure, where
marked decortication was present. No further notes were made of the
gross lesions of the brain, as it was kept whole for microscopical
examination, as were the spinal cord and portions of various nerves.
The general external appearance of the brain was very suggestive of
general paralysis of the insane. The lower lobe of the left lung was in
a stage of grey hepatisation, and the lower and middle lobes on the

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right side of red hepatisation. The rest of the post-mortem showed
nothing of interest.

Case 2.—M. A—, female, aet. 45 on admission in April, 1903.
Family history same as in Case 4, whose sister she is. Has led a very
loose life, and is stated to have been very intemperate. No details of
personal history anterior to October, 1902, could be obtained. She is
reported to have been excitable and impulsive then.

On admission she was garrulous and complained without cause of
bad treatment at the workhouse, whilst her memory for recent events
was impaired. Since admission she is reported as a very quarrelsome
patient. She has expressed delusions of having been promised work
outside, and on that account has made frequent requests for her dis¬
charge. Her mental condition has been slowly progressing towards
dementia. She is now disorientated as regards time and place, and is
inclined to be wet and dirty in her habits. Perception good, but power
of attention poor.

Up to this year there are no notes to the effect that she .had any
involuntary movements, but the matron, who has known her since her
admission, says, though not present on admission, they came on gradu¬
ally and were much worse two years ago than now. The move¬
ments are slow, involuntary, of very small range and affect the whole
body. They are most marked in the face and neck, and sometimes
affect the hands in the form of athetosis. The tendency to pick up
objects with the thumb and index finger, to the exclusion of the other
fingers, is not so marked as in the other cases, but still is noticeable. The
tongue cannot be kept still when protruded. The gait is unsteady, and
she tends to bear to either side when walking. Nothing abnormal was
found in the fundus of either eye.

Case 3.—J. V—, female, aet. 47 on admission in November, 1907.
Her father and paternal grandmother and great-grandmother suffered
from chorea. In the father the disease started at the age of 37, and
he died at 57. Grandmother died at the age of 70. They were all
subject to great irritability of temper, but not of sufficient gravity to
necessitate asylum treatment.

The patient has suffered from chorea since she was 33 years old.
Until then she was bright, and held good situations, and the symptoms
were stated on admission to have been coming on for one month.

On admission she was conscious, had delusions of grandeur, e.g. }
called the asylum a castle, and herself and the nurse, queens. Per
ception good, some ideational inertia, attention difficult to attract;
chatters incoherently, and is very irritable, obstinate and violent at
times. Irregular, involuntary movements are present affecting the
whole body, and are increased during excitement. The movements are
slow, and of a twisting, eel-like character, and are most marked in
the arms, neck and face. No tremors in tongue. Movements cease
during sleep, but are present in a mild form in a half-sleeping
state. Speech slow and halting, with some syllabic stumbling. Gait
reeling and unsteady. Holds articles between thumb and index-
finger. Knee-jerks equal and exaggerated. Pupils equal, small, and
react to light and accommodation. Heart sounds normal. Has slight
optic neuritis, especially in right eye. She was treated without success

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with arsenic, and the disease has run a chronic course since admission.
She still has delusions of grandeur, and is very impulsive, and shows
signs of advancing dementia.

Case 4.—H. V—, male, aet. 48 on admission in March, 19T0.
Father died at the age of 72, after suffering for several years from chorea
and mental enfeeblement. One sister is M. A—, Case 2. Has had
gonorrhoea, and was in the Army. He has been in and out of the
workhouse for the past four years, during which time the most con¬
spicuous symptoms have been marked choreiform movements and great
irritability of temper, leading to acts of violence at times. Symptoms
have been getting worse. On admission he was quiet, but irritable.
Gives a good account of his past life, but his memory for recent
events is bad. Speech slow and halting through lack of control over
the movements of the tongue. Perception and attention umimpaired.
Is inclined to be grandiose. Choreiform movements affect the whole
body, and are of a twisting character. The muscles mostly
affected. are those of the trunk, neck and limbs. Facial muscles
but slightly affected. The grosser movements of the tongue are im¬
paired, but no fibrillary tremors are present. Handwriting almost illegible.
Has a tendency to use thumb and forefinger to the exclusion of the
other fingers. Gait waddling, the adductor muscles being especially
affected. Pupils unequal, left being larger than right in subdued
light, but they contract to the same extent in a bright light. Knee-
jerks equal and brisk. Plantar reflex flexor. Skin-reflexes normal.
Heart-sounds normal.

He has not been so irritable since admission, but the movements
are as pronounced now as they were three months ago.

The diagnosis in all four cases was based on—heredity, age
at onset, the presence and peculiar character of the choreiform
movements, their irritability with progressive dementia and
various physical signs resembling those of general paralysis.

They were all of the working class and belonged to Devon¬
shire. No inter-relation could be traced between the three
families, and it was found impossible to obtain more informa¬
tion of their family history than has been recorded above. No
history of a sudden onset was obtained in any of these cases.
The movements were involuntary and irregular, Case 2 showing
a tendency to repeat the same movements at times. In Cases
3 and 4 the movements could be stopped voluntarily for not
more than a fraction of a minute. Case 2 has shown a tendency
at times to lose control over the sphincters. No gross affection
of the ocular muscles was recorded in any of them, and none
of them ever threatened or attempted suicide. Transmission
was direct in all three families recorded. Cases I, 2, and 4
represent the second generation as far as could be ascertained,

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and have brothers and sisters who have reached middle life
without being affected. Case 1 had two sons who cannot be
traced. Case 3 represents the fourth generation so affected
and has a healthy daughter, aet. 21. Menzies, in a paper in the
Journal of Mental Science , 1893, records the case of a family
affected for six generations, and remarks that the tendency is
for the disease to die out if the other partner in marriage
belongs to a healthy stock.

The close resemblance of these cases to general paralysis of
the insane is remarkable not only as regards physical signs in all
four and the post-mortem appearance of the brain in Case 1, but
mentally as well, e.g., delusions of grandeur. Some continental
writers seem to regard the two diseases as identical, though,
from the point of view of heredity only, this is most unlikely.
It might be mentioned that Wassermann’s reaction has not
been performed on any of these cases yet.

We are indebted to Dr. Davis for permission to publish these
cases.

Three Unusual Cases of General Paralysis . By Guy

R. East, M.B., Assistant Medical Officer, Northumberland
County Asylum, Morpeth.

My excuse for reporting the following three cases is to draw
attention to the fact that occasionally the initial attack of
insanity in general paralysis does not present any of the signs
and evidences of that disease, so that such cases are easily
passed over and not diagnosed, no matter how carefully medical
examination is conducted.

There is no doubt that such cases enable one to account for
reported recoveries in general paralysis, not one of which was
ever permanent where the diagnosis proved correct. In none
of these three cases were there any evident signs of general
paralysis present when they were first admitted, and on recovery
they were discharged as “recovered.” J. C— remained
rational for four years, G. H— for two years, W, H— for one
year.

On re-admission all three cases were readily diagnosed as
general paralysis, and in two cases, where a fatal terminal
occurred later, the diagnosis was confirmed by post-mortem
examination. In one case only (G. H—) will be found gran-

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diose ideas. In most text-books on mental disease great stress
is laid on this phase of general paralysis. So much is this the
case that one is almost led to expect them as a sine qua non
in this type of insanity. In my experience of general paralysis
I have found that the classical ideas of grandeur are rather the
exception than the rule.

G. H—, aet. 30. On admission was depressed and hypochondriacal.
Stated that his head had dropped to his feet, that he was filling up
with water, that I am about to administer chloroform to him prepara¬
tory to killing him, and asked for a few minutes’ respite to prepare for his
impending death.

He presented no signs nor evidence of general paralysis. He con¬
tinued miserable and dejected for three months, always reiterating the
same statements, that he was shortly to be killed or roasted alive, and
that he had not long to live.

Thence onwards he began to improve mentally and bodily; he
gradually rid himself of his depressing delusions and became cheerful
and sociable. Employment in the open air further advanced his mental
improvement. He became quite rational, and one year after admission
was discharged “ recovered.”

On re-admission, two years later, he was wildly maniacal, continually
shouting in a harsh, croaking voice, said he was the king, also Christ,
that he was ninety feet high. He destroyed his mattresses, pulling out
the coir in his desire to find gold, of which he stated he had an enormous
quantity. He was degraded in his habits.

He was evidently suffering from general paralysis ; his expression was
typical : lips and tongue tremulous, with slurred and hesitating speech;
pupils unequal and fixed; gait unsteady.

After remaining in this mental condition for six weeks he gradually
quietened down, and was allowed out of bed. He soon regained mental
and bodily vigour, and for six months was usefully employed in gardens.

The terminal scene was ushered in by a congestive attack, followed
by a prolonged condition of mania, which in many respects resembled
his former attack. He remained in this state during four months, when
he collapsed suddenly. Thence onwards he passed into the typical
condition seen in bed-ridden general paralytics. He ultimately died
four and a half years after his initial attack.

W. H—, aet. 36. On admission was depressed and deluded. Stated
that he could not sleep at night owing to terrifying things at his
bedside, that a man followed him about and frightened him, that electric
shocks were passed through his body which caused him to shiver. He
frequently complained of headache. No motor signs nor evidences
of general paralysis were present. For the next three months he
remained very unhappy and miserable, was quite unable to indulge in
useful occupation, never attempted to distract his thoughts with reading
or amusements, spent most of his time holding his head in both hands,
and groaning as though in great pain.

Afterwards he began to make some mental progress, and was at length
persuaded to work in the flock-room, where he eventually became a

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useful worker. From this time onwards the mental improvement was
gradual. It took him nearly eighteen months to recover. He was
finally discharged after two years as “ recovered.”

On re-admission, one year later, he was maniacal, restless and excited,
whistled and sang frequently, gesticulated wildly, and talked incoherent
nonsense. He had no idea of time or place, could not tell the day,
month or year; did not know where he was. His habits were filthy.
He was destructive, tearing his clothes and bedding, usually wandering
about his room in a nude state. He rarely slept.

His general expression and appearance was indicative of general
paralysis. Fine tremors present in lips and tongue. Both pupils were
“ pin-point ” and fixed. His articulation was characteristic of general
paralysis.

For five months he was kept continuously in bed, and during all that
time was maniacal. He afterwards improved sufficiently to be allowed
up, and for the next five months made himself useful, working in the
wards. He had, during this period, passed into a state of terminal
dementia, which was occasionally interrupted by transient attacks of
mild mania. He became progressively weaker in mind and body, and
died of general paralysis four and a quarter years after his initial attack of
insanity.

J. C— set. 24. On admission his mental state was one of stupor
with occasional excitement. He lay in bed with arms outstretched
pretending to be asleep. He paid no attention to what was said to him,
except that he stated his name. He laughed to himself and made faces.
At times he became restless and destructive. He broke one of the
windows in his room in a fit of excitability, and frequently tore up his
clothes. In this state he was markedly garrulous, talking incoherent
nonsense. Stated that he had come from heaven and that he was now
in the grave.

He required forcible feeding for four days.

There was no sign nor evidence in this case to lead one to suspect
early general paralysis.

After a month’s confinement to bed he was so much improved that
he was able to work in the gardens, where he did well. His mental
progress was maintained so that, nine months after admission, he was
discharged “ recovered.”

On re-admission, four years later, he was acutely maniacal, incoherent
and deluded. Stated that he was tormented by voices of men and
women, that I pass electricity through him by means of my stethoscope,
that his wife tried to poison him, and also attempted to cut his throat.
He pointed at and addressed imaginary persons.

He had the expression and appearance of a general paralytic. His
pupils were unequal, the right reacted sluggishly to light and accom¬
modation, the left was fixed. Fibrillary twitching in lips and tongue ;
his speech was also affected.

In the course of one week he got over his maniacal attack, and since
then has made rapid mental progress. He now talks quite rationally,
is clean, tidy and industrious, being in every way satisfactory, and is
already asking to be discharged.

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Photographs of Patients Suffering from Pellagra , with
Well-marked Skin Rashes. Contributed by John
Warnock, M.D., Medical Superintendent, Lunatic Asylum,
Abbassia, Cairo.

Fig. 1.—This photograph shows the black indurated skin
of the back of the hands and forearms after exfoliation takes
place.

Fig. 2.—Well-defined “breast-plate” of white denuded skin
after exfoliation of the black rash. The “breast-plate” occupies
exactly the portion of the skin of the chest exposed to the sun
by the fellah’s shirt, which is cut low. On the patient’s left
arm the line of demarcation between the blackened skin of the
forearm and the light skin of the upper arm is plainly seen.
The forearm is not covered by a sleeve while the fellah works
in the field. The skin of the legs and knees is seen to be
blackened, also patches on the nose and cheek. The general
muscular atrophy is evident.

Fig. 3.—Shows the blackened scaly skin of neck where it
has been left uncovered.

Fig. 4.—Shows the blackened, thick, wrinkled, rough skin
of legs of a pellagrous man.

Occasional Notes.

The International Committee for the Study of the Causes and
Prophylaxis of Mental Disease.

The report on the meeting of the above committee, which is
published in the opening pages of this Journal, is worthy of the
closest attention from all members of the Medico-Psychological
Association, as affording a most important means of advancing
that branch of our science which more immediately relates to
preventive medicine.

Such a committee, if it becomes thoroughly organised and
equipped, should speak with an authority which should
command the attention of popular opinion and of the legis¬
lative bodies of all the civilised countries contributing to its

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JOURNAL OF MENTAL SCIENCE, JULY

To illustrate Dr. John Warnock’s contribution

Adlaul & Son. Imf.

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JOURNAL OF MENTAL SCIENCE, JULY, 1910 .

Fig. 3.

To illustrate Dr. John Warnock’s contribution.

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OCCASIONAL NOTES.

513

formation. Its influence on civilised communities might go far
to correct many of the faults of social life, which furnish the
basis for the development of mental maladies, and so become
an important factor in preventive medicine.

The one thing needful to put in action the machinery that
has been created is a grant of money from the governments of
the various countries, and it is very desirable that the members
of the Medico - Psychological Association should seize all
personal opportunities of forwarding this object. The Parlia¬
mentary Committee without doubt will exercise that collective
influence, the importance of which has been so recently shown
in the pensions legislation. Very considerable effort, however,
will be needed at the present time to obtain from the Treasury
of the nation the modest sum that is required for a purpose
which may exercise such an important influence on the future
health of the nation.

The Asylum Workers' Association.

The Annual Meeting of this Association was held on May 25th,
under the presidency of Sir W. Collins, when a very satisfactory
annual report was presented.

The report showed that the membership had largely increased
during the past year, having risen from 3,025 at the end of 1908
to no less than 4,575 at the end of 1909. This is very truly
attributed to the interest excited by the Asylum Officers’
Superannuation Act.

The financial position remains sound, the balance at the end
of the year having considerably exceeded that of the previous
year. The Homes of Rest Fund has also increased, but there
would seem to be room for considerable extension in this direc¬
tion. Ninety pounds as the total subscription of 4,000 members
does not appear to be a sum adequate to the usefulness of the
object.

The report very fully recognises the services of Sir W. Collins
in promoting the objects of the Association, and of Dr. Shuttle-
worth, who has so ably aided its development from its earliest
stages. It has now reached a point in which its success, as a
practical and influential body, is permanently assured.

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Psychiatry in Russia ; from Professor Bcchtereff.

Professor Bechtereff’s presidential address, at the recent
Congress of Russian Psychiatrists, gave an outline of the state
of lunacy in Russia which is of singular interest. He estimates
that there are at least 300,000 insane persons in Russia, of
whom only 30,000, or 10 per cent., are cared for in institutions.
The 270,000 unprovided for he describes as often kept in chains
under very miserable conditions.

He considers that insanity is less frequent in uncivilised
Russia, by contrasting the ratio of 1 in 450 of the population
with the much higher ratio in England and other civilised
countries. It may be doubted whether this conclusion is
justified. The mortality of the 270,000 existing under the
conditions he describes would probably be at least double that
of patients treated in asylums, and this extreme waste would
need a larger ratio of occurring cases to maintain the smaller
proportion of existing lunacy.

Professor Bechtereff advocated the establishment of colonies
and of communal supervision to deal with this vast amount of
untreated misery.

Part II.—Reviews and Notices.

A Text-Book of Mental Diseases. By Professor Eugenio Tanzi, of
Florence. Authorised translation by Dr. Ford Robertson and
Dr. T. C. Mackenzie. Illustrations. Pp. xvi + 803. Demy 8vo.
London: Rebman, Ltd., 1909. Price 24 s. net.

This is the third great book dealing with insanity which has lately
come from Italy. It is remarkable that the most advanced ideas of
psychiatry have been formulated in Italy and transmitted to us mainly
by the labours of Scotsmen. We hear much of our insularity, but
Professor Tanzi himself is not above reproach on the score of peninsu-
larity. In the chapter dealing with asylums, omitting reference to
voluntary patients, he finds fault with the English law, which “ refuses
admission to those who most require care, and provides refuges instead
of hospitals.” He holds that psychiatry is cultivated here as a philan¬
thropic institution and not as a science. He finds an exception in the
Scottish Asylums Laboratory, to which the translators add Claybury,
Manchester and Lancaster. It is not surprising, therefore, that the
index of names bears no reference to Bevan-Lewis, Clouston, Crichton-
Browne, Goodall and many others whose scientific work is familiar to

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us. This, however, is not altogether subject for regret, as it leaves Pro¬
fessor Tanzi more free to deal with continental work, which is, of course,
more interesting on this occasion. The translators have omitted his
remarks on the administration of Italian asylums, which, unless it has been
vastly improved within recent years, leaves much to be desired. The
immediately fascinating and important feature of the book is the great
development of clinical observations, largely under the influence of
German and French models. Professor Tanzi endeavours to enlighten
us on the practical measures and the attainment of the ideals of
psychiatry, with a rigorous examination of facts and a hesitation in the
condemnation of hypotheses.

Beginning with the seat of the psychical processes the author advances
to consideration of the causes of mental diseases and the anatomical
substratum concerned. The obscurity of causation as compared with
the comparative simplicity of the pathology of other organs is at once
insisted upon. How is it that out of an emotional experience there can
be materialised an organic change ? Having established the facts that
the psychical processes are localised in the cerebral cortex, and that
localisation of various functions have been very precisely determined,
although our knowledge in this respect is still far from complete,
Professor Tanzi admits that the course of thought is very precarious,
and believes that the psychical centres do not contain ideas, but rather
are able to produce the ingredients that serve to compose the ideas or
to symbolise them. In this discussion the observations of Broca and
Hitzig have not been forgotten, nor are references to Verworn, Flechsig,
Cajal, Ferrari and Bianchi wanting.

Proceeding to consider the causes of insanity, they are divided into
exogenous and endogenous, the former proceeding from the environ¬
ment—physical, psychical or social—while the latter are connected with
the individual constitution and are operative in any environment—
diathetic, hereditary and degenerative.

The somatic causes are first considered, including infective processes,
pellagra, etc. Psychical causes are also held capable of inducing mental
diseases. The chemical importance of mental processes is not great;
only the emotions generally determine the psychopathic process ; they
disturb the trophic mechanism which, initiated by the brain, regulates
the nutrition of the tissues. The brain is injured by the reflected
action of visceral disorders, and specially by the auto-toxins developed
by these disorders, for the characteristic and misfortune of the cerebral
cells is their special sensibility to poisons. Thus inordinate exercise
unfits one for good mental work. The far-reaching results of these
modern opinions must be followed out in the pages of Professor Tanzi’s
book. It is only possible here to give the merest indication of his
position, but from these few notes it will be evident that a reasonable
theory has been promulgated, that the ideas which have been in the
air are now systematised and placed clearly before the profession.
Similarly, it is stated that insomnia arising from worry allows toxic
products to accumulate in abnormal amount.

Comparing the conditions prevailing in the north and the south of
Italy, Professor Tanzi admits that the number of persons in asylums
increases with culture and prosperity. The proportion in the north

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varies between 25’3 and 16 9 per 10,000 inhabitants, compared with
between 1*3 and 6 6 in the south, but that does not mean a relative
scarcity of the insane. Alcoholism is observed to vary in the same
geographical districts, from a maximum of 15-84 per cent, of the asylum
admissions in Liguria to 0-97 in Sicily.

The continuation of this chapter on causes in respect of heredity is
of deep interest, and from that Professor Tanzi goes on to discuss the
anatomical substratum of mental diseases, which is adequately illus¬
trated as regards macroscopic and microscopic details. A very interest¬
ing and important part of the book follows the anatomical section. It
deals with the physiology of sensibility, ideation, memory, the senti¬
ments, movement and will. Taking double consciousness as an
example of the treatment of these subjects, it is regarded as an alter¬
nating amnesia, which is explained by the difference of the mnemonic
material that consciousness has at its disposal. It is likened to the
abstraction of pages from a book at random—in the ordinary state only
the remaining pages would be used, whereas in the other state either
the detached pages only would be used, or a reconstitution of the whole
book.

Passing to classification, Professor Tanzi finds two opposing
tendencies, the symptomatologists multiplying distinctions and clinical
forms, and the anatomists simplifying by synthesis. Esquirol, Guislain,
and Morel are noted as the precursors of Krafft-Ebing, displaced in
Professor Tanzi’s estimation by Kraepelin. The result is that the
author pursues his subject as follows:

Poisonings. —Pellagra, alcoholism, etc.

Toxic infections and auto-intoxications. —Amentia, uraemic psychoses,
thyroid psychoses, progressive paralysis.

Encephalopathies .—Acquired idiocy, tumours and other coarse patho¬
logical incidents.

Affective psychoses. —Melancholia, mania and circular insanity.

Constitutional neuro-psychoses. —Neurasthenia, hysteria and epilepsy.

Demetitiaprcecox in the usual three forms.

Degenerative mental anomalies .—Sexual perverts, constitutional im¬
morality, paranoia, intellectual feebleness (hereditary imbecility).

This classification is a distinct advance on those with which we have
become familiar, but it requires explanation, which we cannot supply in
brief space. The first group is definite enough, but the second opens
with amentia, by which we understand idiocy in this country. The
synonyms here given are : Amentia (Meynert), sensorial delirium, con-
fusional insanity, Wahnsinn, Verwirthheit, meaning an acute psychosis,
not in every case febrile, of varied origin, and characterised by a kind of
mental ataxia which causes disorder of the processes of perception and
ideation, and which in some instances suspends them completely, lead¬
ing to unconsciousness. It is a disease of the young of normal mental
development, generally ending in recovery, not uncommonly in death.
Formerly it included acute mania and acute deliiious mania. It is
greatly to be regretted that this confusing and contradictory vocabulary
of names is permitted to continue. Surely the time has arrived to make
a systematic attempt at an international understanding of these names
and a resolute abolition of those which are inappropriate. Amentia

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plainly signifies deprivation of mind generally, and specially a depriva¬
tion dating from birth or early infancy. Sensorial delirium, in the
French sense, means an insanity in which illusions or hallucinations are
predominant symptoms. Confusional insanity is Griesenger’s term,
which excludes dementia and specialised delusions; Wahnsinn was
monomania, rejected in favour of paranoia, which in turn appears to be
suffering eclipse. Verwirthheit apparently remains as an equivalent,
more or less exact, for confusional insanity, which is a reasonably
descriptive name for a syndrome which occurs frequently enough. It is
an inconvenience, a source of irritation, and a reproach to perpetuate
unsuitable and equivocal names in describing those disorders. We, no
doubt, arrive at the author’s meaning in time, but the process is un¬
necessarily vexatious. If, in reality, amentia is mental ataxia (inco¬
ordination) why not call it that ? But the alleged characteristic of
confusional insanity is also inseparable from other forms of mental dis¬
order.

These considerations lead us far from the immediate subject in hand.
It is enough to say that Professor Tanzi’s work in the great asylum of
Florence has been fitly crowned with the production of a most interest
ing book which enhances the fame of Italian psychiatry. We are
indebted to Dr. Ford Robertson and Dr. Mackenzie, and to those who
have helped them in the production of this translation, which will
command appreciation as a distinct advance in psychological medicine,
scientific in detail and philosophical in outlook.

Text - book of Nervous Diseases and Psychiatry. By Charles L.

Dana, LL.D. Seventh edition. 264 illustrations. J. & A.

Churchill, 1909. 8vo, pp. 782.

When a book reaches its seventh edition it passes beyond the range
of an ordinary critical survey. It has already proved its usefulness to
the profession and has become popular. Prof. Dana has revised his
work, and has fulfilled his desire to make it really representative of
present-day neurology. Following out his original ideal, he has added
to those parts which deal with the neuron histologically, and with the
anatomy and physiology of the brain. It thus becomes a useful hand¬
book for those who desire to keep abreast of the rapidly increasing
knowledge of neurological details. A survey of the numerous and
excellent illustrations is helpful even without reference to the excellent
text. On the other side, psychotherapy, neurasthenia, hysteria, and
psychasthenia have engaged Prof. Dana’s renewed attention with
excellent and practical results. He has been successful in selecting
what is of present value, and in presenting the results to his many
readers.

Turning to the chapter dealing with insomnia we find the memorable
conclusion—that there are many sleep-producing remedies, but no good
drugs available; and the further warning that many from childhood up
do not get a sufficient amount of sleep. The shorter part of the book
relates to psychiatry, and is of less importance than the neurological
section.

LVI. 34

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REVIEWS AND NOTICES.

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The Dissociation Oj a Personality: a Biographical Study in Abnormal
Psychology. By Morton Prince, M.D.Boston. London:
Longmans, Green & Co., 1906. 8vo, pp. 569. Price ioj. 6 d .
net.

This is not a little book. It is crowded with careful observations and
details elucidative of the case of Miss Beauchamp, including facsimiles
of her handwriting and appendices of interest. Yet Dr. Prince sends it
forth as selections calculated to familiarise the reader with the main
phenomena, which will serve as fundamental data for the consideration
of the psychological problems with which he intends to complete a
deeper study in another volume. His first aim has been accuracy of
the observations, which he has interpreted logically from the established
data of abnormal psychology. His purpose is to discuss a series of
problems in another volume, including the theory of this case and dis¬
integrated personality in general ; the subconscious under normal and
abnormal conditions; hypnosis, sleep, dreams, and somnambulism;
hysteria; neurasthenic states; alterations of character; hallucinations,
fixed ideas, aboulia, amnesia, etc. Dr. Prince is of opinion that abnormal
psychology offers a rich field for modern investigation, and submits this
work as a contribution to our knowledge.

The subject of this study is a person in whom several personalities
have developed ; she changes in character and her memories are altered.
She may be any one of three different persons—different characters.
Two of these personalities have no knowledge of each other or of the
third except by inference or at second-hand. Blanks, therefore, occur in
memory. The splitting of personality is along intellectual and tempera¬
mental, not along ethical, lines of cleavage. The appropriate term is
disintegration of personality, a functional dissociation of the normal self,
not a degeneration or destruction which may be equivalent to insanity.
Reference is made to similar cases studied by Pierre Janet, M. Flournoy,
Prof. Hyslop, M. Azam, Hodgson, and William James. Miss Beau¬
champ’s heredity and childhood accounts for the psychopathic soil which
has permitted her present condition, which is described accurately
relative to the various and varying mental phases.

It is unnecessary to follow out these lengthy studies in detail. To
those who are interested in these phases as they occurred and as they
are analysed the whole volume is noteworthy. And one must recognise
in these cases medico-legal problems which are of real importance, so
that Dr. Prince’s record compels serious study.

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Part III.—Epitome.

Progress of Psychiatry in 1909

BRAZIL.

By Dr. Juliano Moreira.

An adequate review of the progress of psychiatry in Brazil during the
past two or three years is not an easy task. The greatest Republic of
South America is so unknown in Europe, the progress accomplished in
asylum care and treatment and psychiatrical instruction is so remarkable,
that any statement of the facts within reasonable compass is difficult.

From another point of view, the selection of what will be of interest
is a matter of some difficulty.

Having a vast area of over 8,524,000 ks., and a population of
25,000,000, the United States of Brazil offers an admirable field for
the study of the comparative racial pathology of insanity.

Statistics having proved an increase of insanity, the Government has
been obliged to make more extended provision for the care of the insane.

In 1903 I succeeded in obtaining from the Federal Congress some
reform of the care of lunatics in Brazil. December 22nd saw the pro¬
mulgation of the new Lunacy Law, which for the last fifteen years has
been lingering in the Legislative Congress.

The law is a public guarantee against arbitrary sequestration, provides
for the safe keeping of the property of patients, and gives to the medical
director authority over the administration necessary for the welfare of
the patients.

The federal decree No. 5,125, of February 1st, 1905, was issued
giving regulations for the application of the new Lunacy Law. The
law establishes that all asylums, public or private, shall have a part
absolutely independent of the rest of the asylum, with a separate staff,
for the reception of new cases. They are to have workrooms, and if
possible a farm, for those patients who will employ themselves, also
places for the isolation of the dangerous cases, those suffering from
infectious diseases, and for those charged with some offence at law, the
medico-legal investigation of which is proceeding.

The law permits a patient to be cared for at home. In all cases these
homes are under the supervision of the commissions of vigilance,
nominated by the Minister of the Interior and Justice, and constituted
by the Attorney-General of the Republic, the Attorney of the Orphans,
and the Medical Inspector, a reputable physician with experience in
the treatment of mental and nervous diseases.

The rules establish a school for the teaching of attendants and
those who aspire to these posts. No person is permitted to resort to any
means of restraint without an express order written and signed by a
medical officer of the asylum. There are a number of precautionary
measures against the possibility of arbitrary sequestration. The new
Lunacy Law has had a very beneficial effect.

The National Hospital for the Insane at Rio de Janeiro has been

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radically remodelled. Many pavilions have been built: two pavilions
for epileptics, two for contagious diseases, two with verandahs especially
for the outdoor treatment of phthisis, one pavilion for idiots, two dining
rooms, a very good modern kitchen, new laundry, workshops (printing
office, book-binder, carpentry, blacksmith, dressmakers’ shop, etc.), a
new mortuary, engine-room, etc. A very good pathological laboratory
equipped with all modern improvements, operating rooms, electro-
therapeutical installations, and a psychiatric library have been provided.
Six new bath-rooms have been equipped in the sections Pinel, Esquirol,
Calmeil, Morel, Meynert, and Magnan. Hydrotherapy has been largely
practised, and massage has also been found a valuable adjunct in the
treatment of the several cases of acute psychoses and a trained masseur
is daily employed. This form of treatment has proved of the greatest
benefit in cases with defective metabolism. The out-door treatment of
psychoses and tuberculosis has been continued with success.

Dr. L. da Cunha was appointed pathologist, and he undertook the
purchase and equipment of the laboratory, after having visited many
of the best laboratories in Germany, Vienna, and Paris, where he
familiarised himself with the latest and most approved developments of
modern neuro-pathology.

With my friend, Dr. Afranio Peixoto, in January, 1905, I published
the first number of the Archivos Brasileiros de Psy chi atria, Neurologia ,
etc. With the collaboration of the Brazilian alienists, we have already
edited five volumes—a vast amount of clinical and pathological con¬
tributions to the study of the psychiatry and neurology in Brazil.

At present, the teaching of mental science is undertaken in the three
medical faculties of Brazil—Rio de Janeiro, Bahia, and Rio Grande de
Sul—by three professors and three assistants. The clinic of Rio gives
opportunity for clinical instruction to the students of the medical faculty
of Rio de Janeiro. The professor of psychiatry, Dr. T. Brandao, has
occupied the chair for twenty-six years. The equipment of the hospital
for clinical investigation is very complete, and not inferior to that of any
similar institution in Europe or North America.

The asylum accommodation in Brazil comprises: Federal district,
National Hospital for Insane (1300 beds); the Colony in Governor
“ Island ” (300); two private institutions; of these the largest is that of
Dr. C. Eiras (100 beds).

State of S. Paulo. —Of the states of Brazil, S. Paulo stands foremost
in wealth and progress. This state has shown a great advancement in
the development of its provision for the public care of the insane. The
hospital colony of S. Paulo is one of the best planned and equipped
institutions in the world. It is located at Juquery at a distance of rather
less than an hour by rail from the city of S. Paulo. It comprises a main
hospital with eight pavilions and two agricultural colonies. The plans
were made by the architect, Ramos, from the suggestions of director
Dr. Franco da Rocha. Dr. F. Rocha has founded at S. Paulo, family
care of the insane in Juquery village with good results. Some of the
other states, notably Pernambuco, Rio Grande de Sul, Para, have
institutions of some merit.

The meetings of the Brazilian Association for Neurology, Psychiatry,
and Legal Medicine were held in Rio at the rooms of the Association.

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A large number of valuable and interesting papers were read. The
demonstrations of interesting cases an i the discussions which followed
were the most instructive part of our meetings. The subjects of hysteria,
psychasthenia, infective delirium, dementia praecox, aphasia, apraxia,
etc., were considered.

The year 1909 was especially distinguished in Brazil by the meeting
of the First Congress of Psychiatry , Neurology, and Legal Medicine , a
Section of the Fourth International Latino-American Congress of
Medicine. The Congress was remarkable not only for the importance
of the subjects that were dealt with, but also for the number of dis¬
tinguished foreign physicians who attended from all parts of South and
Central America. The number of papers presented to the Congress
obliges us to be brief and merely to indicate the leading contributions.
The reader who is desirous for further detail will need to refer to the
Archives Brasileiros de Psychiatria.

Aphasia , Prof. Pinero (de Buenos Aires), and Pe6n del Valle (de
Mexico) ; Alcoholic Psychoses , Prof. M. Nery (Rio), Borda, Jones and
Morixe (Buenos Aires); Sclerosis , Lateral Amyotrophica, Prof. C. de
Freitas (Rio); Infectious Psychoses , Prof. Austreg^silo (Rio), Dr.
Lamas (Montevideo); Arteriosclerotic Cerebritis , Prof. Jakob (Buenos
Aires), Prof. Moreira (Rio); Epilepsy (AEtiology and Pathogeny), Riedel
(Rio), and J. Esteves (Buenos Aires); Dementia Prcecox and Thyroi¬
dectomy, M. Pinheiro and Riedel (Rio), and Esteves (Buenos Aires) ;
Clinotherapy , Prof. Cabred (Buenos Aires); Tumours of the Frontal
Lobe in Man, Dr. H. Roxo (Rio); Urology of Beri-beri, Dr. M. Rego
(Rio); Cerebrospinal Fluid in Dementia Prcccox, Dr. A. Viegas(Rio);
Apraxia, Dr. E. Lopes (Rio) ; Medico-pedagogical Education of the
Abnormal, Dr. F. Figueira (Rio), Prof. Cabred (Buenos Aires), Dr.
S. Rodrigues (Montevideo); The Care of the Insane, Prof. Juliano
Moreira (Rio); The Family Treatment of the Insane in S. Paulo,
Dr. Franco de Rocha ; Cerebrospinal Fluid in Dementia Paralytica and
in Dementia Prcecox, Prof. L. da Cunha and Dr. U. Vianna (Rio) ;
Treatment of Epilepsy, Dr. VV. Almeida (Rio); Responsibility in
Crimes of Passion, Prof. Lima Drummond (Rio) ; Medical Secrets, Prof.
Nascimento Silva (Rio); Civil Capacity of the Aphasics, Prof. Peon del
Valle (Mexico); The Dead after Immersion , Dr. Alf. Andrade (Rio) ;
Identification in Legal Medicine, Dr. A. Lima (Rio).

The social side of the meeting was as successful as the work, and will
long remain as a pleasant memory with those who had the good fortune
to be present.

Prof. Domingo Cabred, at a successful meeting of the Brazilian
Association of Psychiatry, Neurology, and Legal Medicine, with lantern
demonstration, showed the great progress in the care of insane in
Buenos Aires.

Prof. Cabred was elected a member of our Association.

During the meeting of the International American Congress of
Medicine, a visit was paid by several specialists to the National Hospital
for the Insane at Rio de Janeiro.

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EPITOME.

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Epitome of Current Literature.

i. Physiological Psychology.

A Psycho-analytic Study of Leonardo da Vinci [Pine Kindheilserin-
nerung des Leonardo da Vina]. (Schriften zur Angewandten
Seelenhunde, H. 7, 1910.) Freud , S.

A psycho-analytic study of Leonardo, based on his youthful expe¬
riences, is rather hazardous on account of the poverty of the material
extant. There is, in fact, only one statement to rely on. In one of
his notes Leonardo remarks that as an infant in the cradle he remembers
that a vulture alighted near him, and that its tail touched his mouth;
hence, he thinks, his interest in the problem of flight. Freud ques¬
tions whether this was a real experience. It recalls the infantile
pseudo-reminiscences which occur in hysteria and allied conditions, and
frequently have reference to precocious sexual feelings. The bird and
the tail are sexual symbols. Hence, being psycho-analytically inter¬
preted, this phantasy means that Leonardo was marked by infantile
sexuality of passive character, such as is sometimes produced by exces¬
sive maternal caresses. It is well known that Leonardo was an
illegitimate child, who lived with his mother to the age of five, when he
was taken into the house of his father, whose wife was sterile. Freud
imagines that the husbandless mother lavished all her affection on the
child, who reciprocated her emotions, suppressing them as he grew up,
so that they became transformed into an “ idealised homosexuality,”
and left him sexually frigid to women. As a youth, it is proved,
Leonardo got into trouble, and was perhaps imprisoned, through
associating with sexual inverts, and he always loved to surround
himself with beautiful boy pupils, There is no evidence that he
had any relationship, even of friendship, with women. Freud sees
his love to his mother reappearing at the age of fifty in the labour
which he devoted to his portrait of Monna Lisa, whose smile (remi¬
niscent of his mother’s, says Freud) strangely haunted him, and is seen
again in the Anna with her daughter Mary in her lap at the Louvre.
For Freud these two women, who appear of like age, represent the
artist’s mother and his father’s wife—his second mother. Leonardo
always remained much of a child, and delighted in inventing curious
toys ; this is traced to the inhibition exerted by his infantile sexuality,
and his inquisitiveness, which developed into profound scientific
curiosity, is traced to the same source. Freud refrains from labelling
Leonardo as neurotic, but considers that he revealed characters
which allied him to that type.

The argument is developed at considerable length, and the author
has evidently made a careful study of the authorities. He has, how¬
ever, overlooked the statement—made by the almost contemporary
Anonimo Gaddiano, and rather favourable than otherwise to Freud’s
argument—that Leonardo’s mother was not, as he assumes, a peasant
girl, but a woman “of good blood,” and she afterwards married a
citizen of the town of Vinci. It is easy, however, to criticise Freud’s

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interpretation of the statement from which he starts. Childish
memories are sometimes much earlier than is commonly supposed ;
the very early cases are usually associated with an emotion of fright,
and Leonardo’s own account of the matter is entirely possible, though
the big bird need not have been a vulture. Freud himself, at the end,
admits that his essay may be treated as only “ a psycho-analytic
romance.” He almost puts himself in the position of Alnaschar, who
with one kick overturned the basket of eggs on which his magni¬
ficent day-dream was founded; in this case, moreover, there is only one
egg in the basket. But if—to vary the simile—Freud sometimes
selects a very thin thread, he seldom fails to string pearls on it, and
these have their value whether the thread snaps or not.

Havelock Ellis.

Visual Hallucinations in the Sane State [.Hallucinations Visuelles a
r A tat Normal). (Arch, de Psychol., Oct. and Dec., 1908.) Naville, E.

Prof. Naville, eminent as a philosopher and now aet. 92, here
describes the hallucinations to which he has lately become subject. He
first observed them during the summer of 1908, when staying at his
chilet on Mont Salfeoe (at a height of 1,200 metres). On returning to
his laboratory in Geneva they reappeared after an interval, becoming
still more frequent. He is in good health considering his age. Sight
is also good, except for some difficulty in reading and writing j ophthal¬
mic examination revealed no signs of disease. He is not duped by his
hallucinations, though he often requires the negative evidence of other
witnesses to distinguish them. They are exclusively visual, unaccom¬
panied by any special sensations, and they cause no trouble or anxiety,
but are simply an occasion of interesting study. They show no special
relationship to meals or to time of day, and they appear equally in fine
or dull weather.

The visions disappear as soon as the eyes are closed, and they involve
no change in the natural objects surrounding them. They are usually
seen from the window, at a distance of several hundred paces, and are
never recognisable as actual acquaintances. They are, however, always
lifelike, never fantastic, and Naville is usually able to find the germ of
them in actual memories, sometimes of very ancient date. They fre¬
quently take the form of processions of men, women, or children ;
animals, especially sheep, and vehicles also figure in them. A kind of
smoke sometimes rises from the processions. White is the prevailing
colour, and nearly all the. head-dresses are white.

Havelock Ellis.

On the Nightmare. (Atner. Jour, of Ins., Jan., 1910). Jones, E.

The subject of nightmare has been almost ignored by medical
writers, though there is hardly any malady which causes greater distress
to the sufferer. The earlier part of this paper is devoted to an
exhaustive survey of the literature of the subject.

The cardinal symptoms of the attack are shown to be : (1) Agonising
dread (angst) ; (2) sense of oppression or weight at the chest which
alarmingly interferes with respiration; (3) conviction of helpless
paralysis.

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Many hypotheses have been advanced as to the pathogenesis of the
malady. Most of the causes which have been assigned only appear to
play a part of varying importance in the evocation of a given attack, and
there probably exists an underlying predisposition to the affection.
The various theories fall into two distinct groups: on the one hand,
sources of peripheral irritation which consist almost exclusively of
indigestible food; on the other, mechanical sources of embarrassment
to the circulation and respiration (distended stomach and constrained
postures), which act by bringing about a supply to the brain of non-
aerated blood.

Moreau, in 1855, and Spittgerber, in 1866, were the first to point out
the insufficiency of these hypotheses, and to suggest the possibility of a
psychological solution to the problem. The physical explanations are
certainly inadequate to explain the predominating features of the con¬
dition, and there is a singular lack of correlation between the alleged
cause and the actual attack. Observation reveals two facts, viz., that
these causes often occur alone or in combination in persons who never
show any symptoms of nightmare, and that the sufferer from the malady
may be scrupulously careful to avoid these causes and yet not succeed
in obtaining relief.

Recognising the insufficiency of these physical theories, the writer
proceeds to attack the question from a different standpoint, expressing
the opinion that an attack of nightmare is always an expression of
intense mental conflict centring about some form of intense
“repressed” sexual desire. He bases his opinion firstly on the
intimate relation of nightmare to the ordinary angst neurosis , which
Freud has shown to be based on a similar aetiology and also on the
psychology of dreams in general, which the same writer has demonstrated
represent symbolically the fulfilment of some desire which has been
repressed and ungratified in the waking state. The literature of the
subject reveals the erotic significance of the various images contained
in the nightmare. This psychological view gives to the various
exciting peripheral stimuli as well as the supine position to which most
writers have attached such significance, a secondary role as merely
provoking certain emotions which are already developed; the predis¬
position is the all-important essential in the production of the attack.
The frequency with which other manifestations of the angst neurosis
occurs in those subject to nightmare tends to accentuate the importance
of sexual conflict and repression in its aetiology.

H. Devine,

2. Clinical Neurology and Psychiatry.

A Reaction in the Blood of the Insane [ Una reazione nel sangue di
tnalati di inente\ ( Riv . Sper. di Fren. } vol. xxxv, Fasc. 2, 3, 4.)
Botifiglio , F

In May, 1909, Much and Holzmann published a paper in which
they alleged that the blood-serum of patients suffering from maniacal-
depressive msanity(Kraepelin), dementia praecox (Kraepelin), or epilepsy

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with circular mental manifestations, and of individuals in whom the
maniacal-depressive psychosis figured only in the family history, had
the property of preventing the haemolysis which cobra-venom by itself
is capable of producing in the human subject. As they failed to find
this property in the blood of any other individuals, healthy or diseased,
mentally or physically, they regarded it as specific for the above-mentioned
groups of mental affections. Since then many observers have in¬
vestigated the matter, and their findings are reviewed by Bonfiglio in
the present communication. The great mass of evidence proves
clearly that the reaction is not at all specific for the affections named.
All observers have found the reaction present in some cases and absent
in others. The exact proportion of positive and negative findings
varies considerably according to the different observers. Again, the
reaction has been obtained in a varying proportion in other mental
affections, nervous diseases, bodily diseases, and even in the healthy.
The writer also discusses the various hypotheses advanced by the
different observers to explain the nature of the cobra-venom reaction.
The haemolytic properties of cobra-venom are only exhibited in the
presence of an activating substance in the serum which experiments
indicate to be, in the majority of cases, lecithin. An inhibiting body
is also found in human serum, and this would appear to be cholesterin.
The result of the Much-Holztnann reaction would thus depend on the
relative quantity of the activating and inhibiting substances present in
the various sera. Such is the doctrine supported by the majority of the
writers on the subject, followers, apparently, of the Ehrlich school.
It has met with strong opposition, however, on the part of a few,
especially Bang and Zaloziecki. Bang found that solutions of salts,
bases, and acids (amongst the last, carbonic acid) introduced into the
system exercised an inhibiting action on the haemolysis, and that
carbonic and other acids had even the power of driving off the cobra-
venom which the corpuscles had absorbed whilst in ice, and preventing
haemolysis. This finding has given rise to the suggestion that the issue
of the Much-Holzmann reaction may depend upon the quantity of
carbonic acid present in the various sera, and that a positive result (no
haemolysis) would depend on transitory alterations in the material
interchange, and particularly a modified intensity of the processes of
oxidation. Zaloziecki, on the other hand, attributes greater importance
to the presence of lactic acid as an inhibitant of the haemolytic process
deducting this from the fact that he got a positive Much-Holzmann
reaction after two hours of strenuous exercise in individuals in whom
the reaction was negative prior to the experiment.

J. H. Macdonald.

The Complement-Deviation Reaction of Bordet-Gengou [Za deviation du
complement de Bordet-Gengou], ( Journ. do Med. de Bord .,

Jan. 1 jtk, 1909.) Vlrger, H.

These reactions are taking an important place among the laboratory
methods having practical clinical applications. To understand them,
we must in the first place be familiar with certain elementary notions
regarding the general laws of immunity. The writer refers especially

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to Metchnikoff’s work on “ Immunity,” and to recent papers on the
subject in the Attnales de I'lnstitut Pasteur and the Ccmptes Rendus
de la Socidte de Biologic.

(1) If we introduce into a living animal organism anatomical
elements derived from an animal of another species, or if we introduce
micro-organisms, peculiar changes ensue in the blood-serum of the
animal under experiment, which vary according to the nature of the
foreign elements introduced. For example, if fresh rabbit serum be
introduced into the blood of an ox it has no destructive action on
the red blood-corpuscles; but if the rabbit has been previously
treated by repeated injections of red blood-corpuscles of the ox, and
the blood-serum of the rabbit be then introduced into the blood
of the latter animal, the serum is found to have acquired haemolytic
properties, that is to say, it dissolves the haemoglobin from the corpuscles,
so that the blood becomes “ laky.”

(2) In the accepted scientific terminology, the substance first
injected into the rabbit, red blood-corpuscles of the ox, is said to be
an antigen ; the haemolytic powers acquired by the blood-serum of the
rabbit thus treated are regarded as being due to a substance formed in
the blood of the rabbit in the presence of the antigen, a substance
known as an antibody , whose production is the specific reaction due to
the presence of this particular antigen.

(3) (a) But the rabbit serum, prepared as described, and containing
an antibody, loses its haemolytic property after heating to 56° C. for
half an hour, (b) But if to the serum thus heated, and which has in
consequence lost its haemolytic property, some fresh (untreated) rabbit
serum be added (after it has been cooled down), the previously heated
serum recovers its haemolytic property.

From these facts we draw the following conclusions:

Haemolysis depends upon the co-operation of two distinct substances :
one of these, which is to be found only in the serum of prepared
animals, and which is thermostabile (not affected hy heating to 56° C.),
and constitutes the specific antibody in relation to the antigen
employed, is termed the sensibilisatricc (Bordet) or the amboceptor
(Erhlich); the other, which is a normal constituent of untreated
animals, which is destroyed hy heating to 56° C., and is not specific in
relation to the antigen that has been employed, is termed the alexin
(Buchner) or the complement (Bordet).

In fact, it is necessary to suppose that the prepared rabbit serum no
longer contains the complement after it has been heated to 56° C., but
that after it has been heated it still contains the antibody ; whereas the
untreated rabbit serum, which (since it has no haemolytic property)
certainly does not contain the antibody, nevertheless contains the com¬
plement. The mixture of the fresh serum (which has not been
heated, and is derived from an untreated rabbit), with the serum which
has been heated after being derived from the prepared rabbit, recon¬
stitutes the mixture of antibody plus complement which is necessary for
the production of haemolysis.

(4) Neither of the tw T o substances above mentioned can act on the
antigen unless the other is also present. But the antibody is specific
in relation to the antigen, whilst the complement is indifferent in rela-

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tion to the antigen. In a mixture containing the complement and an
antibody, the introduction of the antigen corresponding to the anti¬
body under consideration will determine the fixation of that antibody
on the complement, which it will, as it were, neutralise.

Similarly, in a mixture containing the complement and the antigen,
the introduction of the specific antibody (specific to that antigen) will
determine the neutralisation of the complement.

(5) If, now, we suppose an antigen and its antibody to be intro¬
duced into fresh rabbit serum containing complement, all this comple¬
ment will be fixed and neutralised, provided, of course, that the
antigen and the antibody are introduced in sufficient quantities. If,
then, into this serum, we introduce another quantity of antigen and its
antibody, these latter substances will remain without action upon one
another, owing to the absence of the complement, w hich will have been
deviated towards the antigen and antibody first introduced (Bordet and
Gengou).

(6) Let us now suppose that in infective disorders the micro¬
organism is an antigen, and that the tissue-fluids contain an antibody
specific in relation to this micro organism, and let us take the case of
syphilis, to which disease YVassermann has made the first application
of this method: the antigen will be provided by an extract of the
liver of a new-born syphilitic infant; the antibody will be contained
in the blood-serum or in the cerebro-spinal fluid of a syphilitic patient,
which has been heated to 56° C., in order to destroy the complement,
which is one of its normal constituents ; finally, the complement will
be furnished by the serum of a rabbit which has been treated with red
blood-corpuscles of an ox. In these conditions, the three necessary
substances being all present, the complement will be deviated towards the
antibody and will be neutralised by it. If, now, we add to the mixture
red blood-corpuscles of an ox, these, notwithstanding the presence
of their specific antibody (since the rabbit has been prepared), will not
undergo haemolysis, since the mixture contains no free complement.
But if the serum under examination is derived from a patient not
suffering from syphilis, and, therefore, contains no syphilitic antibody,
its addition to the serum of the prepared rabbit, to which has been
added the preparation containing the syphilitic antigen, will not induce
the fixation of the complement; on the contrary, the complement will
remain free, and when we add the red blood-corpuscles of the ox
haemolysis will take place.

In practice, then, Wassermann’s method consists in the examination
of the serum or cerebro-spinal fluid of the patient under observa¬
tion, the examination being made by the aid of rabbit serum treated
with red blood-corpuscles of the ox and syphilitic antigen, prepared as
already described. In a recent communication to the Academie de
Medecine (December 8th, 1908), Marmorek suggests the application of
the same method to the serum of tuberculous patients. But he reverses
the terms : he looks for the antigen in the serum of the tuberculous
patient, the antibody being provided in his anti-tuberculous serum.
The principle is exactly the same.

In this summary no technical details have been given. The writer’s
sole object has been to enunciate the principles involved, especially in

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view of the fact that the apparent complication of the method has
proved alarming to some who might otherwise have wished to make use
of it. M. Eden Paul.

Systematised Insanity based on Insane Deductions or Paranoia Simplex
(Psychose Systematisee a base I Interpretations Delirantes ou
Paranoia Simple], (Bull, de la Soc. de Med. Merit, de Belg.,
Aug.-Oct., 1909.) Deroubaix, A.

Dr. Deroubaix gives a general account of the ancient and modern
literature of the subject, in which he emphasises the fact that opinions
differ very widely regarding the exact nature of paranoia. He defines
it as a constitutional and functional mental disease, engrafted upon a
basis of mental degeneracy, characterised by delusions of a fixed and
systematised type arising from illogical reasoning and judgment. The
disease terminates in a state of dementia, more or less marked, but
always less pronounced than that which terminates the other insanities.
The author admits, however, the possibility of recovery. Hallucinations
arc for the most part absent. The different types of the disease,
persecuted, hallucinatory, etc., do not lead to anything definite, and the
differences are more or less artificial. The cause must be looked for
more as the outcome of neurotic heredity than as a toxic disturbance;
the educated are more liable to the disease than the illiterate. The
lethargic and dull are immune, but the reverse holds good in the case
of highly strung and precocious. Absence of sensory troubles is
characteristic of the disease. The diagnosis can be made early and is
based upon the absence of hallucinations, “ previous attacks or sensory
distubances,” the long history and the type of individual. Several
cases are given in considerable detail, which demonstrate the writer’s
purpose. The paper is interesting, but left one not quite convinced
regarding the possibility of a differential diagnosis in the various types of
paranoia. The treatment of these cases at once opens out the question of
danger to individuals or communities, and the writer pleads for a kinder
treatment of these people when they have offended the laws of their
country. Asylums, not gaols, should be their dwelling-place.

Colin McDowall.

Litigious or Wrangling Insanity or Paranoia Querulans of the Germans
[La Folie Processive ou Querulante (Querulanten VVahnsinn) ou
Paranoia Querulans des Ailernands ]. (Bull, de la Soc. de Med.
Merit, de Belg., Feb., 1910.) Maere.

This is the querulent paranoia of the Germans. The differences
between the varieties known as cavilling, wrangling, litigious, and
claimant paranoiacs are trifling. The litigious are those with a
tendency to constant procedure, spending the main part of their
existence in the precincts of law courts.

The arguing or wrangling patients are more often bent upon
incessant recrimination. Lastly, the claimants proper crave the
depossession of those they believe frustrate their claims and use all
means to regain possession.

They are all obsessed by the one passionate and prevailing idea.

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In the beginning, the insanity is allied with a wild apprehension of
unforeseen injustice, which is presently transformed into a firm belief
that the patient has been deprived of all his rights, and which results
in a hyperaesthesia of his amourpropre or the hypertrophy of his ego.
The alteration in the psychical personality leads the patient into
absurdly extravagant actions, since he is already intolerant, impatient,
choleric and more difficult and vain in the family circle than with
strangers.

All the patients write, often in an alert but unduly authoritative style.
They abuse and slander in papers and pamphlets, muddling their
sentences and quotations, underlining words and emphasising in large
letters.

The circle of their imaginary enemies enlarges so long as their
grievances fail to obtain satisfaction, all questions or counsel being
received with suspicion. For themselves they only demand their
rights and of others simply their duty. They use any and every
stratagem to reach their ends.

In spite of their apparent logic and conservation of memory, they
miss the clairvoyance of the critical spirit.

Their obsession to seek justice leads them to believe everything is
contrary to right. They are credulous beyond belief and become the
prey of their querulance.

Improvement for a while is the rule, but relapse is certain to follow.

It is recognised that all these patients are most dangerous and often
go to the worst excesses. They are persecutors from the beginning.
At liberty they are scandal-mongers; in an asylum they criticise every¬
one, condemning authorities and discussing their wrongs with other
inmates—instigating all kinds of difficulties. The disease terminates
irregularly, sometimes by accident, cerebral haemorrhage, or softening,
sometimes abruptly, but in this case it is not by cessation of the mania
but by a rather forced resignation. This is only an apparent recovery.

That dementia does appear towards the end of the disease is
undoubted. Colin McDowall.

A Case of Inlerpretational Insanity [ Un cas de delire d'intetpritation].

(Rev. de Psych., April, 1909.) Serieux, P.

The Interpretational Insanity of Serieux and Capgras [Le dilire dinter¬
polations de Serieux and Capgras]. (Ibid., July, 1909.) Mignard,
M.

The Mild Form of Interpretational Insanity \La forme attenuie du
dilire d'interpretation], (Ibid., August, 1909.) Halberstadt.

Since the differentiation of the delire d’interpr^tation from the group
of the paranoias some years ago by Serieux and Capgras, much has
been written on the subject, and the appearance of their work on Les
Folies Raisonnantes, which bids fair to become a classic, has further
stimulated interest in this important clinical entity.

In the April number of the Revue de Psychiatrie for 1909, Serieux
describes a perfect example of this disorder with that accuracy of obser¬
vation and charm of presentment which give such life to his work.
This case exhibited all the classical signs of the disease—that is to say,
the persecutory ideas were based entirely on false interpretations of

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actual facts, the interpretations were multiple and organised, halluci¬
nations absent, mental activity and clearness unimpaired, and the
incurable disorder progressed steadily without any terminal dementia.

Mignard’s paper in the July number of the same review is a critical
digest of the section on interpretational insanity in Serieux and
Capgras’s recent book. He is quite in accord with these authors in
looking on it as a clearly defined variety of paranoia, and points out
that at the base of the trouble lies an exaggerated self-esteem, betraying
that lack of the critical faculty which is so often the cause of error and
even insanity. The patient gives a personal meaning to everything,
hypotheses are formed, a system is built up, and finally the key to the
whole trouble is found in some dominant idea. Wnile the disorder
usually occurs in the mentally degenerate, it is not incompatible with a
high degree of intelligence or even with genius, as in the case of Rousseau,
who was an excellent example of this mental trouble. Remissions,
exacerbations, and even hallucinatory paroxysms may occur in the course
of the disorder, but the insanity progresses steadily and incurably.

Dr. Halberstadt’s paper in the August number of the same journal
describes an attenuated form of interpretational insanity, and a case is
quoted at length. In this type the delusions are of limited extent and
closely surround some central idea, generally of persecution. They do
not evolve progressively, as in the classic form, and may even be for¬
gotten by the patient. (This is probably only the process of eclipse
to which Dr. Legrain has drawn attention in a recent monograph.)
This form occurs most frequently in women of mental development
below the average, and the author gives his reasons, not quite convinc¬
ing to us, for considering that it is a distinct variety of this important
disorder. W. Starkey.

Onomatomania in an Old Man at. 74 [Onomatomanie chez un Vuillard
de 74 ans\ {Bull. Soc. Clin. Med. Ment., Dec., 1909.) Juquelier
el Daltnas.

This old man was brought to the asylum after attempting suicide by
drowning. There was little mental reduction, the only sign of senility
being a slight tremor, which had interfered with his work as a porcelain-
painter. Father died ret. 84, demented. Mother asthmatic; two
brothers, alcoholics, died of tubercle. The patient has always been of
an emotional and suspicious nature, and has had slight attacks of per¬
secutory mania; occasionally also he has experienced mild obsessions,
such as having to count certain objects, alter their positions, etc. A
year ago he quarrelled with a fellow-workman, and this so preyed on
his mind that he retired from business. Almost immediately afterwards
his present form of obsession began. Thinking of his old workmates
one day, he found that he had forgotten the name of one of them. He
tried to recall the name but without success; he experienced acute
distress, felt a sense of oppression, his heart seemed to be in a vice, his
face was bathed in sweat, his hands cold, he wept and paced his room
in a state of extreme anguish. From this time onwards his life has
been made miserable by this incessant search for names. He fears to
go out lest someone pass him in the street whose name he should know,
but fail to remember. He avoids reading the papers, lest some word

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1910.] CLINICAL NEUROLOGY AND PSYCHIATRY. 53 I

or picture should start a new search for names. He spends his days in
writing down words as an aid to his memory, or in reading p iges of the
dictionary in the attempt to find some name or other. His sleep is
interfered with by his obsessions, which continue even at night. He
quite recognises the absurdity of his search for words; they are of no
use to him, and are often of the most bizarre nature. When the missing
word is found his relief is only temporary, as a fresh search starts almost
at once. There has been no improvement in his condition since admis¬
sion to the asylum, and the general opinion as to prognosis is unfavour¬
able. In some cases the distress associated with the obsession lessens
in time, and some recoveries are recorded. W. Starkey.

Two Cases of Squamous Epithelioma in General Paralytics [Deux cas
dlpithiliomas pavimenteux chez des paralytiques g/nerauxj. {Bull.

Soc. Clin. Med. Ment., Feb., 1910.) Vigouroux, M. A.

Dr. Vigouroux reports two cases of epithelioma occurring in general
paralytics, ast. 41 and 35 respectively. In the former, the glans penis
was the site of the cancer, which developed a month before death; in
the latter the lower lip was affected, and the epithelioma existed some
months prior to the onset of the mental trouble. The association of
epithelioma with general paralysis is extremely rare, possibly due in
part to the fact that general paralysis usually ends fatally before the age
of incidence of cancer. It is also interesting in view of the fact that
some writers (notably Fournier) regard these epitheliomata as of para-
syphilitic origin. W. Starkey.

A Clinical and Anatomical Examination of the Nervous System in
Thrombosis of the Abdominal Aorta in Man [Tndagine analomo-
clinica sul sistema nervoso, nell'uomo colpito da trombosi dell'aorta
addominale\ {Ann. del Manicomio, 1909.) Rcbizzi, R.

The author gives a detailed and precise account of the symptomato¬
logy of a case of thrombosis of the aorta leading to complete obliteration
of the vessel below the origin of the renal arteries. The initiation was
sudden and characterised by complete paralysis of the lower limbs,
accompanied by irregular and extensive areas of cyanosis, in which
gangrenous changes rapidly supervened. The patient died twelve days
after the first symptoms appeared, and was the subject of a full patho¬
logical examination. Particular interest was attached to the histological
changes in the spinal cord—mainly chromatolysis in its various degrees
—and the discussion of their relation to the peripheral lesion. From
the facts of his own case, and the published accounts of some thirty
others, the author shows that there is no evidence to support the notion
that the peripheral condition depends upon lesion of the spinal column.
The paralysis and gangrene of the lower limbs are due entirely to their
condition of absolute anaemia resulting from the closing of the aorta.
The lesions in the spinal cord are, in the main, secondary to the
necrosis of the nerves in the lower limbs. Changes of a primary
nature, when they occur, are less intense, and confined to that region of
the cord directly dependent for its blood supply on the abdominal
aorta. J. H. MacDonald.

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EPITOME.

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[July,

The Albuminous Reaction of the Sputa in the Diagnosis of Pulmonary
Tuberculosis in Psychiatric Practice \L'Albumitio-reaction des
crachats dans le diagnostic de la tuberculose pulmonaire en psy-
chiatrie\ {Prog. Mid., April gth, 1910.) Cornu, Ed.

The detection of albumen in the sputum is said to rank as a valuable
aid to the diagnosis of pulmonary tuberculosis, especially as it is easy of
application, and gives, according to the researches of Roger and Levy-
Valensi, followed by those of Oddo and Gachet and then the present
writer, valuable and reliable results. Roger obtained a positive reaction
in 200 cases of tuberculosis and Oddo in twenty-nine, in six of which
the bacteriological examination had been negative. These authors state
that albumen is always present in tubercular sputa, and only cases of
bronchitis associated with albuminuria or cardiac conditions give the
same reaction. The elimination of such cases is easy, and the absence
of albumen would lead to the rejection of a diagnosis of tuberculosis.
The procedure is as follows : Dilute the sputum with about 50 per cent.
of water; add a few drops of acetic acid to coagulate mucine j shake
briskly in a test-tube (with the aid of broken glass if sputum is very
thick); filter; test filtrate for albumen by the usual methods, preferably
by heat. Roger at first employed a concentrated solution of ferro-
cyanide of potassium, but now prefers boiling. Cornu adds to the
filtrate one tenth of its volume of a saturated solution of sea-salt or of
sulphate of soda in order to render coagulation more evident, then boils
the upper layer. Sputum containing blood must be rejected. Cornu
obtained a positive reaction in twenty-four cases. Twenty were manifestly
tubercular, the bacillus being present. Three were suspected to be
tubercular on general grounds—loss of weight, anorexia, poor health—
but the clinical examination had not permitted a definite diagnosis. A
positive reaction was obtained on four different occasions in another
patient who had given no clinical evidence of a tubercular infection.
He had suffered from several attacks of bronchitis, regarded as simple,
and some attacks of acute articular rheumatism, and presented a slight
systolic murmur at the apex. At the time of examination of sputum he
was complaining of rheumatic pain in his knee. The question then arose
as to whether the albuminous sputum was dependent on the cardiac
condition or related to a tubercular arthritis.

J. H. MacDonald.

What is Meatit at the Present Day by the Term “ Arterio-Sclerotic
Psychoses l" [ Was kann man hcute unter Arteriosklerotischen
Psychosen verstehen ?]. {Psych.-Neur. Wochenschr., No. 52, 1909-10.)
Olah, Gustav v.

In order to reach a distinct understanding as to the meaning of this
term, which is now so widely used or misused, Dr. v. Olah points out
that there is no such thing as arterio-sclerotic psychosis in the sense of
a disease having a clinical individuality and specific anatomical findings.
He describes a progressive form of dementia, typical in its course,
specific, virulent, and fatal, in connection with which arterio-sclerotic
changes in the vessels of the brain are found.

The first symptoms are partly of psychogenic and partly of physical
character. The patient complains that an arm or foot is “as if

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paralysed.” Sometimes there is a disturbance or hesitation of speech,
especially after indulgence in alcohol, or when the patient is fatigued ;
he is not quite sure of the form and meaning of words, and inverts
syllables here and there. As the disease progresses there is complete
disorientation, the patient easily misses his footing, and sits clumsily
on the edge of his chair, etc. Sometimes he passes years of comparative
comfort between the stages of the disease—as if the brain had found
a way to accommodate itself to altered circumstances—then there are
fresh symptoms. The faculties of perception, power of attention, and
reproduction are in turn or at the same time affected. The patient,
who is conscious of the loss of his faculties, dies after intercurrent illness.

The chief points to be noted in this article are :

(1) Arterio-sclerosis in the fine arteries of the brain is not to be
inferred from the affection being found in other parts of the body.

(2) In the same way sclerosis of the cerebral arteries does not always
accompany the symptoms above described—as, indeed, common pre-
senile arterio-sclerotic change does not seem to dispose to the specific
affection referred to.

(3) There is a nosological involution psychosis which has not yet
been given a distinct position, and which is found with a greater or
smaller degree of sclerosis of the smaller arteries of the brain. This
form has a clinical individuality, but is not the result of arterio sclerotic
change.

(4) The name arterio-sclerotic psychosis is not well chosen for this

form : Firstly, because the mental symptoms seldom accompany
arterio-sclerosis in the usual sense; further, because the same anatomical
changes are also found with other psychoses ; and lastly, because to
give an anatomical title to the non-anatomical symptoms of a disease
is out of place and absurd. Hamilton C. Marr.

On Myxcedematous Change in the Skin accompanying Manic-Depressive
Insanity \Ueber myxodematose Hautveranderungen als Parallel-
vorgang bei manisch depressiver Psychose\ ( Neur . Cbl. t No. 4.)
Tomaschny.

The author observed in a patient suffering from manic-depressive
insanity a cushion-like swelling of the lower part of the face, especially
of the lips, also great increase of bulk about the shoulders and hips.
The thyroid glands were palpable. Thyroid tabloids, which were
administered for a short time, had a detrimental rather than a beneficial
effect. The myxcedema disappeared with the abatement of the manic-
depressive excitement. Hamilton C. Marr.

3. Treatment of Insanity.

The Value in Private and Institutional Practice of a Regimen containing
a Minimal Quantity of Salt, in Association with the Administration
of Bromides [Die Bedeutung der ralzlosen Brombehandlung fiir
Anstalt und Praxis\ ( Psychiat.-Neur . Wochensch., Dec. 11 th,

1909.) Dorner,J.

After a considerable discussion and extensive trials, says the writer, it
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lias gradually come to be admitted that in nervous diseases, and above
all in epilepsy, the use of bromides in conjunction with a diet con¬
taining a minimal quantity of salt gives more favourable results—in
epilepsy both as regards the individual paroxysms and as regards the
general condition—than other modes of treatment. His own experi¬
ments lasted for four years ; sixty-four patients were subjected to the
treatment, and of these all but one were confirmed epileptics. The
duration of the individual “ cure ” varied from six weeks to one year;
in most cases it lasted from three to six months. In most of the
patients the epileptic seizures occurred at brief intervals; most of them
exhibited the enfeebled mentality characteristic of such patients; all
but one had previously taken bromides for several years.

Pure milk diet was not tried, on account of its well-known disadvan¬
tages—great dislike to it on the part of many patients, gastric disturb¬
ances, etc. For children the diet was chiefly oatmeal, rice, eggs, and
milk ; for adults, ordinary mixed diet, sometimes with, sometimes with¬
out meat, but in all cases without artificial admixture of salt. What¬
ever bread given was also made without salt. The nutrient value of
the diet was from 3,000 to 3,600 calories. The influence of meat was
unmistakable ; when the diet contained no meat the action of the
bromide was far more powerful. Only in one case was there any diffi¬
culty in getting the patient to accept the restricted diet, but it must be
remembered that many of the patients were weak-minded. The diet
was made more agreeable with fruit and various vegetables.

The doses of bromide given varied according to the needs of the
particular case, just as is done when an ordinary diet is given ; but in
the case of salt-free diet smaller doses suffice. The quantity given
ranged as a rule from ten to sixty grains daily. In about half of the
cases the number of attacks gradually diminished for about three
weeks, and then for a time no paroxysms occurred; in 40 per cent.
more a marked diminution in the number of seizures was noticeable—
e.g.y from twenty per month to two or three. In three cases only out
of the sixty-four was there no improvement at all as regards the
paroxysms. In 65 per cent, of the cases there was a notable gain in
weight—six to ten pounds ; and in many the gain in weight lasted for
many months after the “ cure ” was over. In a good many of the cases
there was a very striking improvement in the mental state.

But the good effects of the method are not enduring. The writer
did not observe a single case of permanent cessation of the epileptic
seizures. In two of the cases which had before survived periods of
the status epilepticus, this state reappeared soon after the (enforced)
return to a salt-containing diet, in both cases with fatal issue. In four
cases of the series there was notable loss of weight and marked
anaemia in consequence of the change of diet. Two of these were
advanced in years, and one of them died of heart failure. Ten of the
sixty-four patients displayed great increase in mental irritability with
paroxysms of violence—not controlled by an increased dosage with
bromide. In seven of the patients the “cure” was discontinued on
this account.

Moreover, the advantages and disadvantages of the method were so
variously distributed, that only fourteen of the entire number of

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patients—21 8 per cent.— were simultaneously benefited in all three
respects, viz., diminution in number of paroxysms, gain in body-weight,
and improvement in mental condition.

Since in institutional practice, with the patients under constant
observation, the risks and disadvantages of the method are considerable,
it is obviously unsuited for the treatment of hospital out-patients. The
return to a normal diet must be made very gradually and carefully.

The writer suggests that the salt-free diet should be continued after
the first month only in those who have during that time gained weight
and improved in other respects. Those whom the “cure” does not
suit will thus be eliminated; those whom it does suit undoubtedly gain
long-enduring benefit. M. Eden Paul.

Treatment of Epilepsy with Bromoglidine [Die Behandlung der Epiiepsic
mil Bromoglidine], ( Psychiat. Near. Wochensch., Nov. 20th, 1909.)
Kurt, Halbey.

Bromoglidine and iodoglidine are compounds of bromine and iodine
with vegetable albumen, which have recently been recommended to
replace the metallic salts of these substances for internal administration.
Having tried the first-named drug on ten epileptics for a period of five
weeks, Kurt summarises as follows the results obtained :

Bromoglidine is not inferior to the metallic bromides in its power to
control epileptic paroxysms.

The absorption of bromoglidine being more rapid than that of the
metallic bromides, the physiological effect of the drug is more rapidly
obtained; if it is administered in the usual way during the day-time,
the fits are controlled during the waking hours, and postponed to the
night; this is advantageous, especially in the case of patients who have
to work in the day-time.

Symptoms of bromism do not appear even when very large doses of
bromoglidine are administered (this is in agreement with what has been
noted by other observers).

In many long-standing cases of epilepsy with considerable mental
enfeeblement, great irritability and inclination to violent outbreaks is
noticed—apparently due to the bromides, in great part at any rate,
since these symptoms largely disappear when the drug is discontinued,
and recur when its administration is resumed. But a similar increase
in irritability and in tendency to violent outbreaks was not observed
when bromoglidine was administered in place of the metallic bromides.

M. Eden Paul.

Hypnotism. (.Bristol Med.-Chir. Journ., March, 1910.) Costobadie,

H. P.

The value of hypnotism in the study and treatment of disease, the
author says, depends on the fact that it increases suggestibility. So
greatly is suggestibility increased by hypnotism that it is only necessary
to tell a patient, in a deep hypnotic sleep, that he has just received an
electric shock for his muscles to tighten, and his face to twitch in a
way which shows without doubt that he believes he feels it, and, more¬
over, he will tell you that he does. Every sick person, the author

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536 EPITOME. [July.

believes, is subjected, knowingly or unknowingly by his doctor, to
treatment by suggestion. The limits of hypnotism as an adjunct to
therapeutics largely depend, he says, upon an individual operator and a
particular patient. In his experience, he has found it particularly useful
in functional diseases—tics, tremors, and nervous spasms and cramps,
some neuralgic pains and headaches, hysterical paralysis, convulsions
and aphonia, many phobias, and so on, while sleeplessness and sleep¬
walking can be cured by its use.

He has also been successful in nocturnal enuresis, chronic constipa¬
tion, dyspeptic discomfort, and the vomiting of pregnancy, but he failed
to control the pains in a case of labour.

He was able to benefit a case of melancholia for a few months, but
in a case of epilepsy it had no good results.

He refers to the case of a dentist cured by Sir Francis Cruise of a
coarse tremor of the hand and arm which came on whenever he took
up an instrument to operate, and which at last made his work impos¬
sible. A patient of his own, a miner, became obsessed by a fear of
returning to his work after an injury to his hand, received eleven weeks
previously. He was twice hypnotised and the suggestion made that he
should return to his work on a certain day. He did so, and has
remained at work ever since. In alcoholism and the drug habit, the
myalgia of tonsillitis and the restlessness and headache of influenza, as
well as in slight operations to abolish pain, the author has proved the
value of hypnotism.

Of the complications following hypnosis, headache seems to be the
most common, coming on after the first sitting, but he has never known
it to persist after he has re-hypnotised the patient and made suitable
suggestions. He believes the popular idea as to how hypnotism maybe
used for criminal purposes to be exaggerated and distorted.

In conclusion, he refers to post-hypnotic suggestion and subconscious
memory, and instances the case of a patient who saw and described
minutely the picture of a large room which he had not seen for five years,
and could not remember ever to have seen before until he was re¬
hypnotised, when he described when and where he had seen it.
He could give no reason at all when awakened why he should have
recalled this picture, but when again under the influence of hypnotism
explained that it was recalled to his memory by some little glass knobs
on the chandeliers in a church which he had visited earlier in the day.

The subconscious memory may be an important factor in disease, the
author thinks, for by its repeated stimulus acting, for example, on
imagination, it may be the obscure origin of some of those still more
obscure conditions which occur in so many functional and mental
diseases, if not the cause of some of those diseases themselves.

A. W. Wilcox.

A Criticism of Freud's Psycho-attalylic Method [Die Psychoanalytische
Methode Freud], {Zt. f, die gesamte Neurol, u. Psychiat., Bd. i,
Heft 1, 1910.) Isserlin , Max.

This new journal is a successor to the Zentra/blatt fiir Nervenheilhunde
und Psychiairie, founded by Dr. Kurella in 1890, and is edited by Prof.
Alzheimer and Dr. Lewandowsky.

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The first number opens well with several lengthy and valuable
papers, as by Alzheimer on diagnostic difficulties in psychiatry, by
Hasche-Kliinder on the transformation of obsessions into insane delu¬
sions, and an elaborate attempt by VVeiler to give greater precision to
the measurement of the knee-jerk. Especially interesting, perhaps, is
this very able and seaching criticism of Freud’s methods.

The discussion of Freud’s views is not, Isserlin begins by stating, a
mere fashion ; it really concerns one of the weightiest problems which
psycho-pathology has to-day to solve. The cardinal principles of our
science are at stake, and the establishment of Freud’s doctrines would
mean an entire change in our conceptions. For ten years Freud’s
books found few readers; since 1905 they have become better known,
and attracted many followers, while the experiments and observations
on his lines at the Zurich Klinik, have especially aroused general atten¬
tion. Isserlin carefully traces the growth of Freud’s views and the
considerable changes they have undergone.

Freud’s psychology is specially marked by its peculiar conception of
the unconscious; it is for him something incapable of consciousness,
something that has been repressed, and it is of sexual character as to
its content. The conscious is, for Freud, only a small and fragmentary
part of psychic life, unintelligible and absurd until interpreted by what
is going on in the unconscious sphere. When so interpreted its
absurdities disappear, and life becomes rational. Neuroses, dreams,
and delusions are masks that cover its real aims. They are, indeed,
more than that. Neurosis, dream, insanity, are aids in the conflict of
life, and so become intelligible. They are essential links in a chain
which reaches through the entire psychic life. They are thus allied to
philosophy and religion, and the psychoanalytic method leads to a
comprehensive vision of the entire human soul and its final aims.

We cannot fail to admire this conception, Isserlin proceeds, and we
might be content with that admiration if Freud had not applied his con¬
ception to definite empirical problems. Then we have to challenge his
proofs. Proof is needed both as regards his facts and his method. The
main alleged facts are the infantile sexual constitution and the mechanism
of symptoms through suppression, conversion, and symbolisation. The
method is the process by which this mechanism is uncovered and in¬
terpreted ; it chiefly consists in encouraging free, uncompelled associa¬
tions. The patient takes the leading part and says whatever comes
into his head, however absurd; the physician is passive and supplies no
clues, but he notes everything, and detects those significant points at
which the patient experiences repulsion in expressing what comes into
his head. That there are therapeutic advantages in this method Isserlin
does not deny, but they are easily explained, and he points out that
while the method has undergone radical changes in Freud’s hands
the same beneficial effects are still claimed, though if, as Freud now
holds, psycho-neurotic conditions are constitutional, organically and
chemically based, it is difficult to see how psychic methods can influence
them. Isserlin argues, however, that Freud’s method is not capable of
proving that suppression, in the sense and to the extent claimed, actually
takes place, and that there is no way of proving its validity. Even if
suppression occurs it has not been established by Freud that his analytic

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method necessarily leads to the suppressed material. There is no
proof. The connection between the symptoms and the suppressed
causal facts is pure hypothesis. The psycho-analytic method is not
justified and its claims are untenable. Jung’s assertion that by Freud’s
method it is possible to reconstruct the whole psychic complex out of
every psychic particle is a dismal error.

Isserlin admits that Freud has, in the conception of “ suppression,”
struck on a great problem, and that in a number of cases, both normal
and pathological, it is a fact. The idea of “ conversion,” to a less
extent, has its value, especially in the explanation of hysteria. The
doctrine of the significance of sexuality in psycho-neurotic conditions is,
however, unproved. Freud’s declaration, “With a normal vitasexualis
neurosis is impossible,” should be changed to “ In neurosis a normal
vita sexualis is impossible ”; i.e., it is not the vita sexualis which is
fundamental.

Isserlin believes that Freud’s method of investigation and treatment
by free association is useful. He recognises a real and positive kernel
in Freud’s doctrines. But he holds that while we must not grudge our
tribute of admiration to Freud and his school for the energy they have
displayed and for their self-sacrificing devotion to an unpopular cause,
it is premature to discuss Freud’s claims to our gratitude so long as his
method involves a confusing perversion of scientific maxims.

Havelock Ellis.

The Present Position of Psycho-therapeutics [Zum gegcnwiirtigen Stande
der Psychotherapie\ {Afiinch. med. JVoch., Nos. 3 and 4, 1910.)
Lowenfeld, L.

After a long period of neglect, psycho-therapeutic methods have during
the past ten years become very prominent. In the present paper
Lowenfeld attempts, in his usual judicial and discriminative manner, to
estimate their value. He deals both with hypnotism and with the
psychoanalytic method. He also touches on Bonnier’s method of
nasal galvanisation, which he regards as acting by suggestion.

The cause of therapeutical hypnotism Lowenfeld regards as now
won, though it still has opponents. No one who has had any serious
clinical experience of the method regards it as worthless, so far as he
knows, while none of those who regard it as worthless have any real
clinical experience in its use. Only a small proportion of German
neurologists now reject hypnotism, though a large proportion seldom
use it or use it only as a last resort. Many of them consider the method
has dangers. In twenty years’ experience, however, Lowenfeld has never
seen any evil results, psychic or physical. He mentions that hypno-
therapeutic methods are zealously cultivated in Russia, both by alienists
and neurologists, and are found very successful in combating the
alcoholism which abounds in that country.

Lowenfeld is thus entirely favourable to hypno-therapeutics, properly
carried out in suitable cases. Towards Freud’s psycho-analytic method
his attitude is more complex. That method, though it is supported by
an increasing band of ardent followers, has not conquered general
favour, and is by many severely anathematised. Lowenfeld points out,

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however, that not one of those who adopt this latter attitude has ever
made any serious attempt to employ the method he condemns, and he
reproves those who, with Ziehen, are content to exclaim “Nonsense !”
when, since they refuse to attempt proof, they are only entitled to put
forward the modest verdict, “ unproven.” Lowenfeld is unable to
accept Freud’s theory of the sexual origin of neurasthenia, but after
long investigation he substantially agrees with Freud concerning the
causation of the neurosis of anxiety, and also obsessional neurosis
(which he believes may be successfully treated by Freud’s method but
not by hypnotism), though not as regards obsession in general. He
maintains an attitude of reserve towards Freud’s theory of hysteria,
believing that many facts cannot be harmonised with it, and he points
out that Jung, who is a follower of Freud, considers that there are
types of hysteria not covered by the theory. Freud’s great service, in
Lowenfeld’s opinion, lies in his conception of the part played by the
unconscious in psychic life and his therapeutic method of removing
morbid states by translating them from the unconscious to the conscious.
The place assigned by Freud to the sexual element in the causation of
morbid conditions is a comparatively unimportant matter.

Havelock Ellis.

4. Pathology of Insanity.

The Significance of Plasma-Cells in the Histopathology of Progressive
Paralysis \Uber die Bedeutung der Plasmazellen fur die Histo¬
pathologic der Progressiven Paralyse ]. ( Zeitschr . fi Psychiat.,

vol. Ixvi, part 34.) Be hr, H.

Since Nissl and Alzheimer have drawn attention to the infiltration of
cells into the vessel sheaths, to the regular finding of Marschallco’s
plasma-cells in the infiltrations, and further, to the appearance of
peculiar cells described as rod-like in the cortex of paralytics, the
microscopic diagnosis of the disease has advanced greatly in clearness
and certainty.

Certainly in the remaining tissue of the cortex both ectodermal and
mesodermal “ Provenienz ” changes have been noticed (especially in
advanced cases), and other changes which go to confirm the diagnosis.
To these the author adds disturbances of the normal cortex architecture,
the displacement of, and subsequent changes in, the ganglion cells, which
generally have very distinct growths like fibrous glia, the atrophy of the
tangential vessels of the supraradial crust, and lastly, the various
changes in the vessels (growth of cells in the vessel walls, building of
germs, increase of capillaries).

The pathological changes generally found in the cerebral cortex are
in no way typical of paralysis, while we have, after examination for
plasma-cells, at least a very characteristic, and, by its easiness, an
excellent means of separating paralysis histologically from other mental
ailments, even if the finding of the rod-like cells has not helped to
confirm our diagnosis.

Vogt holds the plasma-cells to be directly pathognomic for paralysis,
and questioned whether they were to be found spread diffusely over the

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54O EPITOME. [July,

cortex in other states. Havet and Alzheimer, on the contrary, are of
opinion that this condition is to be found in certain cases of idiocy.

In the histo-pathological differentiation of paralysis and syphilitic
meningo-encephalitis great difficulties often arise, especially when the
syphilitic process does not confine itself to small portions of the
meninges, but spreads itself over a larger or smaller portion of the pia
and the brain substance thereunder. Here are also to be found
infiltrations of cells into the cortical vessels. The infiltrations, as in
paralysis, contain, besides lymphocytes, plasma-cells. In lues is noted
the dependence of the encephalitic process on the infiltration into the
meninges—a dependence which cannot be traced in paralysis, where
the regular appearance of a larger or smaller purely pia infiltration and
the changes in the cortex are expressions of an inflammatory process,
which attacks equally the vessels of the pia and the brain substance.
At the same time, there can be no question as to the difficulty of
differentiating the two diseases by microscopical findings. There are
cases in which paralysis cannot possibly exist, and in which plasma-
cells have been found, generally in confined spaces in localised diseases,
and mostly in small quantity.

The author gives results of microscopical examination in 115 cases.
Thionin was used very successfully for staining. In 59 of the cases
paralysis was diagnosed clinically, and was confirmed histopatho-
logically in 55. In each of these 55 cases the plasma-cell infiltration
was traced to the sheath of the vessels of the cortex and of the
medulla. Sometimes the cells were isolated and scarce, being with
difficulty discovered among numerous lymphocytes ; at other times
they were found in large quantities among lymphocytes, mast cells and
other forms of cells, forming the broad cell rings which often surrounded
the narrow vessel lumina, and gave to the microscopic picture in many
cases a very characteristic appearance. They were generally confined
to the larger vessels on the adventitial lymph-sheaths, but, in cases
where the inflammatory infiltration reached the media and the intima,
they were found in other layers of the vessel wall, and in the lumen. They
were also to be traced to the smaller capillaries, and often by their
quantity covered the vessel wall. They were sometimes found in the
brain substance, at some distance from the vessels; cells thus found
were isolated and retrogressively changed. It appears from this, that
in relatively rare cases the plasma-cells, which are doubtless of
hsematogenous origin, can over-reach the biological boundary between
mesodermal and ectodermal tissue. According to a lately published work
by Ranke, in young, and especially in foetal organisms, the tendency is,
when there is an infiltrative inflammatory process, to a diffuse spreading
of the hsematogenous elements through the nervous substance. This he
confirmed more successfully in a few cases of diffuse, although not puru¬
lent, fcetal encephalitis, than in cases of lues congenita. At all events, this
is not frequently observed in paralysis, and in each case the examina¬
tion must be most careful, as the delicate capillaries, which are often
only recognised by isolated endo-cells, can easily be overlooked.

Vogt’s opinion that the plasma-cells are most plentiful in cases where
the disease progresses quickly is confirmed, although this was not found
in every case.

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The plasma-cell infiltrations were spread diffusely over the whole
cortex in paralysis, although their quantity differed in the several
regions. They were most numerous in the frontal region. Examination
of the plasma-cells showed degenerative and other changes. They were
also found in the central ganglia, in the cerebellum, and spinal cord.
They were richest in the optic thalami.

The conclusions reached by the author are that stress must be laid
on all sides on the importance of plasma-cell infiltrations into the vessel
sheaths of the brain for the histopathology of progressive paralysis.
There is no true paralysis without this, and its absence denotes that
paralysis is not present. The diffuse spreading of plasma infiltration is
the most characteristic sign of paralysis. At the same time, the finding
of isolated plasma-cells can in no way lead to the conclusion that a
paralysis was present. The cells are also found, isolated and in circum¬
scribed areas, in other diseases of the nervous system, as phenomena of
an inflammatory process, which runs its course subacutely in the vessel
walls. The only certain characteristic as yet is the diffuse entry of the
plasma-cells into the central nervous system. This, it has long been
confirmed, is not found in any other disease, as we have, up to the
present time, found a diffuse inflammatory process of the vessel walls
only in paralysis. Hamilton C. Marr.

A Contribution to the Study of the Pathological Anatomy of
Progressive Paralysis ; Visceral Alterations ; Some Considerations
Regarding Plasma-Cells \Contributo alio Studio deli Anatomia
Patologica della Paralisi Progressiva ; Alterazioni Viscerali ;
qualche Considerazione sulle Plasmacellu/e]. ( Riv. di Patol. Nerv.
e Ment ., vol. xv, Fasc. 1.) Cato la, G.

Dr. Catola has examined the liver, kidneys, spleen, muscles, peri¬
pheral arteries, and in a few cases the optic nerves, in progressive
paralysis, and has reached the following conclusions :

(1) In the viscera of general paralytics a series of vascular and
perivascular alterations are found, lymphocytic infiltration, and plasma-
cells. Alterations are also present in the parenchyma, especially of the
nature of a cloudy swelling and degenerations. These changes are
comparable in great part to what obtains in the nervous centres. They
cannot be considered as lesions essentially specific in regard to pro¬
gressive paralysis, especially when they are found in the nervous
centres, as such changes are found in other dyscrasias and toxic
states. Lymphocytosis and the presence of plasma-cells are pheno¬
mena giving evidence, more or less, of connective-tissue hyperplasia.

(2) The presence of lymphocytes and plasma-cells, especially in the
liver, are characteristic enough of general paralysis when the infiltra¬
tion of such elements is diffuse and more or less uniform throughout
the liver, and more particularly when focal lesions, such as tumours,
parasites, abscesses, etc., and other diffuse but recognisable lesions,
such as tubercle, syphilis, cirrhosis, etc., are wanting. Normally the
liver and kidneys do not contain plasma-cells and lymphocytes ; when
they are rich in such elements, and more or less recent cirrhosis is not
present, the liver and kidneys are probably those of paralytics.

(3) In none of the paralytics examined have the liisto-pathological

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features described by Klippel under the name of “ vaso paralytic
liver” been found. The assemblage of symptoms described as vaso-
paralytic are:

(rt) A greyish-brown liver due to dilatation and weakness of the left
ventricle.

(b) Red atrophy.

(d) Fatty degeneration.

( e) Diffuse sclerosis of embryonal type without marked contraction.

(4) There is no sensible difference in the viscera of paralytics dying
while in a good state of general nutrition, and those dying of cachexia
with more or less extensive bedsores. Meta-syphilitic intoxication, or
whatever state constitutes the fundamental causation of general paralysis,
appears to be sufficient to produce the alterations described.

(5) The plasma-cells are produced from the fixed cells of the con¬
nective tissue. Plasma-cells as described by Unna and Marschalko
are of hsematogenous origin, and may be classed with other elements
separated by many morphological characters. The plasma-cells of
Hodara are pseudo-plasma-cells, being probably mononuclear leuco¬
cytes greatly modified in their staining reactions.

Hamilton C. Marr.

Plasma-Cells and the Reactive Phenomena in Cerebral Cysticercus [Sulle
Plasmacellule e sui Fenomeni Reattivi nella Cisticercosi Cerebrale\
( Riv. di Pa to l. Nerv. e Ment., vol. xiv,fasc. viii.) Papadia , G.

As a result of a parasite in the brain a stimulus resembling a toxic in¬
fluence is produced. The complexity of the reactive phenomena is
clearly differentiated from the structure of the normal histological
elements, and has specific characters. There is an accumulation of
leucocytes with polymorphic nuclei, and a large number of giant cells in
immediate contact with the parasitic membrane. The connective tissue
is markedly increased, and forms the two internal strata of the adven¬
titial cyst. In the external stratum, plasma-cells, eosinophile leucocytes,
and lymphocytes exist as perfectly distinct elements. Transitional
forms of cells are noted between plasma-cells and the special elements
of the connective tissue. These have a basophilic reaction. The con¬
clusions the author reaches are that the plasma-cell is not of haemato-
genous origin, and the evidence is wholly favourable to an origin from
connective tissue. Hamilton C. Marr.

5. Sociology.

The Control of the Insane with Criminal Tendencies [Die Unierbringung
der Geisteskranken mit verbrecherischen Neigungen\ ( Psych.-Neur.
JVochenschr ., April gth and 16th, 1910.) Nitsche, P.

In this paper, read before the Dresden Forensisch-Psychiatrische
Vereinigung last March, the author discusses the rather hackneyed
question of the method of dealing with dangerously criminal lunatics.
The arguments on the matter are too familiar to need re-statement, but
some points brought out by the author may be of interest as showing

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the trend of ideas on the question in Germany. He deals in some
detail with the system of lunatic wings attached to prisons, a system
which exists in Prussia, Wurtemburg, Saxony, and Baden. This system
he approves of so long as the special wings are used only for the tem¬
porary detention of offenders who have shown signs of insanity while
undergoing the ordinary penal discipline. It appears, however, that a
wider extension has been given to this method at Waldheim, where the
lunatic block connected with the penal establishment serves for the
treatment during indefinite periods not only of criminals who have
become insane and of insane persons who have committed crimes, j but
also of lunatics who have shown dangerously violent tendencies in other
asylums. It is suggested that this arrangement has not worked very
satisfactorily at Waldheim, the explanation apparently being that the
medical administration of the lunatic wing is unduly influenced by the
lay authority of the prison. On this account the author is opposed to
having such institutions used for the prolonged detention of insane
patients of any class so long as the prisons with which they are connected
are not under medical control and government; and this view appears to
have commanded the support of the alienists who took part in the dis¬
cussion. Regarding the other possible plans for meeting the difficulty
created by this class of insane patient, the author very reasonably con¬
cludes that the choice between special criminal asylums and special
blocks in ordinary asylums must be decided by the conditions in each
locality. The former plan will be suitable in districts with a large
industrial population, while the special blocks will be found sufficient in
rural populations. Whatever system is adopted, it is urged that the
criterion for bringing patients under these special means of control should
be their distinctly dangerous disposition, and that no regard should be
had to the pedantic consideration whether they had or had not been
legally labelled as criminals. W. C. Sullivan.

Sexual Offences and Diminished Responsibility [Sexual dllikt und
verminderte Zurechnungs fahigkeit ] (Psych.-near. Wochensch.,
December 25 th, 1909.) Niiche, P.

In an earlier number of the same periodical appeared a paper by
Fischer on “ Responsibility in Incipient or Doubtful Mental Disorder,”
in which sexual offences (among others) were considered. Fischer
maintained that if a person of sound mind was affected with an abnor¬
mally powerful libido sexualis and committed an offence, his increased
libido could not be pleaded as a ground for a diminution of the legal
penalty incurred, “ inasmuch as in a person of sound mind no mental
disorder can be induced by an increased libido.” Nacke accepts the
latter statement as true, but disputes the former. He considers that
inasmuch as any strong emotion may diminish or completely overpower
self-control, the same is true of the sexual impulse. Hence in a sane
person diminished responsibility may be pleaded on the ground of
abnormally powerful libido sexualis. In the paper already quoted
Fischer had written, “ Experience teaches us that in persons whose
sexual desires are directed to abnormal ends, libido is no more power¬
ful than it is in those whose sexual desires are normally directed. Even
if in such cases libido was greater, the inhibiting influences offered by

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society and its laws to the gratification of abnormal desires is greater.
It follows from these considerations that those who, in other respects
mentally sound, have inherited pathological sexual tendencies, are fully
responsible for all their actions.” As Nacke remarks, it is fairly obvious
that Fischer has in mind the offences of homosexuals ; and Nacke asks,
Has Fischer any first-hand knowledge of urnings, and, if so, of how
many ? It seems as if his knowledge cannot be extensive, since, in the
first place, those with inverted sexualityare not necessarily the subjects of a
pathological mental state. At most qua homosexuality they are abnormal,
and perhaps even we must regard inverted sexuality as a normal variety
of the libido to which a minority are subject. And it is by no means
proved that sexual inverts are more often psychopathic and degenerate
than the heterosexual. Niicke’s own impression, at any rate, is that this
is not the case. He goes on to say that he is in agreement with others
who have a large first-hand knowledge of urnings in believing that these,
as a rule, have a libido which is exceptionally powerful and makes its
appearance at an earlier age than in the case of heterosexuals. If these
beliefs correspond with the facts, diminished responsibility could justly
be pleaded on behalf of homosexuals who have committed sexual
offences. Urnings are well aware of the existence of Section 175 in
the German Criminal Code ('); they are also aware of the social obloquy
they incur, at any rate in cultured circles of society, and yet these
hindrances often prove insufficient. It is, in fact, unjust, says Nacke,
to demand, under penalty, sexual abstinence from urnings, when no
such demand is enforced upon heterosexuals.

M. Eden Paul.

1 " Unnatural vice between two persons of the male sex ... is punishable
with imprisonment . . . and loss of civil rights.”

6. Asylum Reports, 1908.

London County .—The report of this authority presents, as usual,
many features of interest, and, we think, of general use. It extends now
to over 300 pages.

The increase in total numbers resident at the end of the year is a little
more than that of the preceding two years, but it does not come quite up
to the average increase of the last twenty years. This last number reminds
us that, with the Council itself, the Asylum Committee has now
attained its majority, and we venture to congratulate the body on being
able to look back on its work during that period with much satisfaction.
It began with much activity and determination ; now it has arrived at
marked virility of administration. It may be that here and there are
things which do not commend themselves to all, but it cannot be gain¬
said that it has aimed, successfully on the whole, at procuring the most
beneficent treatment for the unfortunates whose care is confided to it
Referring again to the increase in the insanity of the area, while, as said,
the asylum increase is less than the average, the total increase is over
20 per cent, more than average, the Metropolitan Board Asylums having
nearly three hundred more residents than in the previous year. Not¬
withstanding this, the Committee adheres to its former opinion that

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there is no evidence to support the contention that the disease is more
prevalent than formerly. The lessened death-rate, which is the certain
outcome of improved sanitation and care, with more comprehensive
registration being in its opinion the real causes for increase. Still, the
yearly increase is again becoming proportionately greater, and the
Committee has felt compelled to get on with the eleventh asylum, to
be built from the plans of Mr. Clifford Smith.

Mention is made of the proposed mental hospital, originating in the
munificence of Dr. Maudsley. As was foreseen when this idea was
first mooted twenty years ago, much difficulty arises in connection with
procuring a suitable site, having regard to the essential elements of a
clinique and out-patients’ department being attached to the hospital
but doubtless the difficulty will disappear in good time.

The number of re-admissions in the course of the last fourteen years
is prodigious, being no less than 28 per cent, of the admissions, and
about 40 per cent, of them returned within a year from discharge. The
Committee may well say, as it does, “ that the term ‘recovery ’ in con¬
nection with discharge does not in a large number of cases indicate
radical cure.” No doubt there is some justification, as, indeed, there is
temptation, for regarding relief from a manifestation of existent insane
diathesis rather than relief from the diathesis itself as a recovery, but such
huge divergence from the approximate rate of 4 per cent, of re-admissions
for all England must to a considerable extent affect the value of statistics
relating to recovery. We suppose that the difficulty of accurately
separating diathesis from symptoms led the Statistical Committee to
abstain from offering any suggestion for the definition of the term
“ recovery.”

Alien lunatics have given the Committee much to do. They can be
deported by order of the Home Secretary if within twelve months of
their arrival, and if it is certified by a magistrate that, within three
months of the commencement of proceedings against them, they have
been in receipt of parochial relief. Several cases have been thus
treated, while others have been deported by their own friends, and two
have been deported, on the order of the Home Secretary, by the
shipping companies bringing them into the Kingdom. Some years ago
we drew attention to the drastic action in such cases taken by the
immigration authorities of the United States. It is satisfactory that the
same practice has been established in the United Kingdom. Germany
is the chief country from which the cases came. Legal difficulties,
pointed out by the Local Government Board, foiled the attempts of the
Committee to return Scottish and Irish patients to the country of their
origin.

The Committee is at great pains to inform the friends of patients
that if the full rate of maintenance is paid their relatives can be placed
on the private list, the Committee having found out that in many cases
such full cost is paid to the Guardians. Several availed themselves of
the offer, but many others could not pay the board in advance, this
being a sine qua non. In some cases, too, the Committee has been able
to recover some addition to the maintenance rate, to go towards capital
expenses. The rate for the private wards is only i6j. i i d., but admission
to them is rightly reserved for London patients only.

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A considerable amount of space is given to a review of the report of
the Royal Commission on the Feeble-Minded. This will be read with
interest, seeing that it is the result of combined medical and lay opinion,
with much administrative and scientific experience behind it. The
general view of it is one of cordial approval, with a full recognition of
the immense task set before the community if the recommendations
are to be fully carried out. Beyond a clear exposition of the guiding
principles which dictated the proposals, we note the following points.
The Committee is much in favour of the power being given to the
Asylums Committee, etc., to co-opt members to itself, such members
having no voice in the control of expenditure. The Committee
urged this view on the Poor Law Commission, apparently without
success. The Committee thinks that there is much work which such
co opted members could usefully perform in the direction of “ visitation,
discharging patients, and the supervision of a multitude of administrative
details in connection with institutions for the mentally defective.”

For ourselves, we regard co-optation with considerable suspicion. It
is most useful where skilled advice is desired, as will be the case on the
Board of Control, but it is not free from danger where executive respon¬
sibility is in question. We venture to think that among the honorary
offices which are open to those who freely give their time to local
government, none exceeds that of asylum visitor in requiring serious
attention and regulation. We fail to see why responsibility to the tax¬
payer should serve to prevent a co-opted member exercising control
over expenditure, while he is not debarred from exercising the very
serious responsibility of discharge. If co-optation is to be practised we
think that it should be compulsory, that is to say, that the delegating
body should rule that the Committee must co-opt so many, so that
everyone should know the exact size and composition of the body that
is exercising control. The Committee will not commit itself to any
opinion as to the usefulness of women as colleagues.

We are glad to note that the Committee is most anxious for
co-operation between the education authority and the authority respon¬
sible for the mentally defective in regard to the children of the latter
class, their views in this direction having been pressed on the Commis¬
sion by Drs. Bond and Mott on its behalf. There is not much to be
hoped for, perhaps, in regard to the bulk of infantile and juvenile
defectives from education, however scientifically designed, but proper
co-ordination will at least give more opportunity of removing from
healthy children the baneful influence of moral aments, who are more
numerous, probably, than is suspected, and who do an immensity of
harm.

Payment by fees for certification by the official certifying medical
man does not commend itself to the Committee, who would prefer that
official to be salaried. This would be following experience in Glasgow
and other places, where it has worked well.

Some objection is taken to the addition of a third Government
authority to the two who already have an opportunity of reviewing the
Committee’s proposals in regard of new buildings, in so far that it gives
more opportunity for delay, which has been found, not only by the
the London Committee, to be very annoying. It would, of course, be

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very inimical to the idea of unity in provision for the insane if one
building had to be submitted to one set of authorities and another to a
different set. There is something in the point made by the Committee,
that a County Council is itself the building authority under various acts,
and might be trusted to carry out its own proposals ; but, after all, some
County Councils have been held to be a little extravagant in their
notions of what asylums should be, and it saves much odium if the
final voice in expenditure is given to a strong central authority.

In the matter of diet some rearrangement has been made in the
relative quantities of various articles given. Following experiments at
one or two individual asylums, a general order has been issued permit¬
ting the Medical Superintendent to reduce the meat and vegetables of
the diet sheet, substituting therefor more pudding. This has been
found to increase satisfaction and to decrease waste, and, indeed,
expense. At some of the asylums the plan has been tried in respect
of staff diet, with the same good results. This success endorses the
feeling which is becoming more general, that we all eat too much meat,
and it seems to be well worth following up.

Turning to the copies of the Commissioners’ reports at the various
asylums, we note the following points : At Banstead they remark that
it is possible to contrast on the spot the efficiency of the earlier
buildings with those of a recent villa-form type, and find the advan¬
tage to lie with the latter where space is available. They advert to the
benefits conferred by the Queen Adelaide Fund, out of which patients,
when discharged as recovered, receive a grant to help them over the
first return home if their means are meagre. If the fund is not able
to make the grant some help is given out of the profits made by supply¬
ing patients’ friends with tea when visiting. They commend the
practice to other institutions. The introduction of mat-making, etc.,
and a printer’s shop at Horton are noted, the introduction being
accompanied by economical success.

In the reports of the medical superintendents we find the following
matters of interest: At Bexley Dr. Stansfield is confident that in
cases of alcoholic heredity, when the father has been the drinker,
the type of insanity shown in the child tends to an unstable, impulsive,
and explosive nervous organisation, such as obtains in epilepsy,
hysteria, moral and impulsive insanities, and in certain forms of
paranoia. When the fault is with the mother, it leads to the
impeding of mental and physical development, resulting in idiocy,
imbecility, or mental enfeeblement. This may, perhaps, be summed
up as the alcoholic father tends to hand on functional disturbance,
the mother producing organic defect, and it is no doubt true in
the main, but we think that it cannot be stated as a general rule
unless some account be taken of the duration of the alcoholism in
each parent. Is not a man who from continued drinking reduces
himself to a mere sot likely to beget something little better than
himself as far as intellect is concerned ? This consideration of time
is of interest in connection with the recent dicta of Dr. Karl Pearson
as to the progeny of drunkards. An occasional or temporary drinker
stands on a footing qua powers of transmission entirely different from
that of the persistent self-debaucher. Dr. Stansfield claims that

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syphilis should be a notifiable disease, and its communication a punish¬
able offence.

Dr. Robert Jones makes a neat point:

It is often advanced by certain critics that the amount of drink taken indi¬
vidually by many of those admitted into asylums is exceedingly small, and that
this is confirmed by the rarity and even absence of cirrhotic and fibrous changes
discovered in the principal organs in these cases after death, and therefore it would
be erroneous to consider insanity as caused by excessive drinking. The same
critics affirm that the principal units in the so-called recovery list of asylums are
the drink cases, and that if these cases were eliminated or treated elsewhere, there
would be no recovery list at all ! Both of these statements cannot be true, but
they show to what specious arguments prejudice can deviate reason.

Fifty cases of lumbar puncture have been performed, which are to be
reported on by the Pathologist. The report cannot fail to be of the
greatest interest, possibly of great value.

At Long Grove Dr. Bond has been making large use of the con¬
tinuous warm-bath system, and hopes for opportunities of being able
to carry this on by night as well as by day, so as to make it really
continuous. A report of the results will be very valuable. In the male
verandahs tubercular and some other patients are kept by night as well
as by day.

Bovine tuberculosis .—The importance of this has been much before the public of
late; and ever since the opening of Long Grove a persistent and vigorous effort
has been made to obtain a herd free from tuberculosis—a goal by no means easy
to accomplish. The herd, which numbered fifty-two on March 31st this year, was
started by the purchase in June, 1907, of five cows certified as having then satis¬
factorily passed the “ tuberculin test"; three of these, however, subsequently
developed tuberculosis. In the following month further cows were purchased, and
to these and to all the ninety-six cows subsequently bought the test has been
applied in the sheds here before the completion of purchase. This has involved
the sending back of no less than fifty-five cows as having failed to pass the test.
If our sources of purchase may be assumed to be at all representative, these figures
imply that at least 36 per cent, of young milking cows in the country are infected
with tuberculosis not recognisable clinically—a surely most serious fact from a
public health point of view.

In the report of the Epileptic Colony Dr. Spark writes :

The line of demarcation between the sane and the insane is probably more
indefinite in epilepsy than in any other form of insanity, and in accepting some of
the statements made in the admission certificates, one cannot help suspecting that
the picture of the patient’s mental state is sometimes painted in somewhat lurid
colours in order to relieve the infirmary, and to secure institutional treatment for
one who is rarely a bread-winner and often a burden. When once admitted, a
lengthy period of observation is necessary before determining that continued
detention is no longer justified under the lunacy law, and before recommending a
discharge, home control, environment, and prospect of employment require very
careful consideration.

By the operation of the Employers’ Liability Act the difficulty of obtaining
permanent work for the epileptic has been greatly increased, and perhaps the
prospect might be brightened if some degree of contracting out were possible.

Metropolitan Asylums Board.

The enoimous work connected with the various asylums and homes
directed by this body is carried out with just as much earnestness
as if its apotheosis had not been announced by the Commission on

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the Feeble-minded. A strong authority will be required to do the
work as well, and certainly none will excel in the admirable and pro¬
gressive spirit which has guided the hand of the Board. We might
go further and say that the carrying out of the comprehensive
scheme laid down for future dealing with defectives will be made
the easier by the persistent endeavours of the Board to utilise, in one
way or another, mental capacity, however restricted. Valuable ex¬
perience has been gained not only in ascertaining what is worth
doing, but also what is useless to attempt. The work of the staff
is no doubt dull and depressing as a whole, but some bright spots
must be found in improving results by developing useful labour. The
nature of the medical work no doubt has made it more and more
difficult to secure sufficient candidates for appointment, and the Board
was led to promulgate the subjoined conditions after consultation with
their medical superintendents.

For a considerable time the paucity of candidates for vacant appointments on
the medical staff at the asylums had become very noticeable and unsatisfactory.
Several reasons were advanced by the medical superintendents of the managers’
asylums which in their opinion accounted for the unpopularity which appeared to
attach to these appointments, and these reasons were fully discussed with the
medical superintendents.

In the hope of attracting a larger number of suitable candidates for these
positions it was decided:

(a) That it was desirable that a standing order which required assistant medical
officers in the asylums’ service to be annually re-elected after the third year of
office should be rescinded. (This the managers did on March 14th .1

( b) To recognise the principle that senior assistant medical officers might marry
and be permitted to live off the asylum estate. (Three of the officers have availed
themselves of this privilege.)

( d) That applications for future posts of assistant medical officers in the
asylums’ service should be made through the medical superintendent concerned
instead of through the Clerk to the Board.

We have not yet had sufficient opportunities of judging whether these alterations
in the regulations will achieve their object.

Tooting Bee Asylum. —The burden of the medical care and of the
nursing required here is well shown by the fact that the deaths numbered
262, the average on the residence being 37 per cent, for men and 26
for women. The average ages at death were 69 for the former and 74
for the latter. 158 of them were due to senile decay.

Leavesden. —The deaths here were not far off the general average of
asylums, vis., 7^52 for the men and 8 61 for the women. Senile decay
accounted for 14 out of the 156 deaths. An outbreak of scabies among
the females caused considerable trouble, but was eventually conquered.

Caterham. —The deaths here too closely approximated the general
average, being 7’6 per cent. Dr. Campbell complains bitterly of the
sensational attacks made in the Press on “ walking parties.” His
experience is that complaints from the outside are rare, while on the
other hand he finds that frequently kind acts have been done to parties
when outside the asylum.

Darenth Asylum. —Here the death-rate reached the abnormally low
figure of 3 00 per cent. Eighteen patients were discharged, of whom
Dr. Rotherham writes that they should have been kept under observa-

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tion in an institution, particularly in such as had means for teaching in
school and workshop. He hopes for the passing of legislation some
day whereby it will be made possible to detain them. Dr. Rotherham
is the apostle of work in asylums, and the following shows what can be
done.

At the Franco-British Exhibition, which was open between May and November,
space was allotted in the British Educational Section to the Local Government
Board, and, at their request, an exhibit of articles made by the patients in the
Industrial Colony and Training School was sent up from this Institution. At first
the space for exhibits given to Darenth was so small that there was little prospect
of successfully showing off the numerous articles, but eventfully, owing to the
courtesy of Mr. Hoare, of the Local Government Board, a larger space was
obtained, which, though still not nearly large enough, enabled a fine show to be
made. Some 700 articles, entirely made by patients from six years of age upwards,
with enlarged photographs of the inmates at work, were extremely well arranged
by the craftsmaster, to whom great credit is due for the thoroughness and energy
with which he undertook this, to him, novel work, the result being highly satisfac¬
tory. A great deal of attention was devoted to our exhibit by thousands of
visitors interested in education, the only one in the exhibition which showed what
can be done in an institution for mentally deficient people. A visitors’ book was
kept in which visitors might enter their names and record their impressions. Over
2,600 entries were made by people from all over the world, and their remarks
showed their surprise that such an exhibit made by mentally deficient people was
possible, and their thankfulness and gratitude for the work which was being carried
out by the Metropolitan Asylums Board and the staff at Darenth.

The Visiting Commissioner noted in his report:

It was impossible not to be impressed by the interest which most of those
employed took in the various branches of work on which they were occupied. I
was much struck with the various forms of education that were being imparted to
the different grades and classes of children in the schools.

A debtor and creditor account is kept of each of twelve trades at
which patients work, and this, after full allowance is made for the wages
and expenses of the teachers, adds up to a total of over ^2,100. To
this may safely be added a very considerable amount for the value of
the improvement in health and conduct of those engaged, finding its
account in the less cost of care and management.

We must congratulate the Board on having adopted the Statistical
Tables of the Association. Some of the medical superintendents speak
hopefully of their future usefulness. It may be pointed out that as long
as only the County Asylums thus dealt with their figures, it has been
impossible to examine any point of interest affecting the total insanity
of London. The work of shifting over the system must have been
enormous, and must be the more admirable in view of the threatened
disestablishment of the Board. Of course considerable difficulty must
arise in following up inquiries in consequence of the frequent inter¬
change of patients between institution and institution belonging to the
Board, notably between Tooting and other asylums, but steps have
been taken to minimise the inconvenience.

The most memorable work done by the Board has been in relation
to that large and unsatisfactory body of juvenile deficiency which is
debarred the enjoyment of the ordinary means of education, that body
which fills, unless properly provided for, industrial schools, workhouse
wards, reformatories and, later on, prisons and the streets. Homes

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and colonies now afford better means, and those instituted by the
Board may well provide examples to be followed when the great change
comes over the system of caring for defectives. As mentioned in former
reviews, these have been organised and provided with efficient expert
medical supervision.

All but one of these homes are medically supervised by Miss Turner.
She finds, of course, that many of the inhabitants are beyond hope of
substantial improvement, but with regard to others apparently the con¬
tinued use of appropriate treatment and training is bearing good fruit.
Improvement, however, in the case of the girls raises very serious
questions, which would not arise if there were no prospect of discharge.
She is forced to the opinion that in spite of a bettered mental condition
it would be best, not only for others, but also for themselves, if discharge
were long delayed or altogether suspended. Here are her views of the
nature of the employment that best tends to improvement:

Still another cause contributing to greater improvement in the multiplication of
occupations suited to every variety of mental capacity. Objection has been taken
to this very thing, it being argued that one thing done well would be better than
many done indifferently. But this objection misses the real purpose of the occupa¬
tions, which is not only to perform work, but to educate the capabilities of the girls
by means of work. The members of the Colony represent very varying powers,
and hardly half a dozen are capable of deriving the same amount of advantage from
the same employment. The desideratum is something that every one can do, from
the most intelligent to the least intelligent, and only a variety of employments can
supply this diversity. It would be a move in the right direction to introduce new
and different occupations, as, for instance, straw hat-making in all its branches, as
the preparation of the straw involves processes, such as splitting, plaiting, and
mangling, which can be performed by the most unintelligent. In the straw hat¬
making districts very little children are often seen engaged in these very simple
occupations, which are at once interesting to perform and involve a minimum
amount of labour. On the other hand, for the strong, robust members of the
Colony it would be advantageous to have more out-of-door employment; even the
more laborious occupations connected with gardening could be performed by them,
and, as before suggested, instead of the few head of poultry kept there might be a
fairly large chicken farm, which w'ould afford useful and interesting occupation to
the members of the Colony.

Dr. Rotherham has the supervision of the Industrial Home at
Witham, accommodating about 130 boys. All the boys now attend
school, but the teaching consists almost entirely of object lessons, the
three “ Rs ” being discounted as entirely useless and wasteful of time to
teachers and pupils. In the training-shop 8,224 pairs of boots were
repaired for the inmates of other homes, while the tailoring is as successful,
affording to some of the boys opportunity of showing real skill in making
garments of all kinds. A band of twenty-two performers has attained
such merit that they have been able to play at entertainments outside
the home.

Reading these reports from year to year, we are struck with the
constant devising and trials of new outlets for the exercise of such
mental capacity as is preserved to patients. Experiments, mostly
successful, establish new points of treatment, and in this respect the
Board and its staff are entitled to much gratitude for paving the way
to better things.

The Report of the Commission on the Feeble-Minded tends, of course,
to remove all this great work from the hands in which it now is. It is

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not to be expected that the Board should view the recommendations of
the Commission in a spirit of acceptation, though it speaks of the Report
with respect. The Board being by far the most important exponent of
differing opinion, we think it right to reproduce at some length its
arguments.

The Report of the Commissioners contains a voluminous and exhaustive survey
of the whole field covered by the wide terms of the reference to them, while the
Commissioners also published in six large blue books the minutes of evidence
which they received from 248 witnesses, with the reports of medical investigators
and the report on the visit of certain Commissioners to America. These volumes
contain a wealth of information on most important questions dealing with the
mental, moral, and physical well-being of the community.

We are, of course, specially concerned with the views and recommendations of
the Commissioners with regard to the care of the feeble-minded and of non-imbecile
epileptics, and we think it well, as some of these recommendations have an impor¬
tant bearing on this branch of our work, to refer to them in this place, though of
necessity only very briefly.

In the preamble to their recommendations, the Commissioners place in the fore¬
ground the important reservation that “ it is not intended that the maintenance at
public expense of the mentally defective, or of epileptics not mentally defective,
should be extended to those who, either at their own cost, or at that of their
relatives or friends, can be otherwise suitably and sufficiently provided for." At
the same time, we find nothing in the report adverse to the view which we have
long expressed, and which was supported by the Chairman of the Board in his
evidence, namely, that public provision should be available for all classes of mentally
defectives, subject to payment of the cost in whole or in part, according to means,
by the relatives of the patient. The difficulty experienced at present is that,
speaking generally, a patient must either be a pauper to secure admission to an
institution maintained out of public funds, or sufficiently wealthy to pay the com¬
paratively large fees required by even the least expensive of the voluntary or
private institutions. There appears to be at present no middle course.

With regard to London, the Commissioners discussed fully the work of the
Metropolitan Asylums Board and the London County Council, and their recom¬
mendations are that, notwithstanding any existing statutes, the proposed general
Act for the care and control of the mentally defective should provide that, in the
case of the administrative county of London, the institutions of the Metropolitan
Asylums Board should be transferred to the London County Council for the use
of its Statutory Committee for the care of the mentally defective, on whom the
duty to make suitable and sufficient provision for the care and control of the
mentally defective in the Administrative County of London will by the said Act
devolve. The Commissioners, having already decided that in the country in
general the Poor Law authority cannot suitably undertake the care of the mentally
defective, and that this duty should devolve upon the county authority, remark
that they find no point of difference in regard to London which would lead them
to recommend for it a scheme different from that which they recommend for
England generally. They appear, moreover, to have been impressed (1) as regards
the imbecile work, by the complaints of the London County Council that the
Asylums Board have not kept pace with the need for imbecile accommodation, and
that the pressure falls more and more upon the former body (who provide for
lunatics), and less and less upon the Asylums Board; and (2) with regard to the
feeble-minded, by what they call the institutional disorganisation as to the mentally
defective, by which phrase is indicated chiefly the fact that in London the Asylums
Board provide accommodation, while the Council educate a considerable section
of the feeble-minded, as well as to the fact that the Council also provide some
residential homes.

It is not germane to our report to deal with the first point, however much open
to argument it is, though we may mention that the Commissioners speak of the
" very clear and enlightened policy of the Board ” with regard to the imbecile
work, and one Commissioner refers to the Board as “ a progressive and efficient
local lunacy authority.”

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As to the second point, we may say that this duplication of authority, so far as
the Board’s feeble-minded cases are concerned, will only apply so long as the
small residential homes in London are maintained, and that the Commissioners’
own conclusions point to the replacement of these homes by larger settlements.
They say that "probably in the future more reliance will be placed upon the
education of these children at an early age, and often continuously, in colonies like
that at Darenth and Sandlebridge, than in scattered residential homes.” Again,
as to the utility of special schools and classes, reference is made to the fact that it
is estimated that in London from 5 to 10 per cent, of the children are moved into
ordinary schools and do well, that some 45 per cent, at most “ do manual work
well and are of fair intelligence as regards ordinary matters of life,” and are con¬
sidered capable of earning their own living altogether, or to a material extent, and
that some 50 per cent, are suitable for permanent detention. At Birmingham, as
the result of seven years’ investigation, only 19 8 per cent, have been wage-earners
at all, and only 3'9 per cent, earn as much as 10s. a week.

The Commissioners conclude that “ the result of this survey confirms the
opinion that the special school or class is to be regarded rather as incidental to a
general organisation of industrial and institutional training than as of main or
ultimate importance in itself. This conclusion is far-reaching. If it be accepted,
the special class or school as part of the elementary education of the country does
not remain a central point of organisation round which an industrial and institu¬
tional system should be organised. The latter becomes incidental to its working
and development.”

Thus the special class, except as a kind of sorting-house, must, equally with the
scattered residential homes, give way in the future to the complete self-contained
colony such as Darenth.

As the most suitable local authority for the care of the mentally defective, the
Commissioners appear to have made their choice between the Poor Law authority
and the County Council in favour of the latter, quite apart from the question of the
likelihood of profound changes being made in the administration of the Poor Laws
in the next few years. The fact that the Royal Commission on the Poor Laws
will shortly issue its report, and that this report must inevitably deal alike with
the future of Poor Law work, with the constitution of the Poor Law authority, and
with classification, finance, and other questions, make it almost inevitable that
consideration of the proposals which we have briefly reviewed will be taken side
by side with those of the Poor Law Commission. Till that time, therefore, might
be left further consideration of the problems as to whether the care of the
mentally defectives, a work which is wholly institutional in character, should be
undertaken by a body differing from that which will in future control the institu¬
tional work of the Poor Law, and as to whether the needs of London are of such a
character as to justify a departure from any scheme approved for the rest of the
country.

We must confess that, having regard to the unwearying work done by
the Board, our sympathies are very much with it in this question, but
logic, if not practical convenience, points, we fear, to its being trans¬
ferred to the other authority to be created, if the Commission’s Report
is carried into effect. Whether we regard defective juveniles as lower
grades of insanity or simply as abnormal forms of pauperism, there must
be a dividing line between the duty of caring for the insane and that of
caring for pauperism. The fixing of that line is by no means easy, but
the controlling element will be found to be education. The more that
success attends the attempts to improve defectives by training the more
will education assert its importance in dealing with such young people. It
would seem, therefore, to be appropriate that the care of them should be in
the hands of those who are charged with education, and these hands are
to guide the care of the insane as well. It seems logical that one body
should have the duty to educate all, from the brightest of brains down
to the lowest stages of intellect. It seems equally logical that one body

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should have the care of all defectives, from the acutest of maniacs down
to the most pronounced instances of mental deprivation. Mental
insufficiency must be the test rather than pauperism. But its personal
application will be difficult both in the cases of these juveniles and of
the old people whose bodies outlive their brains.

Some Scottish Chartered Asylums.

Crichton Institute .—The energetic inquiry into the pathology of
insanity is a point of the utmost importance in the view of both the
committee and Dr. Easterbrook. They are collaborating for the pro¬
vision of a first-class laboratory on the estate. No doubt much valuable
result will be forthcoming from the independent mind of Dr. Easter¬
brook. We note that a new term has been chosen for what are now
called “ direct ” cases. Dr. Easterbrook defines them as “ receptions.”
We fail to see any advantage in the substitution. The latter term
suggests nothing but coming in, and in default of applied definition
might easily be taken by the casual reader to cover all admissions.
The term “ direct ” at once challenges inquiry as to its meaning.
Statistics here are quite incomparable with those of the Association,
and, indeed, with those of any other institution. The scheme of tables
is entirely silent on the matter of aetiology. But we note that in the
classification Dr. Easterbrook has no sympathy whatever for toxins or
auto-toxins. These important, not to say fashionable, factors are not
thought worthy of giving their name either to a cause or to a classifica¬
tion except in respect of alcohol. This appears in the definition of
dipsomania, defined as insane impulsion for alcohol. Stupor and
katatonia, linked together, constitute one “ form.” No other form of
stupor is recognised. This rather adds to the complexity of the
question of dementia praecox. There is plentiful evidence of the
continuation by Dr. Easterbrook of that restless quest for improvement
that has marked the Crichton since its inception, and we foresee that
Dr. Easterbrook’s originality of thought and method will be found a
valuable asset of the institution.

Gartnavel .—The venerable term of “ Royal Asylum ” is endangered
by the march of medicine. It is now wished that the Institution should
be known as the Glasgow Royal Mental Hospital. So may it be!
The Chaiiman at the General Meeting rightly adverted to the number
of voluntary admissions (which appear in the last three years to have
constituted 33 per cent, of the new cases) as evidence of the alteration
in the public mind on the nature and treatment of insanity, and also of
the care and skill shown by the medical staff.

The directors expect in the near future to take part in establishing in the West
of Scotland a well equipped laboratory and institute, where the complex problems
of the diseases of the mind may be worked out by specially trained pathologists.
Many new methods of research and treatment have of late years been devised, and
the Directors are desirous that every possible means of recovery or alleviation
shall be available to the patients committed to their care.

Dr. Oswald is hopeful about general paralysis. He says that while
hopes recently raised concerning its causation by a micro-organism still

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lack confirmation, yet the investigations now carried on by many skilled
workers may lead to a cure being discovered. The amount of good
that such an institution can do for the poorer of the middle classes is
shown by the fact that more than one third of its population pay
^40 only, while a seventh part pay less than £a,o.

The Murray, Perth. —Dr. Urquhart supplies yet another table of
causal factors. It certainly more nearly approaches that suggested by the
Statistical Committee, in that it supplies a larger amount of correlation.
We note one particular item “ neuropathic heredity denied.” Is this
term of sufficient accuracy to be ranked with admitted heredity?
Beyond the mere possibility of intentional lying, there is the common
occurrence of a man not being wise enough to know his own grand¬
father, and especially all his own uncles and aunts. Further, many
families get split up as time goes on, and anything may occur to one
member without others hearing of it.

Dr. Urquhart enters a strong plea for the maintenance, in all its
efficiency, of the Scottish Asylums’ Laboratory. As we have noted
above there are signs of activity in the direction of laboratory work
elsewhere, and we may be excused for entertaining some apprehension
that this activity may be perhaps disruptive rather than constructive.
We should most earnestly deprecate anything like the former. If we
recollect accurately the old king when he wanted to show the benefits of
union sent for sticks and bound them together. He was not foolish
enough to show the benefits of union negatively by sending for a bundle
of sticks to unbind and break them one by one. Scotland led the way
in uniting; it should keep the lead by maintaining one national institution
supported by all, as far as possible.

Part IV—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT
BRITAIN AND IRELAND.

A Quarterly Meeting was held at n.Chandos Street, Cavendish Square,
London, W., on Tuesday, May 24th, 1910, Prof. W. Bevan-Lewis, M.Sc.,
President, in the Chair.

Present : The President and the following sixty members: T. S. Adair,
H. T. S. Aveline, Fletcher Beach, G. S. Blandy, C. Hubert Bond, D. Bower,
R. Campbell, J. Chambers, S. Clarke, Maurice Craig, W. R. Dawson, J. F.
Dixon, T. O’C. Donelan, A. R. Douglas, T. Drapes, J. H. Earls, F. W. Edridge-
Green, W. Graham, T. D. Greenlees, W. H. Haslett, R. D. Hotchkiss, D. Hunter,
Robert Jones, R. Langdon-Down, N. Lavers, J. R. Lord, W. H. C. Macartney,
C. Mercier, J. H. Macdonald, M. E. Martin, J. Middlemass, A. Miller, C. S.
Morrison, C. M. Murrell, H. Hayes Newington, L. R. Oswald, S. R. Philipps,
Bedford Pierce, H. E. C. Quin, D. Rice, N. Raw, W. Rawes, H. Rayner, G. H.
Savage, G. E. Shuttleworth, A. Simpson, R. Percy Smith, J. G. Soutar, J. B.
Spence, T. E. K. Stansfield, R. H. Steen, R. C. Stewart, R. J. Stilwell, W. H. B.
Stoddart, J. D. Thomas, T. Seymour Tuke, J. Turner, A. R. Urquhart, W.
Vincent, and F. Watson.

Apologies for absence were received from Drs. Fennell, P. W. MacDonald,
Nolan, Outterson Wood, A. R. Turnbull, and others.

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Attendance at previous Council Meeting: T. S. Adair, H. T. S. Aveline,
W. Bevan-Lewis, C. H. Bond, Robt. B. Campbell, J. Chambers, W. R. Dawson,
W. Graham, H. Hayes Newington, R. D. Hotchkis, Robert Jones, C. Mercier,
A. Miller, L. R. Oswald, R. Percy Smith, H. Rayner, R. H. Steen, W. H. B.
Stoddart, A. R. Urquhart, W. Vincent, and H. Wolseley-Lewis.

The Death of King Edward VII.

The President remarked that before the business of the meeting was com¬
menced he had a very painful function to perform, namely, to refer to the very
serious calamity which happened to our land on the fateful 6th May. None could
dissociate themselves from the great wave of universal sorrow which swept over
the Empire to its remotest confines on the passing away of King Edward. All
felt that a great moral, social, and political force had passed away from our midst;
and those belonging to the medical profession must be only too keenly conscious
of the irreparable loss which had been sustained in the passing away of so princely
a spirit. No monarch of recent times had ever identified himself so intimately,
so earnestly, so sympathetically, and, at the same time, so personally with the
welfare of the profession, with the advancement of progressive medicine, and with
the best interests of those most noble philanthropic institutions, the great hospitals
of the Metropolis. King Edward's Hospital Fund—to mention only one matter
in particular—would ever remain an undying testimony to the wondrous instincts
he had, to his wise forethought, and to his keen interest in the lot of suffering
humanity. His royal dignity, his more than diplomatic tact, his keen earnestness
in the cause of universal peace, had won for him the plaudits of the world. None
the less, along with his Royal Consort, he was, above all other things, the
people's friend. He asked members present to rise and pay silent homage to
the memory of the greatest royal personality of the age, the record of whose life
was really enshrined safely in the affections and in the memories of his people.

The meeting acquiesced by silently rising in their places.

An Address to Their Majesties.

The President said that another subject, arising out of the preceding matter,
had to be referred to. He had to announce that the Council considered the
question of doing what was done on the occasion of the death of Queen Victoria,
namely, sending a vote of condolence and sincerest sympathy with their Majesties
the King and Queen, the Queen-Mother, and the other members of the Royal
Family. He proposed from the chair that that be done, coupled with Members’
own tribute of loyalty and affection to the Crown.

Dr. G. H. Savage seconded, and it was carried by members upstanding.

The following gentlemen were elected members of the Association, Dr. Stoddart
and Dr. Hotchkis acting as scrutineers :

Thomas Peter Conlon, L.R.C.P.&S.Irel., Resident Medical Superintendent,
District Asylum, Monaghan. Proposed by W. Ireland Donaldson, Charles
Rolleston, and C. Hubert Bond.

Michael Henry Downey, M.B., Ch.B.Melb., L.R.C.P.&S.Edin., L.F.P.S.Glasg.,
Assistant Medical Officer, Parkside Asylum, Adelaide. Proposed by W. L.
Cleland, H. Hayes Newington, and C. Hubert Bond.

Hector Duncan MacPhail, M.A., M.B., Ch.B.Edin., Assistant Medical Officer,
Gosforth Asylum, Newcastle-on-Tyne. Proposed by J. T. Calcott, A. M. Dryden,
and C. Hubert Bond.

Richard Caldecott Monnington, M.D., Ch.B. Univ. Edin., D.P.H.Edin., Medical
Superintendent, Laverstock House, Salisbury. Proposed by James M. Ruther¬
ford, P. W. Macdonald, and H. G. S. Aveline.

Oscar Phillips Napier Pearn, M.R.C.S., L.R.C.P.Lond., L.S.A., Assistant
Medical Officer, London County Asylum, Horton, Epsom. Proposed by John
R. Lord, Samuel Elgee, and David Ogilvie.

Robert Walter Joseph Pearson, L.R.C.P.&S.Edin., L.F.P.S.Glasg., Assistant
Medical Officer, London County Asylum, Claybury. Proposed by Robert Jones,
C. T. Ewart, and G. H. Harper Smith.

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Gayton Warwick Smith, M.D.Lond., B.S.Durh., D.P.H.Cantab., M.R.C.S.,
L.R.C.P.Lond., Assistant Medical Officer, Middlesex County Asylum, Tooting,
S.W. Proposed by H. Gardiner Hill, R. Worth, and C. Hubert Bond.

Minutes of Last Meeting.

The minutes of last meeting having already been printed and circulated in the
Journal, were taken as read and were duly confirmed.

Inspectors in Lunacy (Ireland).

Dr. Dawson said that the Irish Division, at a special meeting which was called
by the sanction of the President last week, unanimously sent forward a resolution
asking for the Association’s assistance in bringing before the Irish Government
the importance of appointing inspectors in lunacy who had the proper sort of
training and experience for filling so important a position. He therefore brought
forward for acceptance the following resolution :

"That in view of the importance of the forthcoming appointments, to the
positions of Inspectors of Lunatics, to the welfare of the insane in Ireland, this
Association should take steps respectfully to bring under the notice of the Irish
Government the eminent desirability of having particular regard, in making such
appointments, to the selection of candidates who are thoroughly conversant, by
training and experience, with the administration of lunatic asylums and the
practical treatment of the insane, and that the President be empowered to take
such steps as he may think fit to that end."

The Association could not, of course, know who had entered for the posts, but
he did not see that the course now suggested could do harm, and on the other
hand, it might very likely do good. It would lead to the views of the Association
being brought before the Irish Government.

Dr. G. H. Savage seconded the resolution.

The President said that the matter was a very important one, and it might be
that members would wish to express their feeling upon it. He asked those present
to further the end in view, which he regarded as an extremely desirable one, and
empower him to send a deputation to the Chief Secretary for Ireland, to represent
the views so expressed.

Agreed.

Dr. Charles Mercier read a paper entitled " Insanity as Disorder of Conduct.”
It excited a lengthy and spirited discussion, in which Drs. Savage, Stoddart,
Steen, Draper, Urquhart, Dixon, Bedford Pierce, Langdon Down, Rayner,
and the President took part, and to which Dr. Mercier replied.

This was followed by a paper by Dr. John Turner upon “ The Examination of
Cerebro-spinal Fluid, with Special Reference to the Diagnostic Value of Ross and
Jones’s Test.” It was briefly discussed by the President and Dr. Bond.

The meeting was brought to a close by an enunciation by Dr. Stoddart of a
"Theory of the Toxic and Exhaustion Psychoses.” It was discussed by Drs.
Seymour Tuke, Bedford Pierce, and the President, to whom Dr. Stoddart
replied.

In consequence of His late Majesty’s death the customary Dinner was not held.

MEDICO PSYCHOLOGICAL ASSOCIATION.
SOUTH-EASTERN DIVISION.

Spring Meeting.

The Spring Meeting of the South-Eastern Division was held by the courtesy of
Dr. Percy J. Baily at the London County Asylum, Hanwell, W., on Tuesday,
April 20th, 1910. Among those present were Drs. R. R. Alexander, Percy J.
Baily, W. H. Bailey, David Bower, C. Hubert Bond, J. Francis Dixon, A. W.

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Daniel, H. Devine, S. C. Elgee, Francis H. Edwards, T. D. Greenless, S. J.
Gilfillan, F. Edridge-Green, J. W. Higginson, David Hunter, H. E. Haynes,
P. G. Kennedy, E. S. Littlejohn, T. S. Logan, H. Wolseley-Lewis, M. E. Martin,
J. J. Murphy, H. C. MacBryan, J. Macarthur, A. S. Newington, J. G. Porter
Phillips, R. A. Rankine, C. F. Rolleston, W. Rawes, J. G. Smith, T. E. K. Stans-
field, J. Tattersall, F. Watson, the Rev. E. Hockley, and R. H. Steen (Hon. Sec.).
Apologies were received from Drs. F. R. P. Taylor, H. J. Macevoy, E. S. Pasmore,
T. Outterson Wood, D. G. Thomson, A. Bowles, R. H. Cole, Bernard Hart, and
A. N. Boycott.

The asylum and grounds having been visited, the members were entertained to
luncheon. At the termination of the lunch Dr. R. R. Alexander proposed a vote
of thanks to Dr. Baily for his kindness in so hospitably receiving the Division.
The meeting of the Divisional Committee was held at 2.15 p.m., Drs. Dixon, J. G.
Smith, and R. H. Steen being present. The general meeting was held at 2-45 p.m.,
Dr. R. R. Alexander in the chair.

The minutes of the last meeting having been printed in the Journal, were taken
as read and confirmed.

The following members were elected to take office for 1910-1911 :

Hon. Sec. of the Division, Dr. David Hunter; representative members of the
Division on the Council, Drs. David Bower, J. Francis Dixon, Frederick R. P.
Taylor, and David G. Thomson.

Dr. Hunter thanked the Division for the honour they had conferred upon him
in electing him to the office of Divisional Secretary. Dr. Bower, in thanking
the Division for electing him as a representative member on the Council, expressed
the hope that the time would not be far distant when the Chairman of the Parlia¬
mentary Committee would ex officio have a seat on the Council.

Dr. Wolseley-Lewis proposed, and Dr. Edridge Green seconded, a vote of
thanks to Dr. R. H. Steen for his services as Secretary to the Division during the
five years in which he had held the office. This was carried unanimously. Dr.
Steen replied.

The following gentleman was elected an ordinary member of the Association:

James Farquharson Powell, M.R.C.S., L.R.C.P., D.P.H., Medical Officer of
Caterham Asylum.

Drs. Baily, H. E. Haynes, and Donelan were elected as members of the South
Eastern Divisional Committee of Management, which now consists of the
following:

Retire in 1911. Retire in 191a. Retire in 1913.

Dr. Seward. Dr. Pasmore. Dr. Baily.

,, R. H. Cole. „ Greenlees. „ Haynes.

„ J. G. Smith. „ Peachell. „ Donelan.

The invitation of Dr. Stansfield to hold the Autumn Meeting at the London
County Asylum, Bexley, was unanimously accepted with much pleasure. October

5th, 1910, was fixed as the date of this meeting,
was fixed for April 25th, 1911.

The date of the Spring Meeting

Contributions.

Dr. Percy J. Baily read the following paper, entitled “A Brief Historical
Survey of Hanwell Asylum."

The history of this institution carries us back through a period of rather more
than eighty years—that is to say, rather more than the life-time of those of our
race who, by reason of strength, are able to reach the allotted time of three score
years and ten.

But short as this period is historically, 1 think I may say without much fear of
contradiction, that so far as the knowledge and treatment of insanity are concerned,
the foundations of this asylum were laid in the dark ages. There were then but very
few county or other public asylums in this country. Such as there were were
generally small institutions, and in many, if not most of these, the insane were
treated with scant courtesy. In some they were dealt with more like wild beasts
than human beings, and were regarded as worthy neither of pity nor consideration,
and those unfortunate creatures who raised their voices or battled against the

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terrifying- Phantasmagoria, conjured into their field of consciousness by disease,
were subjected to equally terrifying influences which were brought to bear upon
them under the guise of treatment.

It had been my intention originally to place briefly before you to-day an
outline of the chief historical facts connected with this asylum up to the present
time. When, however, I came to consider the subject, I found that the task of
doing so satisfactorily and with any sustained interest was a very difficult one,
chiefly because the events of each successive year were frequently mere repetitions
of those of former periods. Moreover it appears to me that the most interesting
period of the history of this asylum must be its earlier years (what I may call the
Conolly and pre-Conolly days). I propose, therefore, to deal only with this period
to-day.

The first definite step towards the erection of Hanwell was taken in November,
1827, when, under the Act of the 48th Geo. Ill Cap. 96, the Court of Quarter
Sessions of the Peace for the County of Middlesex determined, after a leisurely
deliberation which extended through no less a period than two years, that it was
expedient to erect a lunatic asylum in that county for the reception of insane
persons, and a committee of the justices was then formed, who should be the
visiting committee of the asylum, with Col. Clitherow as chairman.

The first business of the committee was the issuing of advertisements in various
newspapers which invited tenders of land for the site. The conditions were that
the land should be not less than twenty-five acres in extent, it was to be in a healthy
situation, and well supplied with water. Advertisements were also issued inviting
plans and estimates for building the asylum, which were to be received by March
28th, 1828, and premiums of £200, £150, and £100 were offered for three of
the plans presented which should be deemed to be the best by the committee.

Many tenders of land were received, and the committee finally decided upon a
site consisting of forty-four acres near Hanwell Bridge.

The plan which was selected by the committee as being the best of the fifty-four
submitted to them, and the one, therefore, which gained the first premium of £200,
was that of William Alderson. This plan was accepted only in general outline,
and was taken as a guide in the preparation of the final design. The plan as
finally approved by the committee, on January 21st, 1829, was for a building
capable of accommodating 600 patients, and its cost was estimated at .£124,000.
At an adjourned meeting of the Court of Quarter Sessions, however, on May 5th,
1829, the committee were authorised to enter into a contract only at a sum not
exceeding £50,000 for the erection of an asylum for 300 patients. The original
plans were therefore reduced and the estimate cut down, but even then the lowest
tender submitted was £63,200 and this tender was finally accepted. The contract
was signed on August 4th, 1829, and the building was to be completed on or before
January 24th, 183T.

Ever since the first cart-load of bricks was thrown upon the site, building
operations have been going on here, more or less continuously, and there appears
to be no reason to suppose that they are likely to cease in the near future. As
originally designed, however, the buildings were completed early in the year 1831,
and the committee appointed Dr. (afterwards Sir William) and Mrs. Ellis from the
Wakefield Asylum as superintendent and matron. Dr. Ellis’s salary was to be
£500 a year, that of Mrs. Ellis £100 with board, washing, and attendance; Mr.
Quick was appointed as surgeon and apothecary at £70 a year. Dr. Ellis was
authorised to engage the various officers and servants and male and female keepers
in the proportion of one to every twenty-five patients.

The asylum was opened on May 16th, 1831, when forty-two patients were
admitted. By July, 1831, the asylum was ready for the reception of 300 patients
(the number it was originally designed to contain). Then commenced the process
of stretching, for we are told upon carefully examining the establishment it was
found that 200 more patients, making 500 in all, could be accommodated with
great comfort. Much reluctance was shown at this time by the authorities of
many of the parishes in the country to send in their patients, and the committee
consequently decided in the autumn of 1831 to take measures to compel them to do
so. Hence at the end of the first year, although there was accommodation for 500
patients, there were only 254 actually in the house.

In 1832 the committee appointed a consulting physician, Dr. (afterwards Sir

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[July,

Alexander) Morrison, of St. James’s Square, W., and a consulting surgeon,
George Cooper, Esq., of Brentford.

In the autumn of 1832 cholera made its appearance in the asylum, but the out¬
break was not of a very serious nature. Twenty-one patients—all females—were
attacked, of whom eleven died. A second outbreak of the disease occurred in
August, 1834, when the cases were confined to one ward on the male side. There
were four deaths.

It seems extraordinary that these outbreaks of the disease should have proved
so limited and so easily controlled when it is remembered that at this time of the
asylum’s history the sole source of the water supply was the Grand Junction Canal,
which forms the southern boundary of the estate. At first the water was pumped
direct from the canal into the service tanks, but it soon became recognised that
the water was in a very impure state, and in 1833 a large filterer and reservoir
were provided. So early as 1832 attempts were made to improve the water supply
by sinking a three-inch bore-pipe. The boring reached a depth of 300 feet, and
a supply at the rate of twenty-five gallons a minute was obtained, but owing to the
immense quantity of sand which came up with the water the well proved to be
practically useless, and the canal continued to be the main source of supply. In
1841 the canal company notified the committee that the supply of water from
the canal must cease on March 31st, 1842, and the question of the water supply
then reached a crisis. After consulting Mr. Isambard Kingdom Brunei, it was
decided to carry out the suggestion of Mr. Harris, the resident engineer, to sink a
well to the sand. The well was completed in June, 1843, and has since that time
provided an abundant supply of the purest water.

By the end of the year 1835 there were 604 patients in the house. The additional
accommodation for 104 beds had been found by converting a disused kitchen on
the female side of the house into an infirmary, and by utilising the underground
basements below this, and below the western tower, as sleeping spaces.

Owing to the gradual increase in the number of lunatics in the county the
demand for beds became more and more urgent, and in 1837 it was decided to
add 300 beds by building two additional wings.

It was at first suggested that these wings should run out in a northerly direction
from each of the eastern and western towers, but this idea was fortunately dis¬
carded, and the wings were built in an easterly and westerly direction. The pro¬
posal to enlarge the asylum was vigorously opposed by the Vestry of St. George's
West, one member of which was also a member of the Hanwell Committee, tin.
the Very Rev. the Dean of Carlisle.

On April 25th, 1837, this vestry passed a series of resolutions strongly pro¬
testing against the contemplated expenditure of .£20,000 for the extension of the
asylum at Hanwell; one of these resolutions was as follows:

“That the Vestry accept with many thanks the offer of Mr. Galley Knight to
move for a select committee of the House of Commons to inquire into the whole
management of the lunatic asylum at Hanwell, and to bring under their considera¬
tion the apparently incorrect returns made by the order of the House of Commons
by the medical superintendent of that establishment."

The matter did come before the House of Commons, but Mr. Knight's motion
for a select committee was not carried. On June 30th it was resolved by the
Hanwell committee that the consideration of the statements which had been made
by one of the members for the northern division of Nottinghamshire should not be
entered into. In the early part of 1838, in view of the approaching completion of
the east and west wings and consequent increase in the number of patients, the
committee appointed Dr. William Chapman Begley as medical assistant to the
superintendent physician. They also, at this time, decided to make considerable
alterations in the domestic arrangements for the future government of the asylum.
These suggested alterations had as their immediate result the curtailment to a very
considerable degree of the duties and authority of the superintendent, and, together
with the knowledge that certain members of the committee were opposed to him,
were the determining cause of his resignation, which he submitted in a letter
addressed to Col. Clithero on February 5th, 1838; this letter was considered by
the committee on February 15th, when a resolution was passed which was highly
complimentary to Sir William and Lady Ellis, and which was expressive of the
committee’s deep concern that anything should have induced them to contemplate

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resigning. Sir William was earnestly requested to reconsider his decision, and
thus give the committee the satisfaction of opening the additional buildings under
his and Lady Ellis’s superintendence. In consequence of this resolution, Sir
William wrote on February 19th to the chairman withdrawing his resignation.
His letter terminated with the following passage: " We shall be most anxious to
place the whole concern here upon such a plan as we doubt not will be satisfactory
to the committee if they will permit us under their control to pursue the system
and line of conduct which we have hitherto adopted.”

Certain members of the committee lost no time in assuring Sir William Ellis
that the conditions contained in the last paragraph of his letter, and upon which
the withdrawal of his resignation must depend, would not be conceded unani¬
mously by the committee, and on February 21st he wrote a letter to the chairman,
in the course of which he says :

“ We have come to the conclusion that although we have no doubt that the
majority of the committee approve of the plans we have hitherto pursued, as
expressed in the resolution of the 15th inst., and that we should continue them in
opening the new buildings, yet that the hostility of two or three gentlemen of the
committee who disapprove of the system altogether is so great, we could not
reasonably expect anything but contention even during the short time which would
be. required for that purpose. Instead, therefore, of withdrawing my letter of
resignation of the 5th inst., I beg to withdraw the one of the 19th inst. Perceiving
now that no ultimate good can arise from our continuing, we have no spirit to set
about such a task as that of arranging and appropriating the new building for the
reception of patients. I have therefore again to request that the committee will
adopt their own measures and supply our places as early as possible.”

Sir William Ellis’s resignation was accordingly accepted, and the committee
advertised at once for the following officers:

A superintendent at a salary of .£500 a year, with board, lodging, etc., a house
steward at a salary of ^250, with board, lodging, etc., and a matron at a salary of
/200, with board, lodging, etc.

Dr. John Gideon Van Millingen was appointed physician superintendent on
April 5th, 1838, among the fourteen unsuccessful candidates being Dr. John
Conolly.

The period during which Dr. Millingen was responsible for the management of
the asylum was a brief, but stormy one. His authority was not on all occasions
upheld by the committee, and as a result the discipline of the place became very
lax. At the first meeting of the committee after his appointment, he reported the
new matron for countermanding certain orders which he had given to improve the
cleanliness of the female wards. She was merely requested by the committee to
co-operate with the superintendent “in the kindest spirit.” Her subsequent
conduct was such that the committee were compelled to dismiss her on July 16th,
after being in the service three months. At the installation of her successor, Miss
Powell, who proved to be a very capable officer, the committee had all the chief
members of the staff assembled, and in introducing Miss Powell to them, expressed
their anxious hope and expectation that all jealousies and disagreements among
the respective officers of the establishment would from that moment cease.

The house steward, who was appointed at the resignation of Sir William Ellis,
was called upon to resign in November, 1838, in consequence of gross irregularities
in the keeping of the accounts, and at the same time Dr. Millingen was admonished
by the committee to pay greater attention to the rules of the asylum relating to
himself. Serious friction also arose between Dr. Millingen and Dr. Begley, in
consequence of the former bringing certain charges against the latter which he
was unable wholly to substantiate before the committee, but which undoubtedly
had some foundation. In consequence of all these troubles it was resolved on
January 10th, 1839, to appoint a special sub-committee to inquire into the
efficiency of Dr. Millingen as superintendent of this institution. While the report
of this sub-committee was still under discussion Dr. Millingen resigned, and it was
arranged that he should relinquish his office in June, 1839. In March an advertise¬
ment for a successor to Dr. M illingen was inserted in several of the daily newspapers,
and John Conolly, who had been an unsuccessful applicant when Dr. Millingen was
appointed, again presented himself as a candidate for the vacant post, and was on
this occasion selected by the Committee. The appointment was made on May
2nd, 1839, and he commenced his duties on June 1st.

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It is not very easy to obtain anything like an accurate or detailed idea of the
internal arrangement and general condition of the asylum which prevailed at the
time when Conolly commenced his crusade against the employment of mechanical
restraint, the few details which are available being found chiefly in Conolly’s own
writings. In Sir William Ellis's time there were two keepers in each ward. On the
male side one of these was a mechanic, who, immediately after breakfast, left the
ward “ in charge of the other” while he went to his work in one of the shops, or
about various parts of the house as the case might be. The man who was left in
solitary charge of the ward was not allowed to leave it, except on urgent business,
and before doing so he was to be very careful to see that he locked in their rooms,
or securely fastened up any patient who was likely to become dangerous or excited.
The majority of the male keepers were at this time paid .£20 a year, while the
wages of the female keepers varied from eight guineas to £13 a year. The men
had one suit of clothes (not uniform) a year, but the women do not appear to have
had any corresponding privilege, and Conolly notes that in some of the wards the
nurses were worse dressed, and were much more wild in their appearance than the
generality of the patients. Parties of working patients were sent out to work on
the land without any attendant in charge of them and without any sort of super¬
vision. In consequence of this it was only natural that escapes were very common.
There was no night staff. It was customary for the attendants to do night duty in
rotation, and on these occasions they continued on duty for twenty-tour hours
consecutively. This state of things was not remedied until early in the year 1854,
when the commissioners urged the necessity of appointing a special night staff.
The committee then appointed one night attendant for each side of the house.
All the epileptics were every night, when they went to bed, fastened by one wrist to
the bedstead by means of a strap, and it was the duty of the house-surgeon, as the
assistant medical officer was then called, to see that this was done in every case
when he paid his night visit to the wards. All patients who were faulty in their
habits had only loose straw to lie upon ; many of the female patients were clothed
in trousers, and this custom was only abandoned in the year 1854.

The furniture in the wards was all of the heaviest and most clumsy description,
the tables and most of the seats being immovable. There were seventy-five beds
in which two patients slept together, but not very long after Conolly’s appoint¬
ment these were replaced by 150 single beds. The floors were all of brick or
stone, and no sort of floor covering was provided for the patients to tread upon,
there were no open fire-places, and the lavatory accommodation was in all wards
most defective, in some, apparently, altogether wanting.

The plates from which the patients ate their food were of iron, and the forks
were heavy, unsightly, and dangerous.

No infirmaries were provided in the original building, and in November, 1839,
Conolly, speaking of the ward which was then doing service as an infirmary on
the male side, says, “ It is in the part of the building most remote from the kitchen,
the surgery, and the medical officers, and is accessible only by passing through
refractory wards. It has no fire-place or boiler for hot water. It possesses no day-
room. To reach the airing-court the feeble and convalescent patients must descend
three somewhat difficult staircases.” Writing of this period in 1856, Conolly
attributes many of the faults and defects which he found in Hanwell, described by
the committee at the time of his appointment as a noble institution and a model
for all others of a similar kind, to the practice of a too rigid economy which had been
the fatal vice of the older institutions. An inadequate number of attendants,
engaged at low wages and ill qualified for their duties, became among the first
consequences. Disorders innumerable ensued—quarrels and fightings, and in¬
juries and various accidents. Confusion often prevailed everywhere and escapes
were of frequent occurrence. The cleanliness of the patients could not receive
proper attention, their clothing was defective, and their diet too scanty. Deficient
ventilation, which rendered several portions of the building unpleasant by day
and most offensive by night, was the result of inattention which allowed almost
countless panes of window glass to be replaced by squares of tin and iron.
Scarcely any proper arrangements existed for the sick.

Conolly’s advent was almost immediately followed by a marked improvement in
the general discipline and condition of the place. He at once entered heart and
soul into the task which he had set himself of abolishing all forms of mechanical

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restraint in the treatment of the patients, and on June 13th, less than a fortnight
after he assumed the responsibilities of his office, he reported to the committee the
necessity, in his opinion, of engaging two additional keepers of each sex, stating
that some increase was essential as a means of promoting greater order in the
wards and airing courts, as well as among the patients employed out of doors,
and generally the more systematic substitution of moral for physical restraint.

By the end of September he had increased his staff by the addition of nine
attendants—five male and four female.

I must here ask your indulgence to allow me to make a digression in order that
I may recall to your mind certain facts with which you are familiar as to the
origin, as well as the magnitude, of the task which Conolly had undertaken. It is,
to our way of thinking, astonishing that, so recently as seventy years ago, there
should still have been a blind and persistent opposition to the abolition of a
system of the grossest and most barbaric cruelty which had for centuries blotted
the fair name of medicine, in so far as it was concerned in dealing with a certain
class of the insane.

By long-continued usage and custom this system had assumed the stamp of
authority, and was regarded with heartless callousness by those who not only gave
it their assent, but actually regarded its substitution by a more humane system as
chimerical, dangerous and ridiculous. There was little advance in the methods in
vogue during the few decades that immediately preceded Conolly’s work in
Hanwell upon those which had been employed any time during the previous 2500
years. If anything, perhaps, during the late eighteenth century and early
nineteenth century, the callousness and harsh neglect meted out to the insane by
their sane guardians had become greater and more reprehensible than had been
the case in earlier times. But rather over forty years before Conolly’s work there
began to be exceptions. At the Bicetre, Pinel commenced a crusade against these
barbarisms in France in 1792. At about the same time a movement began to be
set on foot in England by William Tuke, which four years later resulted in the
opening of the Retreat at York. Here, without any knowledge of Pinel's work in
France, the same ideas were practised in perhaps a more complete manner. It is
to the Retreat at York that belongs the honour of being the spot in England
where the light was set up, which ultimately shed its beneficent beams first to
Lincoln, then to Hanwell, and so over the whole of this Kingdom, and thence over
Germany, Switzerland and the whole world. But in its early days it was but a
faint glimmer which had a hard struggle for existence, and so we find that even so
late as 1828, when Mr. Gordon’s Bill became law, the conditions under which
many of the insane dragged out their miserable existence were too horrible to
contemplate. During the deliberation of the Middlesex magistracy, which imme¬
diately preceded their determination to erect this asylum, Col. Clitherow and
others made a personal investigation into the conditions under which the insane
paupers of the county were actually existing. It was found that in one private
asylum near London several of the patients were chained to the walls in dirty,
dark, damp and offensive rooms. They were visited by a medical man once a
month, and in the interval they were left to the tender mercies of a brutal keeper,
a part of whose equipment was a long-thonged whip. When night came and put
an end to each dismal day they were chained in their cribs, and throughout the
whole of Sunday (this being a day of rest for the keepers) they had thus to
remain. Their morning toilet, except on Sunday, when there was no toilet,
consisted in their being driven out into a yard, where they were sluiced down in a
tub, often when the ice had formed over the water. Soap was too precious an
article to be wasted on these miserable wrecks of humanity, and one towel a week
was allowed for the use of 170 patients. Seventy out of about 400 patients were
invariably in irons. No wonder that the magistrates of Middlesex deemed it
expedient to erect an asylum for the county.

For many years before he came to Hanwell, Conolly had taken a lively interest
in matters connected with asylums and the management of the insane. His
graduation thesis at Edinburgh in 1821 was on this subject, and he had been
connected with the Warwick Asylum, to which he held the appointment of
" inspecting physician,” both during his residence in Stratford-on-Avon between
1822 and 1827, and again when he removed from London to Warwick in 1830. In
1828 he was appointed professor of medicine in University College, London, and

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while he held that chair he published in 1830 his Inquiry concerning the Indica¬
tion of Insanity, with Suggestions for the better Protection and Care of the Insane,
in which he raised his voice against the abuses which were then being committed.

Eight years after the publication of this book, on June 21st, 1838, Gardiner
Hill, who since 1835 had been house-surgeon at the Lincoln Asylum, delivered
a lecture at the Mechanics Institute, Lincoln, “ On the Management of Lunatic
Asylums.” In this lecture Gardiner Hill showed that Dr. Charlesworth, who,
since the opening of the Lincoln Asylum in 1821, had been its visiting physician,
had for some years been gradually diminishing the amount of mechanical restraint
at the asylum, where in 1829, owing to the fact that a patient had died during the
night in consequence of having been strapped to the bed in a strait waistcoat, a
rule was established that whenever restaint was used during the night an attendant
should be continuously present in the room. It was soon found that the constant
supervision by a suitable attendant of such cases as were formerly supposed to
require restraint, entirely did away with its necessity.

Gardiner Hill's lecture, which was published only a month before his appoint¬
ment here, had a powerful effect upon Conolly, and immediately after his appoint¬
ment he visited Lincoln Asylum, where he was able to see for himself the practical
application of the non-restraint system, and he found no difficulty in enlisting the
sympathy of Mr. Serjeant Adams, one of the members of the Hanwell visiting
committee, who was much interested in the proceedings at Lincoln. On com¬
mencing his official duties here he was very deeply impressed with the sense of his
responsibilities. His anxiety to avoid the abuses which he had so freely condemned
in 1830 was largely mixed with solicitude as to the dangers to be incurred in the
attempt to abolish all restraint in an asylum containing so many patients as did
Hanwell. He felt, however, convinced that what had been done at Lincoln might
also be accomplished at Hanwell, and ten years later, in one of his annual reports
to the Committee of this asylum, he says: "For my own part, in what has been
undertaken, or in what has been accomplished, I trust I have never shown a desire
to over-state it. I have always acknowledged myself indebted to Dr. Charlesworth
and Mr. Hill (of Lincoln), for the original suggestion of managing the insane
without restraint.”

The publication of Gardiner Hill’s lecture in April, 1839, had naturally attracted
considerable attention in the asylum world. His views were almost universally
received unfavourably, generally in a spirit of hostility or ridicule. Hanwell was
no exception to this rule, but the agitation consequent upon the re. awakening of
this question must no doubt have had some effect in causing those who were at
the head of affairs at that time to give some thought to the matter, and, therefore,
in all probability tended to produce some modification, however slight, in the
infliction of restraint here. It is, however, impossible to form any accurate idea
upon this point, for no sort of record was kept as to the number of patients who
were under restraint, or of the kind of restraint used, until such a record was
commenced by Conolly on July 1st, 1839.

The employment of restraint was left entirely to the discretion of the attendants,
who had unlimited licence in the matter. The risk that such licence would be
abused would be great even in our own time, but in the pre-Conolly days must
have been infinitely greater, when attendants as a class were literally, as they
were then called, “ keepers ill-paid, poorly fed, untrained, and grossly ignorant,
and obviously must only very exceptionally have possessed those qualities of soul
which nowadays are recognised as so desirable in them.” Conolly tells us that
closets full of instruments of restraint were at their command, and it was impossible
for the resident physician to know either by day or by night how many patients
were actually in bondage. There is no reason to suppose, however, that this
abuse ever reached the vast proportions in Hanwell which had been the general
rule in the public and private asylums of England previous to the parliamentary
inquiry into the subject in 1814 and 1815. It seems likely that during the troublous
times which followed the resignation of Sir William Ellis the employment of
restraint became more general than had been the case in the earlier days of the
asylum’s history, for Conolly notes the fact that during the single year that Dr.
Millingen held office the number of instruments of restraint had been increased.

The only record of the actual number of patients under restraint on any given
day, previous to July 1st, 1839, is found in September, 1835, while Sir William

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Ellis was absent on leave. Dr. Morrison, who was then doing duty for him,
reported to the committee on the 5th of that month that four men and eight
women were constantly restrained, while fourteen men and five women were
subject to occasional restraint. There were at this time 591 patients in the
asylum.

Sir William Ellis was undoubtedly most anxious to limit the use of these
instruments of torture as much as possible. He fully realised the cruelty which
their employment involved, for he was a man of kindly feeling and benevolent
disposition. In the introduction to his book, published early in the year 1838,
speaking of the treatment of the insane he says: “ The moral treatment is by far
the most difficult part of the subject. In this the most essential ingredient is
constant, never-tiring watchful kindness; there are but few even amongst the
insane who, if a particle of mind be left, are not to be won by affectionate atten¬
tion ; an attempt must be made day by day, and for weeks together, and no dis¬
couragement must be felt even if the end is not accomplished ”; and yet, even he
was firmly convinced that mechanical restraint was essential in the treatment of
many cases. He invented a special kind of canvas sleeves which, while un¬
doubtedly more humane than the iron shackles and leather muffs which were
then in constant use, effectually trussed up the patient so that it became quite
impossible for him to move his arms, and he also dilates upon the advantage of
the “ arm chair.”

But when Conolly came to Hanwell the kindly precept of Sir William Ellis
had already been forgotten, and the harsher methods advocated, or at least defended
by his successor, had become the common practice. It is not, perhaps, surprising,
therefore, that at this time the use of restraint had become much more general,
and to find that it was by no means limited to cases of violent mania. Instruments
of restraint were so abundant in the wards as to amount when collected together
to no less than 600 in number, half of which were leg locks or hand-cuffs, and
these were applied by the attendants for the most trivial reasons. On the female
side of the asylum alone no less than forty patients were constantly secured by
various kinds of hand-cuffs, muffs, or leg locks, or were fastened in coercion chairs.
Hence Conolly found that the medical and other officers of the asylum were not
among the supporters of the new system, but on the contrary were distinctly antago¬
nistic towards it. They had grown accustomed to witness patients, on the slightest
indication of giving trouble, being strapped by the waist to benches or tables, or
manacled by the feet to gratings, or bars, and Conolly, in a special report to the
committee in September, 1840, complains that throughout the whole of his anxious
task he had received no efficient aid from the medical officers, while from the
attendants, who had been accustomed hourly to practise cruelties with impunity, he
met with sullen disobedience or artful deception. He had the constant and zealous
aid of one officer alone—the matron—and he deeply regretted that her industry and
devotion had only exposed her to the insult of the officers most disposed to
embarrass himself in every direction.

On July 1st, 1839, one month after Conolly came to Hanwell, the total number
of patients under restraint was twelve—nine women and three men. This number
rose on the 6th to eighteen—fourteen women and four men—but after this date the
number gradually declined, and never reached double figures after July 1 ith. On
August 12th only two men wete under restraint, and after this date until September
20th no female and never more than one male patient was restrained on any one
day. After September 20th all restraint was definitely and permanently abolished.

It will not be out of place briefly to review for a moment the methods of treat¬
ment which Conolly advocated and adopted.

It is quite clear from his various reports that he was a very great believer in the
efficiency of seclusion, and this was his sheet anchor in his crusade against restraint.
He speaks of it in the highest possible terms of praise, although he acknowledges
that even it may be abused. Leeches and blisters were freely used. When blisters
were applied a kind of waistcoat made of ticken without sleeves, and fastened by
two or three small locks instead of buttons, was put on the patient in order to
prevent him from interfering with the blister. In cases of unmanageable excite¬
ment the head was shaved, and tartarised antimony ointment was applied to the
scalp. In order to prevent increasing the ulceration of the scalp which was thus
produced by interference on the part of the patient, a tickcn cap, the lower part of
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which was made of elastic cloth, was tightly fastened on the patient's head by means
of a smalt lock. The shower bath was in very frequent use, and Conolly remarks
that by this means a paroxysm of excitement very seldom failed to be subdued.
From Conolly’s description of this mode of treatment one is almost disposed to
think that the paroxysm was subdued by the patient being half drowned. We are
told that the bath should be efficient and not liable to interruption.

" It should be suspended when the patient appears to be overcome and instantly
renewed when symptoms of violence recur. A strong shower continued even for
a minute has sometimes considerable effect, and it is never many minutes prolonged
without careful observation of the patient's state. After four or five applications
of this kind the patient becomes entirely subdued.” Conolly naively remarks that
" A bath of this kind appears to produce a moral as well as a physical impression.”
Conolly was not a believer in drugs, and in one of his reports he says, “ The pride
of medical science is disconcerted by the reflection that mere medicine has had but
a small part in the cure of many patients who have left the asylum well.” In his
first report he states that tables were in preparation to show the asserted but
doubtful influence of the moon's changes on some of the phenomena of insanity
and epilepsy. I do not know whether he arrived at any definite conclusion on this
particular subject for I can find no other reference to it in his later reports.

In July, 1840, Conolly reported to the committee that in his opinion the medical
staff might be reduced to one house-surgeon and a dispenser. It was accord¬
ingly arranged that the services of Dr. Button should be dispensed with on January
1st, 1841. This reduction in the staff was resolved upon in spite of the fact that
there were at this time 849 patients in the house. Button had not readily fallen in
with Conolly's ideas, and from certain correspondence which appears in the minutes
of the meetings at this period it is quite evident that the relations which existed
between Conolly and his junior assistant medical officer were not very cordial.
That this fact influenced Conolly cannot, I think, be doubted, for early in September
Dr. Button was appointed superintendent of the Dorset County Asylum, and on
the 29th of that month Conolly, who was then ill, wrote to the chairman that on
reflection he was convinced that the services of an active, efficient, and faithful
medical officer on each side of the house would be required to enable him to
conduct the asylum to the satisfaction of the visiting magistrates. It was then
resolved to advertise for a successor to Dr. Button.

The chief point of interest connected with this incident is that among the
candidates for this vacancy was that very Robert Gardiner Hill, of Lincoln Asylum,
whose lecture on the management of lunatic asylums two and a half years before
had so impressed Conolly. The choice did not, however, fall upon Gardiner Hill.

In 1842 Conolly gave his first clinical lectures. The proposition to make use of
the material here for the purpose of clinical instruction at first met with considerable
opposition from the committee, who were fearful as to the effect the presence in
the wards of even a moderate number of strangers might have upon the patients.
This opposition was overcome on the understanding that the numbers should be
limited, and it was decided that each of the hospitals in London should be invited
to nominate one student. Eleven students attended the first course, and at ks
conclusion they presented a most eulogistic address to Dr. Conolly. One of the
signatories of this address was Richard Quain.

In 1843 the committee adopted a revised set of rules, one of which required that
the resident physician should devote his whole time to the duties of his office and
should not professionally attend any private patient. Conolly at once intimated
to the committee that it was most unlikely that he could comply with the restrictions
included in this rule, and he was to report later on the matter. This he did in
September, when he definitely informed the committee that as far as he was con¬
cerned it was quite impracticable for him to abide by this rule, and he suggested
that he should continue his superintendence as physician but should be non¬
resident.

This suggestion was adopted t>y the committee on the following conditions:
He was to attend at the asylum twice in every week for six hours on each occa¬
sion. He was also to attend the meetings of the committee and to be liable to be
called upon on every occasion of emergency and to watch over the general interests
of the asylum as heretofore. For these services he was to receive a salary of 300
guineas per annum. He soon found, however, that his agreement to spend six hours

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consecutively in the wards on two days a week became a task far too trying and
exacting to be continued, and in 1845 h e wrote to the chairman of the committee
stating that he believed no medical officers in any other institution undertook to
be actively engaged for more than two or three hours in succession, and that the
duties of a medical officer in the wards of an asylum were particularly fatiguing.
It was therefore agreed that his visits should be of four hours’ duration on three
days a week.

In consequence of these arrrangements with Dr. Conolly, the committee, after
much deliberation and discussion, decided to dispense with the services of the
house-steward and to appoint a lay governor. This person was to be the principle
officer of the asylum and was to be responsible for its control and management.
He was to be responsible to the committee for the general conduct and behaviour
of all the officers, ward attendants and servants in the asylum, and was to visit
every ward at least once a day, and should if he so chose accompany the physician
and other officers in their visit to any part of the establishment. He was to have
full and entire authority as to the classification, instruction, and management of
the patients, both male and female. He had other duties assigned to him both
multifarious and impossible. The experiment did not prove to be a successful one.
The gentleman who was appointed was an army officer. He commenced his
duties on March nth, 1844. Early in August of the same year his conduct and
the manner in which he performed his duties formed the subject of inquiry at a
special meeting of the committee, when it was resolved that he should be called
upon to resign, on the understanding that his duties here should cease at the end
of three months. Owing, however, to further indiscretions on the part of the
governor, his services were summarily dispensed with before this period had
expired. The results of this experiment apparently convinced the committee of the
impracticability of making a layman the principal officer of such an institution as
a lunatic asylum, and no suggestion was ever made of appointing another officer
of this kind.

Conolly resigned in June, 1852. The reason he gave for resigning was the
increased demand made upon his time and his attention by his private professional
engagements. It seems likely, however, that his state of health was such as to
have had some influence upon him in coming to this decision. It was arranged that
he should continue to visit the asylum up to Michrelmas, but in July he had to go
away on leave owing to persistent attacks of neuralgic pain which continued to
harass and trouble him, so that on August nth he wrote from Brighton asking to
be relieved immediately from further responsibilities connected with the asylum.
The committee, therefore, continued his leave of absence until Michaelmas.

Subsequently to Conolly’s retirement there were two resident medical super¬
intendents here, one for the male side and one for the female side, a condition of
things which obtained until some two or three years after the Asylums Committee
of the London County Council became responsible for the government of the
asylum.

I have already indicated that the original building was designed to accommodate
only 300 patients. This number of beds was almost immediately increased to 500,
and by gradual expansion and by utilising every possible available space not origi¬
nally intended for that purpose as sleeping accommodation, the number of beds had
been increased to over 900 when Conolly was appointed. In 1841, by converting
the “ back stairs of the western tower into sleeping rooms ” and fitting up the
basements under the centre tower as dormitories, the number of beds was still
further augmented. In 1844 the committee resolved to build an additional asylum
close to the present building. For this purpose a piece of land (that on which the
temporary buildings now stand), was purchased from Earl Jersey in 1845, and
plans were prepared for erecting a building capable of accommodating 1,010 patients.
Fortunately for everyone concerned these plans could not be carried out before the
passing of the Lunacy Act of 1845. The visiting justices of this asylum were not
in favour of this Act and employed every possible means at their command of
opposing it, including the presentation of a petition to the House of Commons.
After the Bill had became law the Commissioners wrote and suggested that they
would appreciate a meeting with the visiting justices, but to this advance the latter
replied that so far as they could see no possible advantage would result from such
a meeting. In accordance with the provisions of the new act the plans were sub-

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mitted to the Metropolitan Commissioners in November, 1S45. They were
entirely disapproved of by the Commissioners, who reported adversely upon them
to Sir Charles Graham, the Home Secretary. He concurred with the conclusions
which the Commissioners arrived at upon the subject. One of the many objections
of the Commissioners was the proposal to erect a building capable of accom¬
modating 1,010 patients at so short a distance as 100 feet only from the present
asylum. The idea was therefore abandoned, and the new asylum was erected at
Colney Hatch. In 1852 the building of the present recreation room, originally
intended and used for a considerable time as a chapel, was commenced, and below
it a ward capable of accommodating fifty patients. These buildings were completed
in 1854. In 1853 a suggestion was made that a third storey should be added to the
building. Owing, however, to the strenuous opposition of the Commissioners, the
suggestion was not immediately carried out, but in 1855 plans for increasing
the accommodation on a still larger scale began to be discussed. These included
the addition of a third storey and many other buildings, the total increase in the
accommodation being estimated at 600 beds These plans were also strongly
opposed by the Commissioners, but the committee appealed directly to the Home
Secretary, and after much controversy the Commissioners withdrew their active
opposition. These additions and alterations were not completed until i860, when
it was found that instead of 600 additional beds it was possible to squeeze in 690.
Thus on December 31st, i860, the total accommodation was 1743 beds. Since
that time there has been a still further expansion, so that now the number of beds
is only about 400 short of 3000. I do not, however, propose to touch upon the
history of the place beyond the period at which we have now arrived. I have
already detained you longer than I had intended, and in concluding my remarks 1
have only to express my grateful thanks to you for having borne with me so long.

The subject which it has been my privilege to speak to you upon is, I am sure,
one of very general interest; my only regret in dealing with it arises from the sense
of my own short-comings, and the conviction that I have been unable to do justice
to it.

In the discussion which followed, Dr. Alexander, speaking as one who knew
the records from which Dr. Baily had obtained the material for his paper, stated
that the preparation of this paper must have entailed very considerable time and
trouble, and he had nothing but praise for the judicial selection displayed by Dr.
Baily. He hoped that the Hanwell Committee might be induced to print it, as
it would form a valuable summary of the archives of the asylum.

Dr. Bower, commenting on the appointment of visiting physicians to the
asylum in the time of Conolly, expressed the hope that in years to come asylum
officers would be enabled to keep more in touch with their medical brethren in the
outside world. He believed that consultants should be appointed in connection
with every asylum, so that in conference with the medical staff the patients might
have the best treatment for every disorder. The converse was also in his opinion
true, namely, that asylum medical officers should be permitted to give the neigh¬
bouring medical men the advantage of their special knowledge. This would be
beneficial not only to the medical men but also to the patients under their care.
He wished to thank Dr. Baily for the very interesting paper they had heard. Dr.
Greenlees also spoke, and Dr. Baily briefly replied.

Dr. H. Devine read the following paper, entitled, " An Account of the Clinic
for Psychiatry at Munich.”

In view of the fact that there is no similar institution in this country, it was
thought that some account of the clinic for mental diseases, under the direction of
Prof. Kraepelin, might be of interest.

A brief description of the institution will first be outlined, followed by an
account of the post-graduate course which is given every year and extends over a
period of three weeks.

The institution, which was opened on November 7th, 1904, occupies a site of
two and a-half acres, presented to the university by the city of Munich. It is
situated in a central position, in close proximity to various other clinics associated

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with the university. The building, which is self-contained and presents an im¬
posing appearance, consists of three sections—the out-patient department, the
reception rooms and hospital and the laboratories for scientific research.

The central part of the ground floor is occupied by the out-patient department,
consisting of examination room, bath-room for treatment and waiting room. On
each side are four rooms for private patients, the quarters for the staff and the
kitchen, stores and laundry.

On the first floor are the lecture room, receiving room for new cases, wards,
laboratories and library.

On the second floor are more wards, with day-rooms, and on the third floor
pathological, chemical and psychological laboratories. There are two gardens in
which the convalescent patients are enabled to take exercise.

Everything possible that can be done for the comfort and efficient treatment of
the patients on hospital lines appears to have been considered. The wards are
bright and attractive in appearance, none of them accommodating more than ten
patients. The various appointments are ingenious and elaborate. The telephones,
water-valves and an arrangement for heating milk during the night are enclosed
in locked-up boxes. A red electric lamp indicates a telephone call instead of the
more usual disturbing bell. Heat is supplied by hot air from radiators and venti¬
lation by flues in the walls. In order to secure efficient observation, lavatory
conveniences are placed in each ward enclosed by portable screens. There is also
a cupboard containing a glass, tooth-brush and soap for each patient. The floors
are covered with a plain linoleum, which adds to the general appearance of comfort
in the wards.

As regards the treatment, the fundamental principle is rest in bed combined
with hydrotherapy. Bath-rooms, each containing four baths, are placed in close
proximity to the wards, and seeing that many of the patients spend a large pro¬
portion of their time in them they are made as bright and attractive as possible.

Each bath has an automatic arrangement which prevents the water from rising
in any circumstances above 6o° C., and when it rises to 40° C. the fact is indicated
by an electric lamp attached. While in the bath the patient lies on a meshed
sheet, which is said to prevent any possible soreness arising.

The various means of treatment by electricity are fitted up in the out-patient
department.

An important and noticeable feature of the clinic is the absence of single or
padded rooms. All the patients are under continual observation, this obvious
advantage being made possible in several ways. In the first place the small size
of the dormitories affords every opportunity for individual supervision. Then
there is the continuous bath treatment, which has great influence in quieting the
restless and noisy cases. This largely obviates the use of sedatives, and these are
not extensively employed. The most usual one is hyoscine, either alone or in
combination with the warm bath.

Lastly, the use of cot-beds with padded sides would seem to be of considerable
utility. Particularly are such beds advantageous in the case of restless seniles and
general paralytics. These cases are always more or less a source of anxiety owing
to their liability to injury, and for that reason frequently need the protection
afforded by a padded room. With beds of this kind, however, it would appear
that such patients can be quite as efficiently protected, with the additional advantage
of being under the observation of a nurse the whole time.

On this question Kraepelin writes as follows (1): “ Now if we wish to be able
to give a complete account of the condition of all our patients at every moment,
so must we before all abandon a method of treatment that until recently played a
great rdle in asylums, and in consequence tended to be considered their distinctive
peculiarity, via., isolation.

“ If we confine a patient in a padded room, we have certainly shut him off from
the ward, but we no longer know what his real condition is, though we listen to
his cries or look at him through a peep-hole. One can no longer speak of the true
nursing of the patient. The disadvantages of isolation, of which one need only
mention the uncleanliness, the destructiveness and violence, are so obvious that no
one will return to it who has once known the blessings of its removal. Obviously
if we abandon the locking up of excited patients, we must employ other methods
of treatment. If we desist from sedatives, which we only regard as stop-gaps and

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occasional aids, we have a procedure at our disposal that, in spite of its surprising
simplicity and obviousness, has only been used to any extent in the treatment
during the last twenty years, vie., rest in bed."

In considering this question one must remember that here patients are being
treated under ideal conditions, almost regardless of expense and number of staff,
such conditions being hardly possible in their entirety in the ordinary county
asylum. It represents, however, a line of treatment which can be, and is, largely
carried out in this country. With plenty of fresh air, systematic baths and rest in
bed, it is surprisising how little necessity there is for isolation in side-rooms, and
in those cases that would seem better apart from the distracting stimuli of a general
ward, the use of portable screens affords all that is necessary for isolating the
patient.

The laboratories afford every opportunity for scientific research on both the
material and psychic sides of mental disorder. There is a well-equipped patho¬
logical laboratory, under the direction of Dr. Alzheimer, and seven rooms are
devoted to experimental investigations in normal and abnormal psychology.
They contain apparatus for the measurement of mental work, fatigue, association
experiments, and for the study of the influence of mental processes on the pupils,
heart, respiration and blood-pressure. There is a “silent room ” with padded
doors, and an arrangement for darkening, in order to shut out all sense stimuli; a
“ sleep-room" is also fitted up for the measurement of the depth of sleep and the
study of the questions associated with the physiology, pathology and hygiene of
the subject.

There is in addition to the above a chemical laboratory, in which investigations
are being carried on in regard to the metabolic changes occurring in insanity.

Brief mention must be made of the lecture room, which is elaborately equipped
for purposes of demonstration. It accommodates 120 students, and has excellent
arrangements for lantern illustrations and an installation for continuous photo¬
graphs. The room can be automatically darkened in a few moments, this being
an obvious advantage, as most of the lectures are illustrated with photographic
and other slides.

The medical staff of the clinic is made up of the following: The Director; one
Oberarzt (principal assistant); four assistants; three volontaires; three clinical
assistants; four scientific assistants. Seeing that there are only 120 beds in the
hospital, it is evident that this staff permits of a very thorough study of the cases.
The above list does not include the various lecturers and out-patient physicians.

The nursing staff consists of twenty-five sisters (nuns), ten nurses, and eighteen
male attendants, the sisters supervising the nursing on both the male and female
sides of the hospital. Each group of nurses takes night duty for two weeks at a
time, with complete rest during the day.

The admission rate to the hospital is high, being from 1500 to 2000 per annum.
The patients may be brought by the police or by their friends, and no certificate
is required for admission. A large number of cases are therefore seen in the
clinic which are not usually sent to the ordinary asylum. Thus a number of cases
of alcoholic intoxication and delirium are brought in by the authorities, as also
other toxic conditions, ether, and the like.

About 500 cases are transferred annually to the State asylum. The patients
may discharge themselves or be taken out by their friends, unless considered
unfit. About an average of fifty cases per week are treated in the out-patient
department.

As has already been mentioned, the site of the hospital was provided by the
City, and the cost of building and equipment was provided by the State, amounting
altogether to ^78,500. The expenditure is maintained partly by payments from
patients and partly by grants from the State. The post-graduate course extended
from October 25th to November 13th. It was attended by about sixty alienists
from various countries. The course is most comprehensive, as will be seen from
the following brief account.

Naturally especial interest is attached to the clinical demonstrations by Prof.
Kraepelin. Some of these were the ordinary demonstrations for the students and
others more advanced, especially designed for the post-graduate course. The
former enabled one to obtain some knowledge of the methods employed in the
teaching of psychiatry in Germany. In these classes two students are selected in

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turn to examine each case, or else to state what they have observed after the
essential features have been demonstrated by the lecturer from interrogation of
the patient. In this way the method of examining a mental case and the signifi¬
cance to be attached to the various symptoms is practically demonstrated.

The cases discussed in the post-graduate class were either rarer types or those
presenting some difficulty in diagnosis. It is obviously impossible to give any
account of these in a brief communication, but one may perhaps mention an
instructive series of cases diagnosed as manic-depressive insanity, illustrating the
varied clinical picture which this psychosis may present. As some of them had
been under observation for many years at one time and another the course of the
disorder was admirably demonstrated. As might be expected, in the Kraepelin
school the question of diagnosis receives much attention.

In addition to these demonstrations, Prof. Kraepelin gave a series of lectures
on experimental methods in psychiatry—the measurement of the psycho-physical
effects of drugs on fatigue, memory tests, etc.

Dr. Isserlin devoted six hours to the question of psycho-diagnosis and psycho¬
therapy. It included practical demonstrations of hypnosis and a full discussion
of Freud’s psychology and principles of psycho-analysis.

Dr. Rudin gave a series of most useful demonstrations on mental cases of
forensic importance. The patients he brought forward included instances of
misdemeanour in an epileptic state, murder by a paranoic, law-suit by a querulant,
and homo-sexuality in old age. In addition, he gave six lectures on 11 The Causes
and Problem of Degeneration.”

Prof. Liepmann came from Berlin and gave a number of lectures on aphasia,
apraxia and agnosia. They were illustrated by numerous charts, specimens
and lantern-slides, as well as several excellent cases.

The lectures on the pathological anatomy and histology of the brain in insanity
constituted one of the most noteworthy features of the course. These were given
by Dr. Alzheimer, who covered the whole ground of the subject very fully. Each
lecture was abundantly illustrated by means of the projection apparatus, with
specimens and microscopic slides.

Dr. Plaut gave a course of lectures on sero- and cyto-diagnosis, dealing both
with the theoretical and practical sides of the subject. He devoted his attention
largely to the Wassermann reaction, and gave a practical demonstration of the
method of performing lumbar-puncture.

Dr. Weiler, lecturing on clinical psychiatry, exhibited apparatus and instru¬
ments for testing reflexes, muscular power, tremors, and the measurement of
pupils and blood-pressure.

Prof. Brodmann gave several lectures on his researches in the topographical
anatomy of the brain, all excellently illustrated by the projection lantern.

Clinical demonstrations on neurological cases were given by Dr. Kattwinkel at
the medicine clinic.

In addition to these lectures, a visit was paid to the Bavarian State Asylum at
Eglfing. This institution accommodates 1,100, patients, and is built entirely on
the villa system.

The last day of the course was more in the nature of a social event, being
devoted to a visit to the charmingly situated asylum at Gabersee, some distance
out of Munich.

Unfortunately this imperfect account gives but an inadequate idea of the clinic,
which must be visited in order to obtain an actual appreciation of its various
advantages. One cannot fail to be struck by the extreme thoroughness of all the
work which is being carried on in the institution. Every effort appears to be
made to investigate thoroughly the many obscure problems of insanity. Whether
it be the clinical, pathological, psychological, or sociological point of view which
is under investigation, the work is uniformly of high standard and the product of
patient research. While, however, the purely scientific side is so highly developed,
it is not done at the expense of the comfort and individual care of the patients,
who have the benefit of every humane and enlightened form of treatment.

In concluding the paper, one may perhaps be permitted to give expression to a
few reflections which naturally arise out of a visit to this famous clinic.

It is impossible not to be impressed with the somewhat anomalous fact that
Munich, a relatively small town, possesses such excellent facilities for the study

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of mental diseases, while London, the largest city in the world, has no institution
of a similar character. Though one is able to recognise, without being accused of
undue egotism, that the asylums in Great Britain are in general second to none
both in comfort and in methods of administration, and while one also recognises
that this country has always taken a foremost place in furthering the humane
treatment of the alienated members of the community, it is impossible to shut
one's eyes to the fact that the necessity for organised research in mental diseases
is not at present sufficiently recognised, and that in this particular respect this
country is far behind Germany, and, indeed, other countries, such as America. In
enumerating the advantages of such a central institution, with a staff of experts
in each branch of this department of medicine, a staff freed from administrative
details, the possibilities it gives for post-graduate teaching and the scientific
training of medical officers take a prominent place. In this way the fact will be
accentuated that the administrative point of view, however important, is not the
only one, and that the problems associated with mental disorder are such as merit
and repay investigation.

In the next place it gives an opportunity for the study of the earlier phases of
insanity, and that group of cases coming under the head of psycho-neuroses, hysteria,
psychasthenia, etc. Since it is in such disorders that one is enabled to obtain the
most insight into mental diseases generally, the necessity for their investigation is
of paramount importance. Since, also, such cases are rarely seen in an asylum,
and only isolated clinics for purely mental disorders exist in the general hospitals
of this country, and then only in the out-patient department, it has resulted that
comparatively little attention has been paid to these borderland cases. That those
out-patient clinics which do exist at the present time are of considerable value is
beyond question, and their further development is to be desired. They do not,
however, satisfy all the requirements of cases of this type. While on the one
hand it is highly undesirable that they should be sent to the county asylums, on
the other it is necessary to be in a position to give them the facilities for indoor
hospital treatment, both from the point of view of the benefit to the patient, and
also from the opportunity which it affords for a more thorough investigation than
is possible in a brief visit to the hospital once or twice a week. At present there
are practically no facilities of this kind for patients of the class in question.

Lastly, but one would venture to say not least in importance, is the educative
value such a clinic would have on the general public. To have easy access to an
institution, carried on entirely on the lines of a general hospital, would without
doubt do much towards dissipating any erroneous ideas which may still exist as to
the methods of dealing with the insane. The patients at Munich are largely
composed of those who come in and go out of the hospital for short periods. It
would seem that the existence of such an institution where those who suffer from
mental troubles may go to seek relief, just as those who are afflicted with bodily
disease are enabled to do now, could not fail to be of the utmost benefit, both from
an educational and social point of view.

(1) Kraepelin .—Die Konigliche Psychiatrische Klinike in Munchen, 1905.

Drs. Stansfield and Steen criticised the paper, and Dr. Devine replied.

Dr. J. G. Porter Phillips read a paper upon the "Treatment of Melancholia
by the Lactic Acid Bacillus" (see p. 422).

In the discussion which followed, Dr. Baily read the following communication
from Dr. Robert Jones, who was unavoidably unable to be present:

“ I have tried the 1 sour milk ’ treatment at Claybury in four males and four
females. The cases were rather especially selected. The males were—one case of
insanity with epilepsy, the others of melancholia. The urine in the male cases was
examined, and in one only was there slight indican. Their fseces were examined
by the pathologist before any of them went under treatment and their weights
taken. Two men gained and two lost weight. The duration of the treatment was
nearly three months, i.e., February 7th to April 20th, but in one of the men I had
to discontinue treatment after two weeks, as it was refused. One of the men was
kept in bed for the first four weeks, and this case became more talkative about his
hallucinations towards the end of treatment. One case has shown improvement,

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but only after the treatment by sour milk was stopped, and no mental improve¬
ment took place in the other three. The fits of the epileptic continued to be of
the same average in severity and number (about ioo fits per month). The milk
was especially prepared in the laboratory under Dr. Mott from strains of the
Bulgarian bacillus obtained—I think from the Lister Institute.

“ History of the female patients .—Three cases were those of young girls, aet. 19
to 22, suffering from adolescent melancholia of the variety described as dementia
prsecox. One was in bed all the time of treatment owing to symptoms of
pulmonary tuberculosis ; another became noisy and excited a few days after treat¬
ment commenced. In none of the three was there any mental improvement.
The fourth case, set. 20 (adolescent insanity of the maniacal form), remained of the
same weight at the end as at the commencement of treatment. At the commence¬
ment urine markedly phosphatic, no phosphates at the end. In this case there
has been considerable mental improvement, which is believed to be due to ‘ Swedish
drill ’ and ‘skipping-rope ’ exercise as much as to the milk treatment.

“The method of administration in all cases was the addition of one ounce of
‘soured milk’ to a pint of fresh milk, as otherwise all would refuse it, and two
pints a day were given, at 11 a.m. and 7 p.m. There never was any vomiting, but
constipation attended the treatment. No diarrhoea occurred, but in two cases it is
noteworthy that a scarlet rash—something midway between that of measles and
that of scarlet fever—appeared in one, with hyperpyrexia lasting a week. This
rash resembled that in septic intoxication, but it is not possible to connect it
definitely with the sour milk treatment, although they may be related as cause
and effect.

“The whole of this treatment, in my opinion, requires that a careful bacterio¬
logical examination of the faces be made before treatment to note the strepto¬
cocci, staphylococci, bacilli and bacteria, and these notes would have to be
compared with a full examination after the treatment in order to show how
completely the intestinal flora had been modified by the Bulgarian bacillus, which
is supposed to “ oust ” the others and to appear itself in the faces. I would not
consider that conclusions could be reliable unless and until this had been done.
Needless to say, I have given up this method of treatment: the results were not
encouraging, and, as already stated, the stuff is anything but agreeable to look at
or to taste.

“ I wish to record my indebtedness to my colleagues, Drs. C. T. Ewart, W. S.
Hughes, G. H. Harper-Smith, and F. Paine, for their notes and interest."

Dr. Dixon stated that he had treated several cases with milk containing the
lactic acid bacillus, and mentioned a case of hypochondriacal melancholia in a
woman, in which to his mind the results of the treatment had been strikingly
successful.

Dr. Greenless also spoke.

Dr. Phillips, in his reply, stated that the unsatisfactory results obtained at
Claybury might be owing in some measure to the unsatisfactory type of case
which had been chosen for treatment.

The members dined together after the meeting at the Cafe Monico, Piccadilly
Circus, W.

SOUTH-WESTERN DIVISION.

The Spring Meeting of this Division was held, by kind invitation of Dr.
Norman Lavers, at Bailbrook House, Bath, on Friday, April 29th, 1910.

The following members were present: Drs. Aldridge, Bazalgette, Blachford,
Bullen, Rough, Lavers, MacBryan, MacDonald, Marnan, Morton, Mules, Nelis,
Pope, and the Hon. Div. Sec.

There was also one visitor.

Dr. MacDonald having been voted to the Chair, the minutes of the last meeting
were read and signed.

Dr. Aveline was re-appointed Hon. Divisional Secretary.

Drs. Glendinning and Lavers were elected to fill vacancies on the Committee of
Management.

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The date of the Autumn Meeting was fixed for Friday, October 28th, 1910, the
selection of a place to be left to the Secretary.

The date of the Spring Meeting was fixed for Friday, April 28th, 1911.

The Chairman alluded in feeling terms to the loss the Association had sustained
by the death of Dr. Manning, of Laverstock House, Salisbury, and the Secretary
was requested to convey to Mrs. Manning the sympathy and condolence of the
members.

Several letters of regret for non-attendance were read.

Dr. Norman Lavers contributed “A Clinical Note” (see p. 499) dealing with
a case in which, with vague organic sepsis, was connected a mass of hypochon¬
driacal symptoms.

Treatment by methods of suggestion had met with some success.

In the discussion which followed some attempt was made to estimate the value
of the organic changes, and the Chairman was disposed to regard these latter
manifestations as also of a functional nature (and so rendering prognosis more
hopeful).

Dr. Blachford then read a paper on "The Function of the Optic Thalamus
and the Corpus Striatum ” (see p. 452), in which he proceeded to give his reasons
from developmental, anatomical and pathological points of view, for regarding
these ganglia, more especially the former, as important centres of Association.

The proceedings then terminated with a hearty vote of thanks to Dr. Norman
Lavers for his hospitality, and to Dr. MacDonald for presiding.

A number of the members subsequently dined together at Fortt’s Restaurant,
Bath.

NORTHERN AND MIDLAND DIVISION.

The Spring Meeting of this Division was held, at the kind invitation of Dr.
Street, at Haydock Lodge, Newton-le-Willows, Lancashire, on Tuesday, April
19th, 1910. Dr. Street presided.

The following thirteen members were present: Drs. D. Blair, H. R. Cross,
A. K. Douglas, E. Gane, C. K. Hitchcock, H. T. Mackenzie, G. E. Mould, P. G.
Mould, N. Raw, C. M. Smith, C. T. Street, G. S. Williamson, and T. S. Adair.

There were also present as visitors—Drs. T. R. Bradshaw, A. Butler, A. G.
Gullan, A. Hall, D. Harrison, C. T. MacAIister, and N. P. Marsh.

Apologies were received from Drs. W. Bevan Lewis (the President), Middlemass,
Powell, Stewart and others.

The minutes of the last meeting were read and confirmed.

A ballot was taken for William Henry Coupland, L.R.C.S.Edin., L.R.C.P.Edin.,
Senior Assistant Medical Officer, Royal Albert Asylum, Lancaster. Proposed by
Drs. Douglas, Blair and Adair as an ordinary member of the Association, he
was unanimously elected.

Dr. T. S. Adair was re-elected Secretary to the Division for the ensuing twelve
months on the proposal of Dr. Hitchcock, seconded by Dr. Nathan Raw.

Dr. G. E. Mould was re-elected, and Drs. Middlemass and Mackenzie were
elected representative members of Council for the Division. Proposed by Dr.
Hitchcock and seconded by Dr. Nathan Raw.

The kind invitations of Dr. Hopkins to hold the Autumn Meeting at the York
City Asylum, Fulford, on Thursday, October 20th, 1910, and of Dr. Powell to hold
the next Spring Meeting at the Nottingham City Asylum, on Thursday, April 27th,
1911, were accepted, and the Secretary was instructed to write and thank them.
The Secretary was further instructed to ask Dr. Hopkins if Wednesday, October
12th or 19th, would be suitable for the meeting there, instead of Thursday.

Contributions.

Dr. Gane read his paper: "Notes on the Treatment of General Paralysis by
Means of Serum.” He pointed out how the treatment by specific serum had been
brought prominently forward by Dr. Ford Robertson, whose investigations led
him to believe that the disease is caused by a micro-organism allied to the

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diphtheria bacillus. Dr. Gane now wished to bring forward his experience of
cases he had treated with the diphtheria antitoxin. The advantage of the serum
is that it is standardised and the strengths are definitely graduated. The number
of cases in which he tried the serum were six, all of which were general paralytics.
The first four cases were disappointing, and the fifth could only have been changed
by a miracle. In the sixth case after treatment the grandiose ideas and delusions
left, and mentally the patient showed improvement. He believed that the
temperature reaction, temporary excitement and alteration or improvement in the
mental symptoms were probably due to some absorptive process set up by the
serum and not to any specific action.

In the cases mentioned the disease was so far advanced, the probable permanent
destruction of nerve-tissue so considerable, that little more than arrest of the
process could be expected from the treatment and a transient change for the
better.

The paper elicited an interesting discussion, in which a number of the visitors
present took part. An interesting point brought out was the question of the
diagnostic value of the serum in the early stages of general paralysis.

Dr. A. J. Hall, of Sheffield, read a paper on " Insanity following Carbon Mon¬
oxide Poisining,” quoting two cases occurring in the same house and under similar
conditions.

The first was a woman, aet. 33, who was found unconscious in the bath-room
soon after going for a hot bath. She showed most of the signs of CO poisoning,
but there was no smell of gas and the " geyser ” was turned off. By next day she
had completely recovered.

The other case was that of her fiance who had been staying a week end in the
house and went to have a hot bath prior to going away on the Monday morning.
On bursting open the door he was found unconscious, the room full of gas, the
geyser full on, but with the light out. There was no doubt as to the cause, and the
symptoms were typical; but instead of complete recovery the patient was dazed
and confused, had loss of memory, and incontinence of urine and faces. This
condition continued practically unchanged up to the day of his death, which took
place seventeen days after the poisoning.

Dr. Hall then discussed the question whether the mental symptoms were entirely
due to the poison, or was the case one of suicide, there being some prior mental
derangement.

The opinion of a professor of jurisprudence was quoted : “ Whenever an obscure
death occurs in a patient about to be married it is suicide."

Remarks on the paper were made by Dr. G. E. Mould, Dr. Cross, who described
a case he had had under treatment, and others.

Dr. Street opened a discussion on the question : “ Are we doing as much in
the form of treatment of mental disorder as we might do ” ? He said that the two
points which prompted him to ask the question were : First, the general idea that
nothing is done in the way of treatment in asylums ; and second, that the recovery-
rate does not increase. Though much has been written in the way of treatment of
the insane, yet treatment does not appear to have yielded many results: the recovery-
rate has not increased during the past thirty years. He advocated a higher form
of moral treatment than the usual occupation, recreation and amusement; a more
intimate knowledge of the mental condition of every patient, and particularly a
more frank and open method of dealing with it. He believed in discussing a
patient’s mental symptoms freely with him, whether they were delusions or
suicidal inclinations, and had found this method to yield good results, especially in
cases of melancholia and alcoholism.

Several members took part in the discussion afterwards.

Dr. J. R. Gilmour was unable to be present to give his paper.

SCOTTISH DIVISION.

A Meeting of the Scottish Division of the Medico-Psychological Association
of Great Britain and Ireland was held at the Glasgow District Hospital for Mental
Diseases, Gartloch, on Friday, March 18th, 1910.

The following members were present: Drs. Clouston, Baugh, Carre, Chislett,

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Havelock, Hotchkis, Carlyle Johnstone, Keay, Kerr, Marshall, Meek, Middlemiss,
G. D. MaeRac, Neill, Parker, Richard, Shaw, Skeen, Urquhart, Wallace, Wilson
and Marr, Divisional Secretary.

There were also present as guests : Stephen J. Henry, Esq., J.P., Chairman of
the Glasgow District Lunacy Board; George Ogilvie, Esq., Convener of the
Gartloch Hospital Committee; and James R. Motion, Esq., Clerk to the Glasgow
District Lunacy Board.

Dr. Clouston occupied the chair.

The minutes of the last Meeting were read and approved of, and the Chairman
was authorised to sign them.

Letters of apology were submitted from Drs. Yellowlees, G. M. Robertson,
Alexander, Easterbrook, Maclachlan and T. C. Mackenzie.

A letter from Dr. Turnbull, thanking the members for their kind expression of
sympathy with him in his illness, and regretting that he was still unable to attend
the meetings, was read.

The Secretary was again instructed to communicate with Dr. Turnbull, and
express the regret of the Division at his continued illness.

Appropriate reference was made by the Chairman to the death, since the last
meeting, of Dr. James Rutherford,a distinguished alienist, and Physician Superin¬
tendent of the Crichton Institution for twenty-five years. Dr. Rutherford had
been connected with the Association since its inception. It was unanimously
resolved—“That it be recorded in the minutes that the members of the Scottish
Division of the Medico-Psychological Association desire to express their deep
regret at the loss of Dr. Rutherford, and their sympathy with the members of his
family in their bereavement.” The Secretary was instructed to transmit an
excerpt of the minutes to Mrs. Rutherford.

The following were admitted to membership of the Association : C. Lawson
Kerr, M.B., Ch.B.Glasg., Assistant Medical Officer, Argyll and Bute Asylum,
Lochgilphead (proposed by Drs. C. J. Shaw, Hamilton C. Marr, and W. A.
Parker); Donald Ross, M.B., Ch.B.Edin., Assistant Medical Officer, Roxburgh
District Asylum, Melrose (proposed by Drs. J. Carlyle Johnstone, T. J. Clouston,
and Hamilton C. Marr); Theodore Grant Gray, M.B., Ch.B.Aberd., Assistant
Medical Officer, Kingseat Asylum, Aberdeen (proposed by Drs. H. de Maine
Alexander, William Reid, and Arthur Kellas); James H. C. Orr, M.B., Ch.B.
Edin., Assistant Medical Officer, Midlothian and Peebles District Asylum,
Rosslynlee (proposed by Drs. R. B. Mitchell, Hamilton C. Marr, and Charles
G. A. Chislett).

Drs. Hotchkis and R. B. Campbell were unanimously recommended as Repre¬
sentative Members of Council, and Dr. Hamilton C. Marr as Divisional Secretary.

The Asylum Officers’ Superannuation Act and the circular issued by the
General Board of Lunacy in connection therewith were discussed, and it was
agreed that a meeting of representatives of the District Lunacy Boards and
Medical Superintendents of the District Asylums in Scotland should be convened
to arrange, if possible, for uniformity in the valuation of emoluments, etc., of the
several asylums concerned.

Dr. Parker gave a description of Gartloch Mental Hospital, pointing out its
chief features. Special attention has long been paid to open-air treatment in the
Institution. It was one of the first where this method of treatment was introduced.
Dr. Parker thereafter conducted the members through the several wards, and the
sanatorium for the treatment of the consumptive insane. The members were
much impressed by all that they saw and the interesting explanations of Dr.
Parker.

Dr. Baugh, Senior Assistant Medical Officer, gave an account of the results of
treatment of several cases of chronic epilepsy by purin-free diet.

Dr. Middlemiss, Assistant Medical Officer, showed a case of hysteria in a lad
(vide papers by Drs. Baugh and Middlemiss, pp. 470, 502).

The members were entertained to luncheon by the Glasgow Lunacy District
Board.

Dr. and Mrs. Parker were thanked for their hospitality, the Glasgow District
Board for their kindness, and Dr. Clouston for his conduct in the chair.

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IRISH DIVISION.

The Spring Meeting of the Division was held at Hampstead, Glasnevin, and
Highfield, Drumcondra, on Thursday, April 14th, 1910, by the kind invitation of
the Drs. Eustace, who showed the members over Hampstead, and afterwards
entertained them at luncheon.

The subsequent meeting was held at Highfield, Dr. H. M. Eustace being voted
to the chair, and there were also present: Drs. W. N. Eustace, T. Drapes, H. R. C.
Rutherford, J. Mills, James I. Fitzgerald, J. A. Oakshott, R. R. Leeper, and W. R.
Dawson (Hon. Sec.). Apologies were received from Drs. W. Graham, C. E.
Hetherington, F. C. Ellison, and F. E. Rainsford.

The minutes of the previous meeting were read, confirmed, and signed, and the
Hon. Secretary reported on several matters arising out of them, including the
position of the question regarding the payment of the Divisional Secretaries’
expenses.

A resolution was thereupon proposed by Dr. Drapes, seconded by Dr. Oak¬
shott, and carried unanimously, urging upon the Council the desirability of
coming to a decision on the last-mentioned point without further delay.

Dr. W. R. Dawson was elected Divisional Secretary, and Drs. W. Graham
and James J. Fitzgerald representative members of Council for the ensuing year.
Dr. R. R. Leeper was nominated as examiner.

The following dates for the meetings of the Irish Division during the ensuing
session were agreed on, vis., Saturday, November 5th, 1910, and Thursday,
April 27th, 1911. It was decided not to hold a summer meeting in I9ii,as it
was understood that the Annual General Meeting would take place in Ireland.

Two invitations (from Drs. W. Graham and Hetherington) having been received
for the summer meeting on July 7th, 1910, it was unanimously decided to accept
with thanks the former, which had the priority in time.

Dr. Rutherford then read a communication, entitled " The Results of a few
Leucocyte Counts in Mental Cases,” in which he gave his findings in six maniacal
and seven depressed cases. The observations were confirmatory of those of other
workers, and seemed to indicate that there is a greater tendency to leucocytosis
in mania than in melancholia. The paper was discussed by the Chairman and
Drs. Dawson, Mills, Drapes, and Leeper, and Dr. Rutherford replied.

The Hon. Secretary read for Dr. Ellison (who was absent) " Notes on Three
Clinical Cases ” : that of a man who made a practice of kissing the gluteal region
of all whom he could reach, having been told by voices that in this way he would
cure his wife of piles; that of a man in whose rectum a large number of objects
were found which he had swallowed ; and a case where, after death, a briar pipe
was found in the ileum. Drs. Fitzgerald, Mills, Oakshott, Dawson, Drapes,
and the Chairman spoke.

Dr. Drapes then took the chair, and Dr. H. M. Eustace read the following
paper:

A Note on the Prophylaxis of Insanity.

In the first place allow me to express the pleasure we feel in your presence here
to-day, and to thank you for your attendance at this Spring Meeting of the Irish
Division of the Medico-Psychological Association.

I wish to bring under your notice some brief and imperfect remarks on the
possibility of more work being accomplished as regards the prophylaxis of
insanity.

Wright says, in the preface to some of his writings, that “ the physician of the
future will be an immunist.” Knowing the progress that bacteriology and its
applied science, vis., vaccine-therapy, have made in recent years, he is probably
correct, and this transformation may take place in our generation.

In the meantime it is well to encourage all branches of preventive medicine, and
to attempt to blot out of existence some of the awful diseases which ravage
mankind.

Simple measures often succeed where costly ones fail, e.g., Haffkine’s plague
antitoxin has done little in India to prevent the spreading of plague, as compared
with the highly efficient work performed by domestic cats, introduced into Indian
villages, as the natives had noted that where there were no rats there was no plague.

We may be encouraged by our success in dealing with such dirt diseases as

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typhus fever and puerperal fever, and the conquest of yellow fever, malaria, and
Malta fever. In the veterinary field we note the triumph of the officials, who, by
bold measures, have exterminated rabies in the United Kingdom. The obvious
remark will be made that it is comparatively easy to stamp out disease in animals
by ordering compulsory muzzling and compulsory slaughter of the diseased, but
such procedures cannot be adopted with human mammals.

This is quite true, but cannot much be done by compulsory notification of such
diseases as pulmonary tuberculosis and syphilis. The former is now a notifiable
disease, and we are entitled to hope that its notification, by drawing the attention
of the authorities to each case, and by nurses imbuing the poor consumptives with
the absolute necessity for taking all the steps necessary to prevent the spread of
the " white plague,” will in time reduce the appaling death-rate from this disease
in Ireland. (Even this year the Registrar-General’s figures show an improvement.)

Syphilis is a world-wide disease, and especially poisonous to the nervous system.
What physician can assert with an easy mind that a patient, who has been under
his treatment for syphilis, is absolutely cured by a certain date ? Locomotor ataxia
and general paralysis of the insane frequently occur after all tertiary symptoms
have cleared away. The problem of the marriage of a man who has at any time
suffered from syphilis is frequent; and a great responsibility rests on the physician
consulted. One of the most piteous sights in life is the congenital syphilitic
infant. If syphilis was made a notifiable disease the patient would certainly feel
his moral and physical leprosy more, and, shunning society, would be less likely to
marry.

Why should not everyone contemplating matrimony be obliged to undergo a
medical examination, and procure a certificate of physical and mental soundness,
just as one does when contemplating a life insurance policy? Those who know
and feel themselves to be sound would never object to such an examination, but
the weakling and vicious might be deterred by the thought of having to submit
themselves to the search-light of the medical officer of health.

Our rulers, in all their wisdom, at present make it compulsory for one of the con¬
tracting parties in a meditated matrimonial alliance to sleep so many nights in the
parish in which the marriage is about to be solemnised, and he has to present a
certificate to that effect to the officiating clergyman. Surely this law is worthy of
the satire of W. S. Gilbert. Of what real advantage it would be to the health of
the nation and the happiness of the bride and groom if they had to produce
instead the suggested certificate of perfect health.

As regards “ Eugenics,” there was an interesting leading article on “ Eugenics
and Pauperism ” in the Medical Press and Circular of November 17th, 1909. The
editor lamented that no effective steps had been taken to prevent the propagation
of lunatic and other diseased and degenerated persons. He referred to the fact
that lunatics were often discharged from asylums as “cured,” only to return
after a few years' interval, during which they have propagated more insane stock.
He concluded by recommending that “ asylum patients should be kept under such
restrictions that would render their procreation of children impossible.”

[Note .—The writer, I presume, uses the term "asylum” patients to refer to all
patients who have been at any time in an asylum, but in my opinion it is the
unregistered insane who have not been treated in asylums who bring the largest
number of mentally defective children into existence.]

In this connection we may note that the Royal Commission on the Care and
Control of the Feeble-Minded state that feeble-mindedness “tends strongly to
be inherited also in view of the evidence they received of the frequency with
which feeble-minded women were admitted to the lying-in wards of the work-
houses, to be delivered of illegitimate children, they are of the opinion that the
prevention of mentally defective persons from becoming parents would tend
largely to diminish the number of such persons in the population. They therefore
advise that the mentally defective living at large and uncontrolled, both men and
women, should be placed in institutions and kept under efficient supervision so
long as may be necessary !

As regards “asylum” patients, we all realise the difficulty of detaining any
patient in an asylum who is apparently “ recovered,” although we feel quite
convinced that shortly after the hygienic and disciplinary life of the asylum is
removed, many of such cases will most certainly relapse.

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Dr. Robert R. Rentoul has had the courage to advocate the “ proposed
sterilisation of certain degenerates.” Already two states in America have adopted
his proposal, and it has been brought before the Government in Ontario (Canada).

As regards the abuse of alcohol in the causation of insanity, we all know
what a high percentage of cases it is responsible for both directly and indirectly.
As Dr. Clouston said in his Morningside report of 1901, “ Liberty to drink himself
to death or into an asylum was dear to the Briton, but it was an irrational
application of the doctrine of liberty to say that every man had the inalienable
right to render himself a burden on other people, and a source of degradation and
danger to the community.”

All children and adolescents should be taught to do without any form of
alcohol; and a wise step has been taken in abolishing beer from schools. It is
often said by the cynic, “ You cannot make a nation sober by Act of Parliament.”
Very few Parliaments have tried to do so, but remember Norway and Sweden,
who, finding themselves in a perilous and rotten condition, owing to the almost
universal excess in the use of alcohol, and no restriction on its manufacture,
adopted sternly repressive legislative methods about sixty years ago, and have now
become comparatively sober nations.

Although the secretary to the United Kingdom Alliance is able to show that
in the year 1909 there has been a decrease of .£5,000,000 on alcoholic liquors as
compared with 1908, the amount consumed in the British Isles is still far too
high, and there is more need at the present moment in Englard for a "drink
scare ” than a “ war scare.”

National degeneration increased pari passu with the national drink bill up to
1909.

Ford Robertson (in Dr. Clouston’s admirable book, The Hygiene of Mind)
wisely states: " My study of the question forces me to the conclusion that the

effects of alcoholic intemperance upon the people of this country are much more
grave and far-reaching than has generally been suspected. Most people have
seen with any degree of clearness only its most immediate effects. The influence
it has upon the race has only been dimly suspected by a few, and they have been
derided as ignorant and unscientific. The evidence of science is, I maintain,
entirely on their side.”

I am sure that many gynaecologists do harm by ordering various forms of
alcohol in their treatment of dysmenorrhcea. As a recent writer on this subject
neatly put it, “ the periodic recurrence of the pain leads to a periodic desire for
alcohol, which is taken in increasing doses.”

The present Government deserve praise for endeavouring to tackle this grave
matter of the Nation's alcoholic intemperance; and although it may not matter to
us whether there are ten public-houses in a street or only one, we know that it
often makes a difference of ten drinks or one to our weak-willed fellow citizen,
who, maybe, is wrestling with his enemy under these adverse conditions.

It is interesting to note here that popular lectures on personal hygiene, tem¬
perance, and venereal diseases are now given by the fleet-surgeons in the Royal
Navy to the crews; and it is encouraging to find that Dr. B. Leppington (signing
himself a member of the International Society for the Prophylaxis of Venereal
Disease), in a letter to the Medical Press and Circular, points out that the number
per 1000 admitted to the Army hospitals suffering from venereal diseases has
gradually dropped from 275 in 1885 to 72 in 1907, while the writer states that
other statistics, official and unofficial, seem to indicate the same thing, vis., a
reduction of these diseases in our population, both civil and military. He points
out the influence that doctors have, if they would only use it, and advises the
profession "to work on, not as those without hope.”

I now come to the medical inspection of school-children. Much valuable work
was performed by the recent Royal Commission on the Feeble-minded, and it is to
be hoped that their valuable suggestions will be adopted. That the general public
are gradually awakening to the importance of this subject is shown by the Govern¬
ment appointing such a commission ; and also by the fact that the Third Inter¬
national Congress on School Hygiene will be held in Paris during August
this year.

When medical inspection of the board schools in England was determined
upon, it was recognised that the duty of treating the defects disclosed must be

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undertaken by the State, but the problem was not fairly faced, and as the British
Medical Journal, in a leading article entitled “A National Emergency,” points
out, " the central and local authorities were anxious to avoid responsibilities—more
especially as they involved expenditure. They turned to existing voluntary hospitals
with a view of seeing how much could be got out of them and the medical pro¬
fession for nothing.”

This is altogether wrong, and if the scheme of district school clinics staffed by
the local practitioners is carried, they should be highly paid by the State. From
a national health point of view, it is much more important to take care of the
coming generation than to medically inspect the flotsam of society in our asylums.

Now that the old-fashioned family physician has almost disappeared, I think
a great responsibility rests upon the school physicians appointed to the public
schools. He has great opportunities of detecting the early symptoms of disease of
body and mind, if he is paid sufficiently well to inspect the boys frequently.

This has not been so in the past. Indeed, at my public school you only saw the
doctor if you happened to break your neck or developed diphtheria!

"Obsta Principiis," as Dr. Clouston truly says, is the most valuable motto in all
effectual mental hygiene; and who is in a better position than the school doctor
to detect the stigmata of degeneration, the necessity for rest, the appearance of vice,
in the various pupils? He should be their mentor as well as their physician, and
should give friendly addresses on the problems of sex to the senior classes, who
are much troubled by a natural appetite. Such a friend would be a great help
to many school boys, and he would without doubt assist to avert the sad break¬
down of many adolescents after leaving school.

This, gentleman, brings to a conclusion a discursive paper. If it succeeds in
stimulating a discussion it will achieve its object.

Discussion.

Dr. Drapes said that the paper was highly suggestive. The nineteenth century
had been eminent in preventive medicine and hygiene, bnt mental hygiene had
been omitted—Hamlet without the Prince. Medical examination before marriage
was good in theory, but stopping marriage would not stop procreation. The
public must be educated, and the teaching of the structure and function of the
body should commence from infancy. Sterilisation would be even more necessary
in improvable cases, those which were discharged quasi-recovered, and these
should be given the choice of sterilisation or perpetual detention. He also
alluded to the necessity for better teaching of medical men in psychology and
psychiatry.

Dr. Fitzgerald expressed his agreement with Dr. Eustace. He knew of a
case where a high dignitary of the Roman Catholic Church had used his influence
against the marriage of a girl to a man of bad heredity. There were few weak-
minded girls who had not been parents, but he did not think sterilisation a feasible
measure.

Dr. Leeper attributed the increase of insanity to the fact that every workhouse
was a lunacy manufactory run by State aid. Weak-minded girls ran there to be
confined of illegitimate children. As regarded syphilis, where notification had
been enforced the disease increased, owing to concealment. Educational methods
were the only ones likely to be successful. He quoted cases of a girl who had
been four times insane at four deliveries, and another in which the same thing had
occurred in five or six consecutive confinements.

The Secretary agreed on the whole with Dr. Eustace as to the causative
importance of alcohol, though as sole or chief cause he thought it had been over¬
rated, and did not account for more than 10 per cent, of cases or less. As regarded
detention, it should be borne in mind that, though an onerous measure at first, if
it were strictly enforced the numbers requiring to be so treated would progressively
diminish, it might be hoped almost to vanishing point. He concurred, however,
in the view that education of the people was the most important remedial measure.

Dr. Oakshott thought that the churches of all denominations could do much
to educate the people.

Dr. Fitzgerald mentioned that the young clergy at Maynooth were now
lectured on physiology and hygiene.

Dr. Eustace made a few remarks in reply.

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The meeting terminated with a cordial vote of thanks to the Drs. Eustace for
their kind hospitality, and for the pleasant day which had been spent.

Special Meeting.

A special Meeting of the Division was held, with the sanction of the President
of the Association, on Thursday, May 18th, 1910, at the Royal College of
Physicians, Dublin. Dr. M. J. Nolan was voted to the chair, and there were also
present: Drs. W. Graham, R. R. Leeper, W. Smyth, J. Mills, J. O’C. Donelan,
J. M. Redington, T. A. Greene, F. O’Mara, and W. R. Dawson (Hon. Sec.).
Apalogies weie received from Drs. C. E. Hetherington, E. O’Neill, J. A. Oakshott,
B. C. Harvey, T. Drapes, and H. M. Eustace.

The Hon. Secretary explained that it was a matter of common rumour that
amongst the applicants for the post about to be vacated by Sir George O’Farrell
were men who had had no special training in lunacy, and there was also the possi¬
bility that a man might be transferred from some other Government Department.
Under these circumstances the meeting had been summoned in haste, as the
Quarterly General Meeting of the Association would take place on May 24th, and
the Division might wish to ask them to make representations on the subject.

The discussion was opened by the Chairman, who expressed warm appreciation
of Sir George O'FarreH's work, in which all concurred. A general debate followed,
in which most of the members joined, and it was finally proposed by Dr. Graham,
seconded by Dr. Donelan, and passed unanimously:

“ That the Irish Division of the Medico-Psychological Association would strongly
urge the Association at large to represent to the Irish Government the extreme
importance, in filling the posts about to be vacated by the Inspectors of Lunatics,
of selecting candidates who are thoroughly conversant, by training and experience,
with the administration of lunatic asylums and the practical treatment of the
insane.”

A resolution in somewhat similar terms was proposed by Dr. O’Mara, seconded
by Dr. Leeper, and directed to be sent to all the Irish Members of Parliament.

In view of the fact that this was the first meeting of the Division since the
lamented death of His Majesty King Edward VII, a resolution expressing sorrow
and sympathy with the Royal Family was proposed by Dr. Graham, seconded by
Dr. Leeper, and passed unanimously in silence.

The meeting terminated.

Note.

The mention of Dr. John Gideon Van Millingen in Dr. Bailey’s interesting
article upon Hanwell Asylum deserves a note on the family. Dr. Bailey charac¬
terises Dr. Millingen’s period of service in Hanwell as brief and stormy, and
Millingen himself did not hesitate to make that known to the public. His father
was a Dutch merchant who eventually settled in Westminster. One of his brothers
died at the age of fourteen, and was buried in the Abbey Cloisters, the epitaph
having been written by William Cowper. In 1790 the family migrated to Paris,
and passed through the horrors of the Revolution, after which the brother James
went to Italy, and wrote valuable works on antiquities before his death in 1845 * n
Florence. John repeatedly met the Jacobin leaders in Paris in his boyhood, and
after adventurous service in the army he retired with the Waterloo and other
medals. He was connected with the Military Asylum at Chatham when appointed
to Hanwell, and after his service there he is said to have opened a private asylum
in Kensington. He died in London in 1862. He produced various dramatic
writings, one of which, '*The Illustrious Stranger,” is yet sometimes played by
amateurs, and also a novel, and various compilations more or less medical in
character. His Aphorisms on Insanity, and another work on Mind and Matter,
are not uncommonly found on the lists of secondhand booksellers. Julius Michael
Millingen, John's nephew, was also a physician, and is chiefly remembered owing
to his connection with Lord Byron, knowledge of whose last hours is principally
gained from Millingen’s memoirs. He was Court Physician to five successive
Sultans of Turkey, and persuaded David Urquhart to establish a Turkish bath
in London. He died in 1878 in Constantinople. His son still resides in Dunblane,
after a business life spent chiefly in Turkey.—U.

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OBITUARY.

Robert Smith, M.D., L.R.C.S.E.

Dr. Smith died on May 28th, in his seventy-eighth year, somewhat unexpectedly,
at the residence of his son-in-law, Dr. Robert Stuart, Hallgarth House, Durham.
It was indeed fitting that he should have passed in the county in whose service he
had spent so many years. He was a remarkable man, unfortunately known by too
few of our Associates, and therefore not fully appreciated by those who were not
brought into actual contact with his notable personality. We who mourn his
loss, even at his advanced age, and knowing that he had done a noble and long
day's work, recall memories of his life for which we are grateful, and endeavour to
set forth some record of a worthy nature in the pages of the Journal.

Dr. Smith was the fifth and youngest son of the late Rev. Robert Smith, D.D.,
senior minister of St. Machar's Cathedral, old Aberdeen, and of his wife, Mary,
daughter of Colonel Molison, Brechin. His education was gained in the classic
surroundings into which he was born—at the Grammar School and King's College,
where he took his degree of M.D. in 1858. Previously, in 1854, he had become
M.B. and L.R.C.S.E., and fora time acted as assistant to Dr. Fyfe, Professor of
Chemistry. He was fortunate in having been selected to act as assistant medical
officer by Dr. W. A. F. Browne, of the Dumfries Royal Asylum, who remained his
life-long friend.

After travelling in Canada he was appointed to the post he so long held as
Medical Superintendent of the Durham County Asylum, although that institution
was not then ready for occupation. The patients were boarded at a private asylum
at Bensham, Gateshead, and afterwards at the Bath Lane Asylum, Newcastle. In
April, 1858, however, the Durham County Asylum was opened, with accommoda¬
tion for 400 patients, at Sedgefield, and it gradually increased in size until it held
1600 in 1899, when Dr. Smith felt that the time had come for him to retire.

Under his fostering care, watchful over every detail of development, it became
an important institution, throughout which the welfare, the comfort, and the
happiness of his patients were Dr. Smith’s constant concern. Nothing was left to
chance, everything was brought under his personal notice by his active staff, and
his rapid decisions kept the routine of life on the right lines. His profound know¬
ledge and his skilful use of it made him a chief who commanded respect, while
his kindly, generous nature endeared him to all.

Like his intimate friend, the late Dr. Howden, of the Montrose Royal Asylum,
Dr. Smith had a deep sense of the importance of interesting the insane in occupa¬
tions and amusements ; he led them into the way of regarding life from the bright
and cheerful side. It is rather the fashion to deride these practical philanthropic
duties of asylum management, to regard with condescension the man who labours
for the happiness and comfort of his patients, to speak apologetically for all that
has gone to make the reputation of English asylums as homes of healing directed
with beneficent zeal. We are apt to incline to ultra-scientific absorption, and
decline to occupy ourselves with the incessant cares of administration in detail,
but we must always remember that our Association was established and is main¬
tained, not only for the cultivation of science in relation to mental disorder, but
also for the promotion of improvements in administration. When we think of the
turbulent, difficult patients who so often require treatment in the Durham County
Asylum, and his repeated statement that he never found seclusion necessary, and
his adroit management of men and women, we find it hard to mention anyone who
did more for the humane and enlightened treatment of those committed to his
care. And, apart from his profound medical knowledge and wide expeiience, Dr.
Smith was gifted in no small degree with that scientific competence which rendered
him capable in mathematics, astronomy, chemistry, and histology. These were
his interests and avocations in the time which he could spare from the duties of
his professional life, which were rigidly fulfilled. Dr. Smith’s first concern was
always the organisation of relief for the alleviation of his patients, and his range of
action was wide. Apart from the ordinary labours of the day, he organised and
fostered healthful outdoor sports and indoor recreations. His musical capacity
was productive of concerts and entertainments of notable excellence, and the chapel
services were memorable in the use of music and singing. Dr. Smith was fortunate

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in securing a fine organ and capable choir, and in interesting his people in the
chapel and all it stood for.

Dr. Smith's patients loved him, and one of his friends truly said, “ he was sturdy
in wisdom, high-minded and unselfish, and very able; one can give no higher
praise, and this he deserved." He was one of the very best of men, and only those
who were closely associated with him officially or as assistants are able to fully
appreciate his worth ; amongst the latter (and the list is a long one) may be men¬
tioned the late Drs. Aitken (Inverness), J. A. Campbell (Carlisle), John A. Wallis
(Commissioner in Lunacy), Colin Mclvor Campbell (Perth), Drs. John Merson
(Hull), Robert L. Rutherford (Exeter), Edmund Rowe (Ipswich), J. T. Callcott
(Newcastle-on-Tyne), and John W. Geddes (Middlesborough). Sir Patrick
Manson and Colonel Kenneth McLeod, I.M.S., were also assistants with Dr.
Smith for several years in their early career.

A link which bound Dr. Smith to Aberdeen, where his sisters still live, was his
marriage with a daughter of the late Rev. Principal Campbell, of the University.
His wife’s recent death told heavily upon Dr. Smith’s health. Of a family of
five sons and four daughters, all survive with the exception of the eldest son, who
was in the medical profession, and died several years ago. Other three sons
also entered the medical profession. One is a doctor at Tunbridge Wells, a
second in Norwich, and a third in the Indian Medical Service. The fourth sur¬
viving son is a lawyer in New Zealand. Of the four daughters three are married,
and it was with one of them that Dr. Smith went to reside recently, before his
fatal illness.

Henry John Manning, B.A.Lond., M.R.C.S.

By the death of Dr. Manning, the well-known Superintendent and Licensee of
Laverstoke House, the Association loses one of its elder members, who has long
held the friendship and esteem of a wide circle.

Born in 1835, and educated at University College School, he graduated in arts
at the London University, and subsequently studied medicine at University College,
taking his M.R.C.S. in i860.

After several voyages to Australia in a medical capacity, he joined Dr. Bushman
at Laverstoke House in 1862, and became medical superintendent on the death of
Dr. Stanley Haynes in 1870.

Dr. Manning was a contributor to this and other medical journals, but especially
devoted himself to the work of the British Medical Association, becoming Honorary
Secretary and Treasurer of the Southern Branch. He also took an active part in
the management of the Salisbury Infirmary.

Dr. Manning preserved his literary activities throughout his life, and was distin¬
guished by the thoroughness of his execution of duties, both professional and
public. He obtained and held the confidence of his patients as well as of his
numerous confreres, to whom he extended a genial and liberal hospitality.

Dr. Manning married the elder daughter of the late proprietor of Laverstoke
House, Mr. Joseph Haynes, J.P., who, with two daughters, survive to mourn his
loss.

INTERNATIONAL CONGRESS FOR THE CARE OF THE

INSANE.

The Fourth International Congress, which will meet from October 3rd to the 7th,
1910, in Berlin, at the “ Abgeordnetenhaus ” (Prussian House of Parliament), will,
like the previous congresses, not only deal with questions regarding the treatment
and accommodation of patients suffering from mental derangement, but will also
promote investigations and arrangements conducive to the protection of the
general mental health in every respect.

The Congress hopes to secure the interest not only of physicians, but also of
municipal officials, lawyers, and schoolmasters. It will investigate the injuries
caused to the mind by social and hygienic abuses, will endeavour to explain the
origin of mental diseases from infancy, and point out the best possible methods for
the prevention of mental derangements. It proposes to promote the means of com-

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bating abnormal psychical conditions, vis., medical treatment in and outside the
asylums, regular home nursing, help and advice to relations, regulation of the legal
conditions of patients, assistance, providing work for and care of the patient after
his treatment in an asylum. It proposes, furthermore, on the basis of scientific
experience, to improve the education and protection of juveniles with abnormal
mental traits and of those who are backward in development.

An exhibition illustrative of the care and treatment of patients suffering from
. psychical or nervous derangements will be held in connection with the congress,
and will afford a view as complete as possible of the progress made in this branch
of medical science during the last thirty years.

In this exhibition, which will also take place in the rooms of the “ Abgeord-
netenhaus,” explanatory lectures (with slides) will be given.

The subjects already provided for these lectures are: " Modern Asylums,’’
“Care and Treatment of Infants and Juveniles in the Asylums," “ Means to Pre¬
serve Mental Health,” and “Can an Increase of Mental Diseases be Proved-'’

In addition arrangements have been made for the inspection of some recently
built hospitals and asylums in the neighbourhood.

Papers should be announced by June 15th, 1910, to Professor Dr. Boedeker,
Schlachtensee-Berlin, who will give all necessary information.

The president will arrange the programme.

The official languages are : English, French, German, Italian.

The meetings will be presided over by the honorary presidents, to be elected at
the inaugural meeting.

Each paper of a general report is limited to thirty minutes, the reading of papers
on any other subject to fifteen minutes; five minutes will be allowed to each
member taking part in the discussion. The president will be entitled, with the
consent of the meeting, to make exceptions in special cases. At the termination
of the discussions the readers of reports will be allowed a short reply.

The readers of reports and the members partaking in the discussion must hand
in a short extract of the same, written on one side only, to the secretary within
twenty-four hours.

Reporters are requested to send a short summary to Professor Dr. Boedeker,
Schlachtensee-Berlin, by September 1st, 1910, so that the reports maybe presented
for discussion.

Each paper (manuscripts in type-writing, please) that arrives in time will be pub¬
lished in the official general report of the Congress. Drawings, curves, etc., are
printed at the expense of the author only. Each author may claim fifty copies of
his paper.

Requests concerning the International Congress for Care of the Insane are to be
treated at the closing meeting. Written requests are to be delivered two days
before to the president.

The office of the Congress will be open from September 30th to October 7th,
from 9-12 a.m. and 2-4 p.m. (House of Parliament, 5 Prinz Albrechtstrasse,
Berlin). A post and telegraph office is established in the same building.

Requests for membership of the Congress are to be addressed as early as
possible to Mr. Mietzner, 5 Prinz Albrechtstrasse, Berlin S.W. The members'
tickets can be obtained from July 1st upon receipt of the amount of member's fee,
£1 (20 marks). The fee for a lady’s ticket is tos. (10 marks).

The member’s ticket entitles to admittance to the meetings, to entertainments
and to the exhibition, to receiving the daily paper and the Report of the Congress
(for members only).

The badge of membership, etc., are issued at the office.

THE LIBRARY OF THE MEDICO-PSYCHOLOGIGAL ASSOCIATION.

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The following books have recently been added to the Library:

A System of Syphilis: Vol. IV, Syphilis of the Nervous System, by F. W. Mott,
F.R.S.

Report of the Royal Commission on the Care and Control of the Feeble-minded
(8 vols).

The Lunacy Law of Scotland.

The Lunacy Law of Ireland.

Applications for books should be addressed to The Resident Librarian, Medico-,
Psychological Association, II, Chandos Street, W. Other communications should
be addressed to the undersigned at Long Grove Asylum, Epsom.

H. Devine,] Hon. Secretaries,

B. Hart, j Library Committee.

NOTICES OF MEETINGS.

Medico-Psychological Association.

The sixty-ninth Annual Meeting of the Association will be held on Thursday
and Friday, July 2ist and 22nd, 1910, in Edinburgh, under the Presidency of Dr.
John Macpherson.

On Wednesday, July 20th, there will be meetings of Committees at the Royal
College of Physicians, as follows: Parliamentary Committee, 2.30 p.m.; Educa¬
tional Committee, 3.30 p.m.

Reception. —In the evening Dr. and Mrs. Macpherson will hold a reception at
the Royal College of Physicians from 9.30 to 11.30 o’clock.

The Council will meet on Thursday, July 21st, at 9.30 a.m.

The Annual Meeting will commence at 11 a.m. on Thursday, 21st July, at the
Royal College of Physicians, when the usual business of the Association will be
transacted.

Notice of motion by Dr. Bond : That the subjoined rules as to the appoint¬
ment of examiners for the Nursing Certificate shall take the place of those
provided by the last sentence of present Bye-law 71 :

“ The Council shall similarly appoint examiners for the Nursing Certificate,
whose number shall correspond with the number of divisions. They shall
each be eligible for re-election for three years, but having acted for the
whole of that period they shall not be eligible for re-election (except as
interim examiners) until the expiry of three years. Provided that any
examiner holding office for less than three years shall be eligible for re-elec¬
tion after the expiry of one year.

“ Each Division may suggest the names of two members (one at least of whom
shall be a medical superintendent) for the consideration of the Educational
Committee, who, in recommending to the Council, shall, as far as practic¬
able, arrange that each Division supplies an examiner.

“ In making the appointments annually, the Council shall so arrange that at
least two of those appointed shall have acted asexaminers for a year. In case
of a casual vacancy occurring between the meetings of Council, the Presi¬
dent, with the concurrence of the Chairman and Secretary of the Educa¬
tional Committee, shall appoint an interim examiner to hold office till the
next meeting of Council."

Notice of motion by Dr. Bower: That the member holding the office of Secre¬
tary to the Parliamentary Committee be an Official Member of the Council,
and that Bye-law 31 be varied accordingly.

Notice of motion by Dr. Hayes Newington: That new members elected in
the last half of any year shall have the option of joining the Association as
soon as their election is complete, or of deferring joining to January 1st of the
succeeding year, and that Bye-law 19 be varied accordingly.

2 p.m.—The President’s Address, after which the following papers will be read :
Dr. Ford Robertson on “Infective Foci in General Paralysis and Tabes
Dorsalis." Dr. John Carswell on “ The Treatment of Insipicnt Insanity in

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Observation Wards." Dr. J. P. Sturrock on “ Certain Forms of Insanity
in the Criminal Class.” Dr. R. M. Marshall* on " Periodic Attacks of
Mental Excitement and Depression in the Chronic Insane.”

Friday, July 22nd, at io a.m.—The following papers will be read: Dr. A. R.
Urquhart on “ Lunacy Administration in Scotland.” Dr. Lewis C. Bruce
on “ The Deviation of Complement in Connection with the Diseases known
as Mania.” To be followed by three papers by Drs. Hamilton Marr, Ivy
McKenzie, and Browning, on “The Arsenical Treatment of Protozoal
Diseases.” Dr. C. T. Ewart on “ Eugenics and Degeneracy.”

12.45 P- m -—Adjournment for luncheon.

By the kindness of Dr. G. M. Robertson and the Board of Managers of
the Edinburgh Royal Asylum, an invitation to luncheon at Craig House,
Morningside, is extended to members, to be followed by a Garden Party, to
which ladies are invited, at 5 p.m., in the grounds of Craig House, when an
opportunity will be afforded of inspecting the Asylum.

2 p.m.—Afternoon Session, in large Hall at Craig House. Dr. George M.
Robertson will open a discussion on “The Treatment of States of Mental
Excitement in the Insane.” To be followed by the following papers : Dr.
Leonard D. H. Baugh on “ A Clinical Study of Anaesthesia, Mental Con¬
fusion, and Moods in Epilepsy, Confusional Insanity, and Hysteria.” Dr. R.
Dods Brown on “ The Viscosity of the Blood in Mental Diseases.” Dr. G.
Rae Gibson “On the Treatment of Dementia Praecox by increasing the
Blood-Tension.” Dr. Alice Babington, “A Note on the Opsonic Index in
Insane Persons.” Dr. G. Scott Williamson, “A further Contribution to
the Study of the Cerebro-spinal Fluid.” Dr. Winifred Muirhead on
" The Wassermann Reaction in the Blood and Cerebro-spinal Fluid, and the
Examination of the Cerebro-spinal Fluid in General Paralysis and other
Forms of Insanity.” Dr. H. Morton on “ The Chemistry of the Cerebro¬
spinal Fluid ” ; Dr. Gilmour on “ The Wassermann Reaction, a more reliable
Technique”; Dr. C. G. A. Chislett on "Syphilis and Congenital Mental
Deficiency,” from the Scottish Western Asylums Research Institute.

N.B.—Owing to the number of paper, it has been decided to limit the time
for reading a paper or opening a discussion to fifteen minutes, and the time
for subsequent discussion to five minutes for each speaker.

5 p.m.—Garden party at Craig House.

Saturday, July 23rd.—Excursion to Bangour Village Asylum. (By the 10.35
a.m. train from the Waverley, and four minutes later from the Haymarket
Station.)

By the kind invitation of Dr. Keay and the Edinburgh Board of Lunacy, a
visit to Bangour Village has been arranged for the members and their friends,
ladies being included in this invitation. The party will arrive at Bangour
Station at 11.23 a.m Prior to inspecting the Asylum, Dr. Keay will read an
account of the Segregate System as exemplified by Bangour Village. After
luncheon at 1 p.m., a further Inspection of the Village will be afforded,
followed by tea at Dr. Keay’s house.

Return train from Bangour Station at 4.5, arriving at Edinburgh at 4.52.

Members accepting this invitation are asked to early notify their intention
on the accompanying form.

The Annual Dinner will take place on Thursday, July 21st, at the Caledonian
Hotel, at 6.45 p.m. for 7 o’clock.

It will very considerably facilitate the making of necessary arrangements,
especially in regard to seating, if members will kindly signify at an early date to
the General Secretary their intention of dining. If any member desires to bring
a guest, or to sit near other members, this will be arranged on his signifying his
wish to the Honorary Secretary before the meeting.

It may be clearly understood that no liability is incurred by announcing an
intention to dine if later on a member finds that he cannot attend ; and further,
if a member finds that he can dine, his not having given notice of his intention
does not preclude his doing so. But in either case a letter or telegram addressed
to the Treasurer, at the Caledonian Hotel, Edinburgh, will be serviceable and
kind.

The charge for dinner tickets (wines included) will be One Guinea, and pay-

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NOTES AND NEWS.

I9IO.]

53 ;

ment should be made, either by cheque or in cash, to the Treasurer, who will
supply a voucher.

Honorary Membership of the University and Conservative Clubs, opposite the
Castle in Princes Street.—The Committee of the University Club have kindly
agreed to admit fifty members of the Association to the privileges of the Club
from the 20th to the 23rd July inclusive. The same privileges have been granted
for the Scottish Conservative Club to those members to apply to the Secretary
for tickets.

South-Eastern Division. —The Autumn Meeting will be held, by the courtesy of
Dr. Stansfield, at the London Connty Asylum, Bexley, on Wednesday, October
5th, 1910.

South-Western Division. —The Autumn Meeting will be held on Friday, October
28th, 1910.

Northern and Midland Division —The Autumn Meeting will be held, by the
courtesy of Dr. Hopkins, at the York City Asylum, Fulford, on Thursday,
October 20th, 1910.

Scottish Division. —The Autumn Meeting will be held on Friday, November 18th,
1910.

Irish Division. —The Autumn Meeting will be held on Saturday, November 5th,
1910.

APPOINTMENTS.

Grills, S. H., M.D., R.U.I., Medical Superintendent of the Chester County
Asylum.

Hart, Bernard, M.B.Lond., M.R.C.S., L.R.C.P., Lecturer on Mental Diseases
and Mental Physiology at University College Hospital Medical School.

Planck, Charles, M.A.Cantab., M.R.C.S., L.R.C.P.Lond., Medical Superintendent
of the Brighton County Borough Asylum, Hayward’s Heath.

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PRINCETON UNIVERSITY

THE

JOURNAL OF MENTAL SCIENCE

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

No. 235 [ n ' n w 0 ."T] OCTOBER, 1910. Vol. LVI.

Part I.—Original Articles.

The Presidential Address on Conceptions of Insanity and
Their Practical Results , delivered at the Sixty-
ninth A nnual Meeting of the Medico-Psychological
Association , held in Edinburgh on fuly 21st and
22nd , 1910. By John Macpherson, M.D., F.R.C.P.E.,
Commissioner in Lunacy for Scotland.

You have called me suddenly and unexpectedly to a high
honour, and I have willingly responded to your call. Had I
done otherwise it would have been inexcusable, for the very
fact of my ordinarily enforced aloofness from your deliberations
left me, perhaps, freer than many others to step into the breach
caused by the very regrettable indisposition of your President¬
elect, Dr. Turnbull. Another reason prompted me to accept
your gracious invitation. Only two of your former Presidents,
Dr. W. A. F. Browne in 1866, and Sir James Coxe in 1872,
held similar official positions to mine. It seems not inappro¬
priate, therefore, after the long flight of thirty-eight years, during
which momentous changes affecting our attitude towards mental
diseases have swept over this Association and over the various
Lunacy Commissions, that the identity of our interests, our
aims, and our aspirations should again be marked by the
election of a member of one of the Central Boards to this
Chair.

When I looked over the long list of the presidential ad¬
dresses of my predecessors I confess I was alarmed by their
erudition. Some of these, more especially in recent years, can

LVI. 39

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590 PRESIDENTIAL ADDRESS, [Oct.,

only be described as scientific monographs. It was plainly out
of the question for me, in the time at my disposal, and with my
rusty weapons, to attempt to instruct you after their example,
while of dry-as-dust statistics we have all of us had recently
more than enough in the ponderous reports of two Royal Com¬
missions. I have, therefore, taken as my subject a review,
scientific and critical, of the various conceptions of insanity and
their practical results.

The conceptions which have influenced the study and pro¬
gress of psychiatry are all of them theories of causation, or, at
any rate, they may, in a remarkable manner, be identified with
the broad causal concepts which, from the earliest times until
now, have dominated the thoughts of mankind.

Comte affirmed that human knowledge passed through three
stages—the theological, the metaphysical, and the positive or
scientific.

Whether we prefer a philosophical or a sociological classifica¬
tion of civilisation, we must believe that the change from one
stage to the next is not accidental, but evolutionary—the one
phase preparing the way for the succeeding one. Correspond¬
ing to these evolutionary phases are the three great causal
concepts which underlie them or arise from them, as we choose
to think. They are as follows :

(1) The volitional concept, which accounts for consequences
as the result of will, either animating an object or operating
upon it from without.

(2) The empirical concept, which presents only an uncon¬
ditional succession of events, and which tends to regard a
preceding event as the cause of the immediately succeeding
one.

(3) The scientific, or, as it is technically called, the ideal
concept, which goes a step farther and sees in the phenomenon
which we call consequence the continuation of that pheno¬
menon which we call the cause (1). The latter alone is a satis¬
factory concept of causation. Yet, as we shall see, it is but
beginning to operate, and we are far from having done with the
others.

I. Period of the Volitional Concept.

Our present civilisation dates from the introduction of
Christianity into Europe. The absolute subjection of the social

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592 PRESIDENTIAL ADDRESS, [Oct.,

The rise of Christianity and the concomitant decadence of
Greek and Roman culture was marked by the appearance of a
new element, namely, an altruistic ideal of the very highest
conception. It was “a proclamation of the universal brother¬
hood of men.” “ The affection which the members bore to each
other, the devotion of all to the corporate welfare, the spirit of
infinite tolerance for every weakness and inequality, the con¬
sequent tendency to the dissolution of social and class barriers
of every kind, beginning with those between slave and master,
and the presence everywhere of the feeling of actual brotherhood,
were the outward features of all the early Christian societies." (5)
It was undoubtedly because of the dissolving influence of these
altruistic ideals upon existing society, and not because of
their theological tenets, that the early Christians suffered
martyrdom, for the Romans were proverbially tolerant of the
abstract religious opinion of others, owing largely to the
agnosticism and indifference of the educated ruling classes.
Slowly and gradually Europe came under the absolute domina¬
tion of the Church, until in the twelfth century the individual
reason was wholly subordinated, independent judgment was
extinguished, and almost every form of intellectual activity
was crushed by the tremendous supernatural idea which
engrossed the thoughts of men and possessed their minds.
Moreover, the organic continuity of the intellectual attain¬
ments of the older civilisations had been completely broken
and lost. That is the indictment which has aroused the
wrath of successive modern authors, such as Gibbon, Lecky,
and Maudsley. Says Mr. Lecky (6): “ A hideous, sordid, and
emaciated maniac, without knowledge, without patriotism,
without natural affection, passing his life in a long routine
of useless and atrocious self-torture, and quailing before
the ghastly phantoms of his delirious brain, had become the
ideal of nations which had known the writings of Plato and
Cicero, and the lives of Socrates and Cato.” Again, Dr.
Maudsley (7): “If, like St. Macarius, he slept for months
together in a marsh, exposing his naked body to the stings
of venomous flies, or, like St. Simeon Stylites, he spent the
greater part of his life on a pillar sixty feet high, or, like
St. Anthony, the patriarch of Monachism, he had never, in
extreme old age, been guilty of washing his feet, he was thought
to have reached the ideal of human excellence and was

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BY JOHN MACPHERSON, M.D.

593

canonised as a saint.” The fault of these, and many similar
vituperative criticisms, lies not only in their captiousness, but
conspicuously in the fact that they are strangely oblivious to a
cosmic event of such ethical importance. Imagining that
social progress depends wholly upon intellect and upon the
spread of mere knowledge, these critics have failed to realise
the significance of the great element of altruism which under¬
lies modern civilisation, and which undoubtedly owes its
prevalence to the introduction and growth of Christianity in
Europe. We may conclude from all this that it was by means of
the extraordinary strength of its super-rational sanction that the
ethical system associated with the Christian religion, in which
the thought of Europe was steeped for ten centuries, has
resulted in raising the people coming under its influence to the
highest state of social efficiency ever yet attained.

It is believed by not a few that the day of super-rational
sanctions is over, and it is not unnaturally asked by such
people why the edifice of altruism does not fall when its prop
is removed. The answer is surely very clear. In an evolu¬
tionary process there can be no discontinuity. The external
appearances—the forms—change, but the process itself is un¬
alterable, for religion, which is one of the most concentrated
forms of psychic life, will probably always continue to reveal
itself in new forms. If, then, the social process, whose founda¬
tions were laid in Christian altruism, is an evolutionary process,
as who can doubt, the main characteristic must continue to the
end, and there is abundant evidence that it is not only con¬
tinuous but progressive. When we consider our own speciality
we find that altruism has prompted almost all the great
advances in the care of the insane, and that sympathy has been
the characteristic feature in the mental endowment of its more
famous leaders. Speaking of Conolly, Dr. W. A. F. Browne (8),
then Commissioner in Lunacy for Scotland, said in his Presi¬
dential Address to this Association forty-four years ago : “ His
ideas seemed to have passed through his heart, and his feelings
to have raised and rarefied his intellect . . . The insane

he positively loved.”

No one can read Lord Shaftesbury’s life without appreciat¬
ing the motive power which led to his great endeavour on
behalf of the insane ; and no one can fail to believe that without
his indomitable—I might, without offence, say obsessive—deter-

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inination to obtain his end, the course of lunacy administration
in the three kingdoms would have been totally different to-day
from what it is. Before Shaftesbury there were others, such
as Tuke, Conolly, Charlesworth, and Gardener Hill. In
Scotland we had movements which resulted in the erection
of the royal asylums towards the close of the eighteenth
century.

But these and many other examples of pious benevolence
were sporadic, and sank into insignificance before the great
socialistic legislation of 1845, by which, for the first time in
any civilised country, the English State assumed the real—
not, as previously, the pretended—supervision of the insane.
The primary object of State intervention w r as not alone to
prevent abuses of the insane, which were real enough, but
partly no doubt also to protect the liberty of the sane, which
was alleged to have been in danger. But, having intervened, it
assumed among other functions the promotion of the physical
and mental well-being of the insane. There the function of the
State rests to this day; its intervention has not extended
legally beyond these requirements. In this respect, at any
rate, we have fulfilled the desideratum of John Stuart Mill,
who thus expresses himself in his Essay on Liberty (9) : “ A
government cannot have too much of the kind of activity
which does not impede, but aids and stimulates individual
exertion and development. The mischief begins when, instead
of calling forth the activity and powers of individuals and
bodies, it substitutes its own activity for theirs; when, instead
of informing, advising, and, upon occasion, denouncing, it
makes them work in fetters, or bids them stand aside and does
their work for them.”

Throughout the whole of the theological period the voli¬
tional concept exclusively prevailed under the form of demoni¬
acal possession. The philosophic basis of the thought of the
period was a kind of dualism, in which by far the greater
importance was assigned to the spiritual side of the union.
Not only so, but the interests of the body were believed to be
antagonistic to those of the soul. In the words of St. Paul:
“ The flesh lusteth against the spirit and the spirit against the
flesh, and these are contrary the one to the other.”

Martyrs, ascetics, and anchorites not only endured the
severest penances, but gladly submitted to death for the soul’s

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BY JOHN MACPHERSON, M.D.

595

sake. It is no wonder, therefore, that the strict discipline of
the body was freely resorted to if by that means the interests
of the immortal soul could be advanced. There are, however,
one or two gross errors which modern writers have been guilty
of when commenting on the treatment of the insane in the
middle ages. In the first place , they have not sufficiently kept
in mind that the people of these times displayed such a com¬
plete indifference to physical conditions as seems to us almost
incredible. They witnessed with apparent pleasure and relish
scenes which are to us sickening to read of—tortures, mutilations,
executions. They seemed not only able to endure pain and
extraordinary physical discomforts themselves with comparative
composure, but they inflicted the most diabolical tortures upon
others without compunction or remorse. To compare their
mental attitude towards suffering, especially physical suffering,
with the standards of to-day is manifestly to compare the
incomparable. In the second place> there has been a mis¬
understanding of the attitude of the media:val people towards
disease and suffering. So far from neglecting them, many of
the religious orders and of the secular priesthood devoted their
lives to the relief of suffering, the redress of wrongs, and the
care of the sick, including the insane. It has been established
beyond doubt that in almost every country in Europe pro¬
vision was made for the insane in the monasteries and else¬
where. When we think of the middle ages we must blot from
our minds the picture of modern Europe with its teeming
millions, and imagine a sparsely cultivated continent with a
comparatively small and scattered population. In such con¬
ditions the number of the insane must have been also small
and easily dealt with. I say nothing of the manner of their
care, which could not have been worse, but was probably
infinitely better than it was in the eighteenth and early part of
the nineteenth century. A third error into which historians
and social writers of all kinds have fallen has arisen through
carelessly confusing the treatment of the insane with that of
the demonomaniacs and the so-called witches of the time. A
true explanatory account of the extraordinary epidemic manias
of the middle ages has yet to be written. That the victims
were not lunatics in the ordinary sense is abundantly evident
to the most casual reader, and yet we are gravely informed
that in France 20,000, in England 30,000 lunatics were

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burned or done to death in less than 200 years. Take, for
instance, the most recent, probably the last outbreak of
epidemic mania in Europe, which occurred only the other day,
so to speak. Between 1857 and 1862 the inhabitants of the
village of Morzines in Savoy became possessed. The victims
of this epidemic, who openly declared themselves to be
animated by the Devil, had to be isolated by the police in
order that public worship in the local church might proceed
uninterrupted, the clergy having failed to exorcise the demons.
In the year 1563 Dr. Johann Weyer, a French physician,
experimented upon some of these infatuated creatures, and
called the disease hystero-demonomania. By tying some old
women to their own bedposts he effectually proved that they
neither changed themselves into wild beasts, as they said they
could do, nor ate young children or corpses, as they—for some
strange reason and knowing the consequences—freely declared
they had done. I am indebted to Dr. Urquhart for bringing
under my notice the fact that Michael Scott’s Discovery of
Witchcraft , published first in 1584, was—for containing views
similar to those of Weyer—burned by the hands of the
common hangman by order of James I. Things reached a
climax in 1670, as the result of a trial for sorcery before the
Parliament of Normandy, at which it was affirmed on oath
that a rat had been seen talking to a child ten years old.
More than 500 persons were concerned in this affair, and 17
were condemned to death, which so disgusted Louis XIV that
he not only quashed the convictions, but forbade the parlia¬
ments from henceforward to conduct trials for witchcraft.
However we of to-day may reprehend the manner of dealing
with hystero-demonomania, we must in fairness distinguish
between the treatment of the insane under the rule of the
Church, and the punishment of the victims of epidemic delu¬
sional excitement by the ecclesiastical and civil authorities.

Under the influence of the Renaissance, the Reformation,
and the new metaphysical philosophy, the rule of the Church
relaxed, and the authority of the mediaeval dogmatic theology
was sapped and loosened. The tendency of the new movements
was to replace the supernatural agent of the theological con¬
ception by natural agents inherent in objects themselves. The
doctrine of vitalism replaced the concept of the variable action
of will, and in lieu of deities it imagined “ entities.” Hence

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1910.] BY JOHN MACPHERSON, M.D. 597

arose the theory of disease entities, which replaced the theory
of demoniacal possession as the causal concept of insanity.

The belief in disease entities is a mere transition from the
earlier belief in demoniacal possession, with this difference, that
whereas the demon might possibly be exorcised by spiritual
means alone, the entity could only be got rid of by disturbing
and drastic remedies of the nature of expulsants, which were
almost without exception injurious to the normal functions of
the body. The chapters in the history of the insane which deal
with the vitalist doctrine of disease entities are incomparably
the most repulsive of all, and we gladly pass over them in
silence, but we must in justice remember the temper and quality
of the times, which we cannot possibly compare with our own.
Hardships of all kinds, as we regard them, were very lightly
considered, and life was held cheap. The brutal and excessive
punishments inflicted for trivial offences, the gross medical and
surgical treatment, and the neglect and cruelty practised
towards the insane merely reflected the general tone of existing
manners and customs. Misconception on these matters has, on
the whole, been only too common, for we are apt to forget that
our forefathers were as anxious to confer benefits as we are.
It is in the kind of benefit that they, and we, hold highest that
the difference lies, and in the treatment of disease it is, of
course, the conception of what disease is believed to be that
distinguishes the medical methods of one age from those of
another.

II. Period of the Empirical Concept.

The empirical causal concept rests upon the more or less
invariable succession of phenomena. If the phenomenon A is
invariably followed by the phenomenon B, it is assumed that A
is the cause of B, even though it cannot be shown that any
causal connection exists between A and B. The fallacies of
the concept are numerous and obvious. For example, we
know that night invariably succeeds day, but in this particular
instance we also know that day is not the cause of night. Un¬
fortunately in too many other instances where knowledge is
imperfect we too readily incline to assume a causal relation
between succeeding phenomena where none exists. We can
trace the rise of the empirical causal concept from the decay

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of the metaphysical philosophy and through the rise of the new
materialistic philosophy. It was mainly, however, through the
writings of Darwin and the birth of the doctrine of evolution
that a new significance was given to the influence of the materia¬
listic philosophy in its application to science. It is true that
evolution belongs essentially to the ideal causal concept, which,
however, was at that date only faintly foreshadowed. The
more ardent materialists and Darwinians of the middle part of
the nineteenth century too readily assumed that they had
attained finality when in reality they were only embarking on
a great voyage of discovery. Psychiatry, no less than the other
medical sciences, was swept into the current of this enthusiasm,
and a movement commenced in the treatment of the insane, the
high tide of which we have just touched, which was of far-
reaching consequence to our specialty—indeed, it is not possible
to exaggerate the influence of this movement.

I can best illustrate the conception upon which it depended
by quoting the words of one of its most active and practical
exponents. In his presidential address to this Association in
the year 1872, Sir James Coxe, then one of the Commissioners
in Lunacy for Scotland, said (10): “But I am ambitious to see
them (medical superintendents) exercising their great and
legitimate influence in their respective districts, by pointing out
how mind depends upon matter, and how insanity is but the
expression of a faulty physical constitution having its origin in
causes which we can readily trace, and which, in a great
measure, are under our control.” Again, in the same address,
he said(ii): “As a rule recovery from insanity is due far
more to an adherence to the broad rules of hygiene than to
any peculiarity in the treatment. In supplying abundance of
food and clothing, in providing a comfortable lodging and bed,
in giving proper attention to cleanliness, and in affording ample
means of varied occupation and exercise in the open air, lies
the great secret of the successful treatment of insanity. Purga¬
tives, hypnotics, narcotics, and tonics are useful as auxiliaries;
but a comfortable meal is the best of sedatives, and abundance
of exercise the best of hypnotics ... it follows that
insanity is mainly the result of a deteriorated condition of the
body generally, and not in any exclusive manner of the nervous
system.”

To the same effect, but in a different strain, Maudsley wrote

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in 1870(12), and in 1879(13) : “ It is strangely overlooked
by many who write on this matter that the brain is not a dead
instrument, but a living organism, with functions of a higher
kind than those of any other bodily organ, insomuch as its
organic nature and structure far surpass those of any other
organ. What, then, are those functions if they are not mental ?
No one thinks it necessary to assume an immaterial liver
behind the hepatic structure in order to account for its
functions.” Again, “ if one could persuade or compel a strong
and turbulent maniac to plough a field, or row several hours a
day, or to walk twenty miles a day for a month, taking plenty
of nourishment the while, the treatment would do him more
good than he would get from all the drugs of the Pharma¬
copoeia.”

In quoting these views it is far from my intention to criticise
them adversely, much less to hold them up to ridicule. They
are honest, strenuous, and virile opinions, far too serious to be
lightly treated. My obj’ect is to exhibit the origin of a con¬
ception of insanity which has profoundly affected us for at least
fifty years. The first result of this conception that I shall
mention is, that it has been instrumental to a large extent in
unifying the standard of the care of the insane under official
cognisance throughout Great Britain and Ireland. It accom¬
plished this by gradually increasing the bodily comfort of the
insane and their hygienic environment in the larger and more
central institutions. By force of example, and by means of
the informative and stimulative influence of the central
authorities, the remoter and the less advanced local authorities
slowly raised their standard of care until, at the present time, it
is exceptional to find any insane person in this country who is
subjected to official supervision whose condition is conspicuously
faulty or seriously neglected. It has also removed defects and
abuses, so far as these are not inherent in any system which
deals with large masses of human beings, sane or insane. But
it did more than this. If the root cause of insanity were
physical deterioration, it followed that its treatment lay in the
direction of attempting to establish such an environment as
would most effectually restore the disordered functions of the
body as a whole. It therefore became a paramount duty to
provide a sufficiently nourishing dietary, tonic, bracing, but not
excessive exercise, sufficiently spacious and comfortable lodg-

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ment, and not only strictly hygienic buildings, but, as far as
possible, an amount of cheerfulness and brightness in the living
rooms which would react favourably upon the morbidly hyper¬
sensitive nervous organisations of the insane. Not only so,
but strenuous efforts were made to eliminate the “ institution ”
or “ barrack ” character of the larger asylums, and to conform
the surroundings as far as possible to those of ordinary
domestic life. Hence the open doors, the abolition of walled
airing courts, the villas, the farms, and a score of other devices.
The result has been that, taking everything into consideration,
the care of the insane in Great Britain has attained a more
uniform standard and a more general solidarity than in any
other country in the world. I do not say that there are not
better features to be found in many other lands, but certainly
nowhere else is there such a high average standard of good
care.

What, then, from the purely medical standpoint has been
the value of this system ? It has modified the more distressing
symptoms of the mentally disordered to such an extent as to
transform the whole aspect of insanity as a disease, compared
with the period immediately preceding. We hear occasionally
that the type of insanity is changing; there are no doubt
grounds for such a view, but to what extent it is true it is
difficult to say. One thing, however, is certain, that a lapse
from our present methods would result in a very striking
alteration in the conduct and demeanour of the insane under
care in our asylums. Again, the results of treatment in asylums
will bear strikingly favourable comparison with those in ordinary
general hospitals. The restoration of the disordered physical
symptoms, the discipline, the nursing, the exercise, the employ¬
ment in the fields, all when judiciously and discriminatively
employed, conduce to the recovery of from 30 to 40 per cent.
of all those admitted to our asylums. Can more than this be
hoped for, looking to the nature of the heterogeneous mass of
the various cerebral anomalies, physical diseases, and degenera¬
tive processes in the human system, which are loosely classified
under the heading “ insanity ” ? I am not prepared to answer
this question either in the affirmative or in the negative, but
content myself with saying that, in the then state of our
knowledge, the empirical method had amply fulfilled its
purpose. But this is just the point at which the critic enters

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with the accusation that our methods are altogether too
empirical. I fear we must accept service of this criticism, but
with the reservation that our critics have omitted to take into
account the vast and honourable progress we have made in
less than one hundred years, the services we have rendered to
humanity, and the high example we have presented to the world
of what can be accomplished on behalf of the most helpless class
of mankind. What has in this way been accomplished can never
be undone, however advanced our medical appliances and our
knowledge of disease processes as they affect the nervous
system may in the future become, for the art of medicine is
not limited to the exhibition of drugs. This concept of
insanity was no doubt a bold confession of ignorance, but a
confession devoid of reservations and of dishonest pretensions.
The conception, it must be admitted, is, however, too sceptical.
One may certainly treat diseases of the liver without assuming
an immaterial liver behind the hepatic structure, but a modern
physician would scarcely be justified in treating all diseases of
the liver on the principle of merely restoring the general
physical health, however successful the results of his practice
might be.

I cannot pass from this part of my subject without a brief
reference to the loss which this Association has sustained
through the death of two of its distinguished members who
were among the chief exponents in Scotland of the great
system I have endeavoured to describe. They were both
contemporaries of Coxe, and ardent apostles of the same views.
Sir Arthur Mitchell was a man who by his earnestness, his
learning, his strong will, his untiring energy, and his genial and
persuasive personality would have adorned any profession.
These exceptional qualities he devoted with all his might,
throughout a long career, to the good of the insane in this
country. Dr. James Rutherford, whose services to lunacy in
Scotland it would be difficult to over-estimate, carried into
practice the views of this vigorous school. As an administrator
he was bold to the verge of rashness, but many of his pioneer
enterprises are now in general use as ordinary methods of care
in Scottish asylums. In every departure he undertook—and
they were many—he seemed to be actuated by the desire to
ascertain the limits of the conditions of the personal freedom
of the insane compatible with their detention in institutions,

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and to conform, so far as that was possible, asylum life to
ordinary domestic conditions.

Throughout the earlier part of this empirical period, the
literature of the specialty will be found to be filled with theories
intended to effect an escape from an itnpasse then imagined to
be much less intricate than we now know it to be. These
theories illustrate, if nothing else, the keen unrest of the medical
spirit to emancipate itself and to pursue the study of mental
diseases on the same plane upon which general medicine
investigates the disorders of bodily organs. Violent diatribes
were copiously hurled against metaphysics and theology, which
were erroneously regarded as impediments to the freer accept-
tance of new pathological conceptions. That these accusations
were uncalled for is manifest, for there existed no pathological
data of any working value upon which to proceed, supposing
metaphysics or theology had never existed. “We ought,”
said Skae, in 1863, when submitting his famous classification
from the Presidential Chair of this Association, “ to classify
all the varieties of insanity, to use a botanical term, in their
natural orders or families ; or, to use a phrase more familiar
to the physician’s ear, we should group them according to
the natural history of each.” “ Why should we perpetuate
a nomenclature so indefinite and conventional, and which has
no other foundation upon which to rest than an imperfect,
if not an obsolete, psychology ? ” “ It has been supposed,”
wrote Griesinger in 1867, “up to the present time that the
study of mental disease was distinguished by some difficulty
sui generis , and that the study of ordinary medicine had no
direct bearing upon it—that the only entry to psychiatry lay
through the dark portals of metaphysics.”

But neither Skae nor Griesinger—the one by means of
nosology, the other by treating nervous and mental maladies
in the same clinique—could overcome impossibilities ; they
might fly within the limits of existing knowledge, but they
could not possibly overstep those limits. Nor did their
railings against metaphysics and psychology avail. Their
attempts to advance, which are illustrative of many others, are
typical examples of arguing in circles ; they convey an illusive
sense of progression, but ultimately they return to the point of
their departure.

During the very time when this ineffectual unrest against

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the limitations of existing knowledge was proceeding in this
country and in Germany, the French school were quietly
achieving momentous success by means of ordinary clinical
observation. Working v/ith the despised psychological termi¬
nology and the old empirical methods, and without the aid of
modern anatomical or physiological discoveries, men like
Esquirol, Baillarger, Bayle, Morel, Lasegue, and Falret
succeeded in establishing a new epoch in psychiatry.

Esquirol laid the foundation of paranoia by his description of
monomania, and, along with Bayle and Calmeil, described and
isolated general paralysis, the most important psychiatric dis¬
covery of the nineteenth century. In i860 Morel published
his treatise on hereditary degeneracy, showing for the first
time the connection between heredity and degenerative mental
and physical conditions, and describing the association of
physical stigmata with hereditary mental degeneration.

About the same time Lasegue published his ever-memorable
monograph on the insanity of persecution, delimiting that form
of insanity from the group of melancholias and monomanias
with which it had previously been confounded. Baillarger, and
later, Falret, described circular insanity, and taught us the
significance and importance of hallucinations of the senses in
mental disease. Finally, Magnan, who still survives—the
ultimus Romanorum of the group—has by his classical con¬
tributions to our knowledge of delusional insanity fittingly
crowned the labours of his famous predecessors.

The empirical method was, as we have seen, surpassingly
successful in the hands of the French school. Their empirical
method is just the method by which general medicine, before the
advent of the physiological reforms of recent years, achieved its
successes, so much so that in the case of certain diseases, for
example, phthisis, the discovery by Koch of the tubercle
bacillus added little or nothing to the existing symptomato-
logical knowledge of the disease. The discovery fitted into
the vacant gap in knowledge. It is the same with the
character of the teaching of the French psychiatric school of
the nineteenth century. By careful and laborious observation
the members of that school laid down the substratum of a
knowledge which future discoveries may widen but cannot
destroy. The mistake of many eminent writers (*) of the same
period lay in the belief that our methods of study and our

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system of classification were on wrong lines. Classification,
over which we have all along disputed, is an unfruitful subject
of discussion, for the very fact that we continue to wrangle
over it is the surest proof that our knowledge is obscure.
When our knowledge is perfected, and only then, shall we
have a perfect classification, and only then, probably, shall we
cease to dispute about it. The value of any classification lies
neither—within limits, of course—in the nomenclature nor in
the arrangement of diseases, but in so far as it enables us to
form more accurate conceptions regarding diagnosis, prognosis,
and treatment^ 14) To take one example : Clouston made a
distinct step forward when he wrote his description of adolescent
insanity, but Kraepelin greatly improved upon this knowledge
when he enabled us to see that the group of adolescent
insanities, among others, might be split up into two, one of
which from the commencement was doomed to dementia, and
the other of which did not tend towards dementia. Kraepelin’s
clinical work, whatever individual reservations may be held
regarding it, will hereafter be looked upon as the great
psychiatric achievement of the opening of the twentieth century,
for the sole reason that it has advanced our conceptions of
diagnosis and prognosis. It is a striking example of what can
be attained under the empirical method. The purely empirical
concept, as exemplified by the work of the French school in the
last century, and by Kraepelin in this, is sufficient reminder
to us that we are far from having exhausted the resources of
the method, and that great undeveloped opportunities lie before
us ere it is replaced by the rapidly approaching ideal concept
of causation. In this present time, which in certain particulars
is a transition period, it is unfortunate that so many appear to
be discouraged from pursuing clinical investigation because of
the more brilliant results of laboratory research. There could
scarcely be a greater mistake. Laboratory research demands
as highly technical a training as violin playing, and it is impos¬
sible that those who devote their lives to it—as, to be efficient,
they must—can at the same time acquire an adequate proficiency
in clinical knowledge. The purely scientific investigator must
be dependent for advice and information upon the clinician,
without whose aid he cannot advance successfully. If the
clinician cannot supply the pathologist with a satisfactory
description of clinical processes, then assuredly the pathologist

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cannot ascertain for him what he should investigate, or tell him
what lines of inquiry to follow.

It is for reasons such as these that many of us desire a
closer union between general medicine and psychiatry by the
establishment in every university in this country of a chair of
psychiatry, the occupant of which should be the head of a
clinique in the connected medical school, as is the case in every
one of the score or so of German universities. Only in this
way can scientific research and clinical investigation mutually
benefit one another, and the study of mental disease be carried
on on an equality with that of other bodily diseases. The
proposal emanating from this Association, and now under con¬
sideration, which has been most favourably received by every
interested medical school and public department to which it
has been submitted, to establish post-graduate courses and
diplomas in psychiatry is from this point of view of the first
importance, and may lead to consequences of great value.

III. Period of the Scientific Concept.

From the point of view to which I have endeavoured to give
prominence in the preceding remarks, the progress of psychiatry
has been evolutionary, and its evolution has been dependent
upon the development of certain phases of human opinion,
aided by the influence of the basal causal concepts. The main
feature of the scientific concept is continuity—the passing over
of the cause into the effect so that they become identical. It
is manifest that until we possessed such a knowledge of the
minute anatomy of the cerebral cortex as we now do, a proper
realisation of the scientific concept of causation was an impossi¬
bility. For this knowledge we owe an unceasing debt of
gratitude to Professor Bevan Lewis, who has just vacated this
Chair. His pioneer studies in cortical lamination alone, to say
nothing of his pathological researches, have not only enriched
our knowledge, but have helped to lay the foundations of a
new epoch. Bevan Lewis, Cajal, Golgi, Nissl, and Flechsig, to
mention a few of the principal workers in this sphere, have laid
down the stepping stones over which we are slowly passing
from the old order to the new. On the physiological side,
again, we must recognise the value of cerebral localisation, the
mapping out of the different cortical functional areas, which we

LVI. 40

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owe, among others, to Hitzig, Ferrier, and Horsley. Finally,
we have to take into account the work of numerous neurologists
and pathologists who have described the effects of cerebral
lesions upon sensation, motion, speech, and thought.

The first effect of the advent of the new concept has been to
alter our attitude towards those psychic and moral causes which
were formerly accepted without question as fully accounting
for the incidence of insanity. As this is of the very essence of
the scientific causal concept, I feel that I must be quite explicit.
It would be absurd to deny that moral or psychic events, which
produce mental shock or prolonged worry, do not act injuriously
upon the nervous system ; we may even go a step farther and
admit that they may produce psychic lesions of a functional
nature, whatever meaning we may choose to assign to such an
indefinite phrase. But a statement like this does not satisfy the
new conception. Suppose, for example, an individual, on the
receipt of bad news, or under the influence of strong emotion,
is suddenly stricken down with cerebral apoplexy. Such a
case has never occurred in my experience, but I can conceive
its mechanism, and I am bound to accept credible medical testi¬
mony on this point, however sceptical one may be of similar
accounts in lay literature. Should such a case occur in the
practice of a modern physician, he would at once proceed to
locate the cerebral lesion, to estimate its extent, to examine the
arterial system and the blood-pressure, and to base his diagnosis,
prognosis, and treatment wholly upon these clinical facts. In
such a case the extravasation of blood from a sclerosed vessel,
say in the corpus striatum, in a man past middle age with a
gouty constitution, make up the chain of facts which alone
satisfies the demands of the scientific causal concept. While
the moral shock is interesting as an interpolating event, which
suddenly raised the blood-pressure (which many other circum¬
stances might equally have done), the pathological chain of
causes passes without interruption into the culminating event—
the apoplexy. If I have made myself clear, and if I have con¬
vincingly stated the case, we perceive at once the essential
difference between the empirical and the scientific causal
concepts, as they affect our views of disease. But when we
pass from a consideration of the grosser nervous diseases of the
brain to the more purely mental affections, we are at once con¬
fronted with numerous difficulties, which at first sight appear

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insuperable. Before I discuss these difficulties, it is well to
mention the retiological advances in psychiatry which the
scientific causal concept has almost imperceptibly achieved
within the past few years. Not many years ago general
paralysis, perhaps the most minutely studied of all forms of
insanity, presented, to the ordinary psychological methods of
examination, such a variety of symptom, especially in its earlier
stages, as often to lead to mistaken diagnosis. When, two or
three years ago, Wassermann discovered his now famous
reaction, the aetiology of the disease was at once transferred
from the empirical to the scientific category of causation.
Thyroid insufficiency, as exhibited in endemic and sporadic
cretinism, and in the myxcedema of adults, gives rise to a
definitely characteristic set of symptoms, which, although we do
not yet fully understand thyroid action, are sufficient to justify
us in placing this group also in the sphere of the new concept.
An immensely important new field of investigation is all but
explored—the study of the production of arterio-sclerosis.
When the influence of the supra-renal capsules and the equally
important influence of exogenous and endogenous toxins upon
blood-pressure and arterio-sclerosis are better understood, we
shall at once enter upon a vast fund of explanatory knowledge
touching innumerable phases of mental decay.

The second effect of the influence of the scientific causal
concept is evidenced by the gradual replacement of the belief
in disease entities, which has descended to us through the
centuries, by the concept of “ syndromes ” dependent upon
underlying cerebral lesions. Instead of thinking of, say,
“ mania ” or “ melancholia ” as disease entities, we prefer to think
of them as “ syndromes,” which we are content to designate by
the same names. To say that we are merely juggling with words
in so doing is to miss the whole significance of the altered
attitude. Lugaro (1 5) defines syndromes as “ groups of symptoms
associated together by some common factor in the anatomical,
physiological, and pathological conditions.” Mania and melan¬
cholia, for instance, may either occur apart from one another, in
which case they are separate symptoms of one or more patho¬
logical conditions, or they may occur as parts of the complex
syndrome which was first described by Kraepelin as manic-
depressive insanity, in which latter case they are symptoms of
another and different type of pathological condition. As

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Lugaro(i6) aptly illustrates, “progressive blindness—due to
atrophy of the optic nerve—and loss of the patellar reflex
undoubtedly occur separately as the result of different causes,
but their association suggests the action of a tabetic process,
the late result of a syphilitic infection.” That we are still far
from a knowledge of the pathological conditions which under¬
lie the various mental syndromes is only too true, but we have
advanced so far as to realise the utility of substituting the
syndrome for the disease entity. When we have still farther
advanced, the psychological syndrome will have become sub¬
sidiary to a knowledge of the underlying pathological condition.

A third effect of the scientific causal concept has been to
define the limits of our knowledge respecting the functions of
mind and matter as they enter into the mysterious combination
of human personality, and to simplify our views of the nervous
system. At last we are freed not only from the older meta¬
physical doctrines, but also from the teaching of the materialistic
philosophy. Not that we know what mind is, but that we are
content to believe that we may never know ; nor do we claim
to know what matter is. In his magnificent exposition of
sceptical philosophy Professor Karl Pearson (17) says: “We
are like the clerk in the central telephone exchange, who
cannot get nearer to his customers than the end of the
telephone wire. We are, indeed, worse off than the clerk, for,
to carry out the analogy properly, we must suppose him never
to have been outside the telephone exchange, never to have
seen a customer—in short, never, except through the telephone
wire, to have come in contact with the outside universe. Of
that ‘ real ’ universe outside himself he would be able to form
no direct impression ; the real universe for him would be the
aggregate of his constructs from the messages which were
caused by the telephone wires in his office. About those
messages, and the ideas raised in his mind by them, he might
reason and draw his inferences ; and his conclusions would be
correct—for what ? For the world of telephonic messages, for
the type of messages which go through the telephone.” To
this picture of our limitations we must humbly subscribe.
Each of us constructs from our sense-impressions a phenomenal
world, and the fact that the phenomenal world of one man
closely resembles that of another is a sufficient proof of the
similarity of the nature of the sense-impressions which proceed

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from the environment of each of us, as well as of the identity
of the functions and structure of the human nervous system.

Upon the clarity of our views of the functions of the nervous
system will depend, largely, our conception of insanity. To
guard against confusion in this respect we must most carefully
define to ourselves what we mean by such expressions as
“ stored impressions,” “ mental pictures,” “ centres for the
association of ideas,” and a host of similar phrases. It may
be replied that these are legitimate psychological terms. But
psychology is one science and physiology is another.
Undoubtedly there have been great achievements in the
psychological investigation of certain types of nervous affection
by such men as Janet, Freud, and Jung, of which I am not
qualified to speak, but any measure of success attained by such
men has been attained because they adhered strictly to their
own empirical psychological methods.

We can hardly open a treatise on psychiatry or a text-book
on neurology which does not contain references to “ latent
images,” ‘‘deposited memories,” or “association centres.” It is
no wonder that lay literature should follow suit, and that a
paragraph like the following can appear in a leading English
review.(18). Writing of a famous novelist the author says:
“When the mind in question glows with a larger number of
stored-up images of anterior perceptions than are wont to be
deposited in any save the most sensitive brain stuff, every
fresh onset of outside sensation produces a wonderful chromatic
emotional atmosphere.” If this sentence suggests anything
comprehensible, it conveys the idea that the brain is a photo¬
graphic apparatus, and that each cell is a kind of sensitive
plate which not only records images of the outside world, but
stores them and reproduces them at will. A more unthinkable
proposition was never formulated.

Even such an eminent physiologist as Flechsig writes of
“ association centres ” and “ intellectual areas ” as if these
actually existed. As Hoffding says, in his criticism of Flechsig
on this point : “ The psychological inadequacy of his concept
of association sufficiently shows how difficult an undertaking it
is to replace psychological with physiological conceptions.”

Are we, then* to be debarred from the use of psychological
terms in our description of mental diseases when there is
scarcely a term in general use in psychiatry which has not had

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a psychological origin ? To the use of these symbolic terms
objection would be futile, if not harmful, but it must always be
remembered that they are only symbols of symbols ; the danger
lies in thinking psychologically while we are acting physio¬
logically, and for that reason it is necessary that we should
accept with strict reservation such cardinal psychological ideas
as “stored impressions,” “deposited images,” and “intellectual
areas.” Any semblance of valid argument in favour of
“ deposited memories ” and “ stored images ” is deduced from
the cerebral pathology of aphasic conditions, but when the
facts are carefully analysed it vanishes absolutely, and we see
that it is the faculty of recollection which is weakened or
abolished when the local sensory or motor centres are diseased
or the connecting fibres or neurons between these centres are
injured.

The physician who attempts to reconcile physiological and
psychological methods is attempting the impossible, for the
scientific causal concept cannot operate in the sphere of
psychology. Psychical states are discontinuous, often unrelated
to one another, immaterial, non-spatial, qualitative, and, for all
these reasons, non-measurable. Physiological states, on the
other hand, are related to one another, continuous, material,
spatial, quantitative, and therefore measurable. All our certain
enduring advances have been made in the physiological field.
We often regret the tardiness of our progress, but we should
not forget that every inch gained physiologically is solid,
irrefutable ground which may be safely built upon.

What, then, should be our conception of the nervous system ?
For what it is worth I give the conception I myself incline to.
The nervous system, in its psychic aspects, will probably
always remain a mystery, but there is no greater or more
insoluble mystery in the higher cerebral than in the lower
spinal centres. We imagine we understand a spinal reflex
action. If we do—and we need not cavil over the point—then
I hold emphatically that in the same physiological sense we
understand all the functions of the nervous system. The
nervous system, when all is said, is a sensori-motor mechanism
of various degrees of complexity. It is constantly acted upon
by perturbations from the material world, including those of
its own living habitat, the body, and is constantly responding
to these perturbations. But—and herein lies a difficulty—it

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PRINCETON UNIVERSITY

i9io.]

BY JOHN MACPHERSON, M.D.

61 I

selects from the mass of the material impressions constantly
impinging upon it certain impressions and ignores others, which
are either not received or remain subconscious. The selected
impressions are those conveying ideas of benefit or danger to
the individual, and according as the impressions belong to the
one or the other of these categories the nervous system reacts
upon the external world. Whether the reaction is actually trans¬
mitted into motion or merely remains latent an intention to act
is formed, and that intention is the flash-point of momentary
consciousness. The frequent repetition of a sensori-motor reaction
establishes an habitual memory, whether the reaction takes
place in the spinal cord or in the highest cortical centre, which
memory must be most carefully distinguished from the psychic
act of “ recollection.” We can each of us recall what we please ;
at any moment we can summon up our sins, sorrows, joys, or
past experiences, real events or imaginary events, and, more
wonderful still, we can tack these or any of them on to the
actual consciousness of the moment, and sail off into an
imaginary future with this motley congeries of ideas. When
we reach this plane we are, in my humble opinion, in the
region of the Psyche, and neither psychology nor physiology
can explain it.

It is open to anyone to formulate any theory he pleases
regarding the “ Psyche ” ; with such theories I have here no
concern. My object has been to show that there is a gap in
our knowledge which may never be bridged, and at the same
time to urge that our obvious duty as psychiatrists is to work
our laborious way up to the edge of our side of this gap by
means of the ordinary methods of investigation ; there is suffi¬
cient to occupy all our energies in this task for many long
years.

Gentlemen, I have done. I should have liked to refer
to some of those profound changes which the scientific causal
concept is almost certain to affect in the theory and practice
of the future, but time does not permit.

I have endeavoured to review the history of those main con¬
ceptions of insanity which have profoundly influenced our own
opinions on the subject and those of our predecessors from a
very early period. I have also endeavoured to show that,
running through and modifying these conceptions, from the
introduction of Christianity into Europe until the present time,

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612 LUNACY ADMINISTRATION IN SCOTLAND, [Oct.,

has been the strong religious element of altruism which has
actuated and moulded every sincere effort for the better care
and treatment of the insane. When we hear it said, not infre¬
quently on high authority, that these efforts are fanciful, or
wasteful, or incommensurate with utilitarian results, we may
calmly assure ourselves that the forces fighting for us are
infinitely stronger that those against us, and that the harsh
tenets of the philosophy of Nietzsche cannot prevail against
that older, milder gospel of which Tolstoi is the modem
prophet.

(*) It must, however, be frankly admitted that the teaching of Morel and of
Skae had the effect of introducing into psychiatry the essential clinical element
of physical symptoms correlated with mental symptoms.

References.

(1) Hoffding, Problems of Philosophy , p. 66.

(2) Hereditary Genius, p. 329.

(3) Social Life in Greece, chap. v.

(4) History of Philosophy, vol. i, p. 405.

(5) Benjamin Kidd, Social Evolution, p. 149.

(6) History of European Morals , vol. ii, p. 114.

(7) Body and Mind, p. 117.

(8) Journal of Mental Science, vol. xii, p. 326.

(9) P. 106.

(10) Journal of Mental Science, vol. xviii, p. 333.

(11) Loc. cit., p. 318.

(12) Body and Mind, pp. 324-5.

(13) Pathology of Mind, p. 563.

(14) Dr. Bernard Hart, Journal oj Mental Science, vol. liv, p. 458.

(15) Problems in Psychiatry, p. 224.

(16) Loc. cit., p. 225.

(17) Grammar of Science, p. 61.

(18) Quarterly Review, April, 1910, p. 408.

(19) Problems of Philosophy, p. 35.

Lunacy Administration in Scotland , with Special Refer¬
ence to the Royal Asylums.?) By A. R. Urquhart,
M.D., F.R.C.P.E., Royal Asylum, Perth.

The legal system .—Scotland is fortunate in its legal system,
which has proved elastic enough to permit of the adoption of
new ideas as they ripen and mature. The representative of
law and order in each county or group of counties is the
sheriff, an advocate of proved skill and experience who visits

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PRINCETON UNIVERSITY

JOURNAL OF MENTAL SCIENCE, OCTOBER, 1910.

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A (Hard &r Son, Impr.

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PRINCETON UNIVERSITY

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BY A. R. URQUHART, M.D.

613

his sheriffdom at intervals to deal with such cases as may be
submitted to his judgment. He hears appeals from the decisions
of his substitute, who is also an advocate selected by the Govern¬
ment in recognition of his abilities, and who resides within his
own jurisdiction. Thus, legal matters are dealt with by lawyers
who are competent and accessible. They are distributed over
the country in positions of independence, and hold their courts
in such manner as to command the respect and confidence of
the people. The tendency is to decentralisation, to demand
of the sheriffs more work and more important work. For
instance, it is often necessary to appoint a curator bonis to an
incompetent person. Formerly that appointment was invariably
made by the Supreme Court, the Court of Session in Edinburgh.
But the expense of that procedure bore heavily upon the
poorer class, and therefore it was enacted that the Sheriff
should deal with those cases, provided that the annual value of
the estate does not exceed .£100 yearly.

In the year 181 5 an Act of Parliament put lunacy administra¬
tion in some semblance of order. The sheriffs were empowered
to grant licenses for keeping asylums, inspectors were elected,
it was laid upon the sheriffs to grant orders for the detention
of insane persons on medical certificates and to ascertain if
they were properly confined. The results were not satisfactory.
Great numbers of the insane were in a deplorable condition until
the middle of the last century. They had many and power¬
ful advocates, but those were unable to persuade Parliament to
effective action. The royal asylums had been provided, and
numerous private asylums existed, but they were unable or
unfitted to cope with the necessities of the insane. In 1837
Dr. W. A. P'. Browne wrote a memorable book on asylums,
“ as they were, are, and should be,” and many others might
be named who were urgent in their endeavours to induce the
country to do justly by the insane. The advent of Miss Dix
“ the American invader,” in 1855, was a crucial point in those
long-drawn debates. To her is due the credit of obtaining a
Royal Commission of Enquiry, and upon the report of that
commission the present Lunacy Law of Scotland was established.

Statistical notes .—Appended is a table showing the distribu¬
tion of the insane on January 1st, 1858, compared with the
conditions at the beginning of last year, as reported by the
General Board of Lunacy :

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6 14 LUNACY ADMINISTRATION IN SCOTLAND, [Oct.,

Statistics of January 1 st, 1858 and 1909.

Poorhouses j n

Class.

Year Public

' asylums.

Private District Idiot
asylums, asylums, schools.

parochial

Total.

Private ,-f

196 . O

• 23

asylums.

6 . ? .

1011

l .

1909 . 1940

. 90 . 329

. 204

. 0 . 119

2682

Pauper . '

1858 . 1594

. 520 . O

• 833 . 1784 .

4737

1909 . 1701

O . 9380
or

Females.

. 261

. 1296 . 2877 .

I 55 I 5

Yfar,

Males.

Total.

Proportion to population.

.858

2718

3030

5748

. = I in 522

1909

. 8892

9305

18197

. = 1 in 268

The main features of this statement are: (1) the great
increase of reported insane persons between 1858 and the end
of the year 1908 ; (2) the increase in proportion to the popu¬
lation of Scotland ; (3) the great increase of private patients,
and the moderate increase of pauper patients in the royal
asylums; (4) the development of district asylums with a
certain proportion of private patients; (5) the abolition of
private asylums in respect of pauper patients, and the notable
diminution of private patients maintained in them ; (6) the
great increase of idiots in training schools; (7) the great

increase in licensed poorhouses, and the number of boarded-out
pauper insane.

A general increase of the cases of mental defect and

disorder is common national experience. It is largely due to
better methods of dealing with them. When the statement is
scrutinised there are familiar reasons in explanation of the
statistics, but in Scotland, at least, there are signs that the

high-water mark possibly has been reached. The Com¬

missioners give the following table showing the proportion of
the insane per 100,000 of the estimated population of Scotland
since 1904 :

January 1 st. Private. Pauper. Total.

1904 . 52 . 307 . 359

1905 . 52 . 311 . 363

1906 . 51 . 312 . 363

1907 . 50 . 312 . 362

1908 . 51 . 314 . 365

1909 . 51 . 315 . 366

The rise last noted was due to accumulation, as the Com¬
missioners show a diminution in the numbers placed on their
register in the last-named year.

Original from

PRINCETON UNIVERSITY

i9io.]

BY A. R. URQUHART, M.D.

615

District asylums .—The Lunacy Act provided for most
urgently required accommodation by the erection of district
asylums. It had become evident that the royal asylums could
not cope with the wants of the country, and, indeed, they have
not shown any considerable increase in the numbers of their
pauper patients, while the private asylums no longer deal with
that class. Broadly the position in 1855 was that the royal
asylums could not meet the demands made upon them ; it
was imperative to provide suitable accommodation and to
extinguish unsuitable. That was made a national undertaking
on lines which have stood the test of time and demonstrated
the wisdom and prescience of those who initiated it. Contracts
were entered upon between the district lunacy boards estab¬
lished by the Act and the directors of royal asylums in
localities where the arrangement was and continues appropriate,
but it was immediately evident that contracts for the erection
of district asylums were called for imperatively, and in a few
years these were opened in Inverness-shire, Banffshire, Perth¬
shire, Argyllshire, Stirlingshire, Fifeshire, Ayrshire, Midlothian,
Haddingtonshire, and Roxburghshire. Later additions were
made, such as Lanarkshire, Glasgow, etc. The following table
(p. 616) shows the present establishments, and the distribution
of the insane in Scotland on January 1st, 1909.

It will be observed that the royal and district asylums
largely predominate in the above printed return, that they deal
with private and pauper patients to the number of 13,350, that
the private asylums contain only 90 private patients and
not one pauper. The Commissioners found that the great
majority of the private asylums of 1855 were unsuitable in
every respect. Many of them were abolished within a few
years, and a dark chapter in Scottish history was closed. The
shameless competition for unfortunate persons at rates of main¬
tenance which could not be regarded as sufficient was brought
to an end, not so much by the operations of law as by steady,
calculated pressure which extinguished the unfit. On the
other hand, those few private asylums which survived continue
to serve a useful function, and to fulfil modern requirements for
those who prefer the privacy of houses directed by distinguished
physicians.

The parochial asylums are few in number, and require
some explanation. They are practically poorhouses with un-

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PRINCETON UNIVERSITY

6i6

LUNACY ADMINISTRATION IN SCOTLAND, [Oct.,

Asylum.

Name of superintendent.

Number of patients.

Total.

Private.

Pauper.

Aberdeen Royal Asylum

Dumfries Royal Institution

Dr. Reid .

'39

160

233

266

79 S

Dr. Easterbrook

217

266

155

190

826

Dundee Royal Asylum .

Dr. T. Mackenzie

—

Edinburgh Royal Asylum

Dr. Robertson .

196

234

'56

73 S

Glasgow Royal Asylum .

Dr. Oswald

'77

235

4'4

Montrose Royal Asylum

Dr. Havelock .

255

292

673

Perth Royal Asylum

Dr. Urquhart .

—

127

Aberdeen District Asylum

Dr. Alexander .

—

220

194

4>4

Argyll District Asylum .

Dr. Shaw . . . .

220

21 I

463

Ayr District Asylum

Dr. MacRae

I I

258

25'

537

Banff District Asylum .

Mr. Fowler

188

Dundee District Asylum

Dr. T. Mackenzie

—

189

214

403

Edinburgh District Asyium .

Dr. Keay .

—

361

3S0

74 '

Elgin District Asylum .

Mr. Hendry

166

Fife District Asylum

Dr. Turnbull

—

I I

287

310

60S |

Glasgow District Asylum, Gartloch

Dr. Parker

—

404

361

765

„ „ >. Lenzie .

Dr. Marr . . . .

—

555

5'7

1072

Govan District Asylum, Hawkhead

Dr. Watson

316 249

577

Haddington District Asylum .

Mr. Macrae

157

Inverness District Asylum

Dr. Mackenzie .

345 355

7>5

Kirklands Asylum, Bothwell .

Dr. Skeen

—

114

I Oo

222

Lanark District Asylum

Dr. Kerr .

473

383

937

Midlothian District Asylum .

Dr. Mitchell

152

126

325

Perth District Asylum .

Dr. Bruce.

186

185

374

Roxburgh District Asylum

Dr. Johnstone .

'52

150

336

Stirling District Asylum

Dr. Campbell .

37 '

300

7°9

Totals in royal and district asylums

999

1270

5626

5455

13350

Balgreen.

Sir John Batty Tuke

—

s :

New Saughton Hall

Do. and Dr. J. Batty Tuke

Westermains.

Mr. Lawrie

Totals in private asylums .

—

Greenock Parochial Asylum, Greenock.

—

'35

120

255

Paisley Parochial Asylum (Craw Road), Paisley

—

Paisley Parochial Asylum (Riccartsbar), Paisley

—

112

210

Totals in parochial asylums .

—

275

285

560

Lunatic Wards of Poorhouses with unrestricted Licences.
Buchan Poorhouse .

5 '

Cunninghame Poorhouse .

—

Dumbarton Poorhouse

—

Dundee East Poorhouse .

—

Govan Poorhouse

—

'94

Inveresk Poorhouse .

—

Kincardine Poorhouse

—

Linlithgow Poorhouse

—

Long Island Poorhouse

‘

—

Old Monkland Poorhouse .

—

Perth Poorhouse

—

Wigtown Poorhouse ,

—

Totals in poorhouses with restricted licences

—

370

366

736

General totals

1030

1329

6271

6106

14736

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PRINCETON UNIVERSITY

BY A. R. URQUHART, M.D,

617

IQIO.]

The Daily Rate of Maintenance for Each Mode of Providing
for the Pauper Insane in Each County of Scotland during
the Year ending May i$th, 1908.

COUNTIES.

In royal,
district,
and

parochial

asylums,

and

training

schools

for

imbecile

children.

licensed
wards of
poor-
houses
with

restricted

licenses.

private

dwellings.

General
averages.
(This also
includes
the extra
expendi¬
ture for
certifi¬
cates of
lunacy,
cost of
transport,
etc)

Percent

royal,

district,

and

paro¬

chial

asy¬

lums,

and

training
schools
for im¬
becile
child’n.

age of p

licensed
wards
of poor-
houses
with re¬
stricted
licenc’s.

Itients.

private

dwell¬

ings.

5. d.

s. d.

5. d.

1. Aberdeen .

1 7 i

0114

1 6 f

82*2

1 r6

2. Argyll

* 3

—

Ilf

1 3

81'4

—

186

3. Ayr .

• 5 i

O IOf

Ilf

1 4

73 ' 1

164

105

4. Banff .

I 2f

—

iof

1 ii

70'3

—

297

5. Berwick

* 7

—

lof

1 54

708

—

29'2

6. Bute .

1 2}

—

1 3

813

—

187

7. Caithness .

1 9 i

I 24

9 f

1 4 f

52-0

1 '9

46' 1

8. Clackmannan

« si

I 64

1 5 f

806

i '5

*79

9. Dumbarton.

i 6

0 II t

1 4 f

65 '1

20 ' I

i4’8

10. Dumfries .

1 3 f

—

Ilf

1 3 i

886

—

11 '4

11. Edinburgh .

1 94

0 84

1 8

757

1 '3

23-0

12. Elgin .

1 3 i

—

10J

1 3 f

807

—

193

13. Fife .

1 5

—

1 5

85'9

—

141

14. Forfar.

1 6$

I 4 f

i 6

728

i 7'3

15. Haddington

1 5

0 9

1 5

87-8

6-5

16. Inverness .

1 3 i

1 64

9 f

1 if

55 ‘i

2-4

42-5

17. Kincardine.

1 9

0 nf

1 74

760

167

18. Kinross

1 5

—

lol

1 5

967

—

19. Kirkcudbright

1 4

—

1 4

90'5

—

20. Lanark

1 Si

1 if

1 5

789

5'6

i 5'5

21. Linlithgow .

i 6

I 45

1 6

707

183

iro

22. Nairn .

1 4

—

ioj

1 3

74 ’°

—

26'0

23. Orkney

1 9 f

—

9 f

666

—

33'4

24. Peebles

1 si

—

1 5 f

976

—

2'4

25. Perth .

1 5 j

I 2 4

1 4 f

775

157

26. Renfrew

1 6*

1 2j

1 6f

883

27. Ross .

1 3 f

—

I I

565

—

43'5

28. Roxburgh .

1 7

—

1 7

88 - i

—

11 '9

29. Selkirk

1 7 i

—

1 7 f

9 i '9

—

30. Shetland

1 9k

—

i 6

66' 1

—

339

31. Stirling

1 54

I 3

1 5 i

804

1 '5

18'1

32. Sutherland .

1 3 i

—

1 U

660

—

340

33. Wigtown .

1 3 i

1 04

10I

1 3

64^0

163

197

General averages

i 6

1 ii

1 5 f

76-8

i8'4

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618

LUNACY ADMINISTRATION IN SCOTLAND, [Oct.,

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restricted licences. It has been a feature of Scottish adminis¬
tration to license wards in poorhouses for the reception of
chronic and harmless patients. These parochial establishments
are not used for those who require curative treatment, nor are
they used as reception houses where acute cases may accumulate
until it is convenient to send them to the asylums. They
receive cases from the asylums for whom expensive treatment is
not required and for whom boarding-out is not considered ex¬
pedient. It will be seen from the return that there are only 736
patients distributed among twelve poorhouses. On the other
hand, parochial asylums ( J ) are not restricted to the reception of
chronic cases, but are rather a survival of less satisfactory
methods of administration. Certain parishes owning asylums
have been granted District Boards of Lunacy, and so conform
to the description of district asylums, such as Dundee and
Govan. It is felt that district asylums might be empowered to
add accommodation for private patients and thus increase their
usefulness, and it will be observed that even as matters stand
there is a movement in this direction. There were no district
asylums in 1855, and now they deal with 9,380 patients of the
pauper class, besides 329 who are wholly maintained from
private sources.

The boarding-out system .—No discussion of Lunacy Adminis¬
tration in Scotland is complete without reference to the board¬
ing-out system ; but it has been so often described in detail that
it is unnecessary to do more than point out that the patients so
maintained have apparently greatly increased in numbers, that
their condition is favourably reported upon by the Deputy
Commissioners, and that the country is fortunate in continuing
this method of administration, which returns chronic patients to
home life and at the same time lessens the national expenditure
upon the insane.

The poor private insane .—There is a large class of private
patients who are in poor circumstances, and the following table
shows the rates of board per annum charged by the royal
asylums in the endeavour to meet their narrow means, especially
assisting those who belong to the locality served by each :

Royal asylum. Minimum rate.

£ s. d.

Aberdeen . . . 30 o o

Dumfries . . .2500

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BV A. R. URQUHART, M.D.

619

Royal asylum. Minimum rate.

£ s. d.

Dundee . . . 25 o o

Edinburgh. . . 32 10 o

Glasgow . . . 26 o o

Montrose . . . 25 o o

Perth . . . . 30 o o

By these moderate payments it is sought to conserve that
spirit of independence which animated Scotland, and to avoid
the necessity of appealing for help to parochial authorities.

The royal asylums of Scotland were established by the
exertions and benevolence of private individuals long before
legislative enactments compelled the erection of asylums for
pauper patients. They are also called chartered asylums,
because each has a Royal Charter of Incorporation. At first
they all received pauper as well as private patients, but, later,
there has been a tendency to reserve them in whole or in part
for the insane of the middle classes. It has been felt that the
charity of the founders should not form a grant in aid of the
ratepayers to relieve them of the obligations imposed by law.
The royal asylums are seven in number, and the oldest is at
Montrose, erected in 1781. The only aid given by the
Government to these asylums was a grant of ,£2,000 in favour
of Edinburgh, the erection of which was advocated specially
for those who belonged to the cultured classes and those who
were in straitened circumstances. Of the seven royal asylums
five were built by public subscription, and two were endowed
by charitable founders. There is reason to believe that no
other country proportionately to its population and resources
voluntarily did so much for the care of the insane in advance
of the laws which now govern administration. Unfortunately
this practical benevolence has been swamped by the necessarily
compulsory erection of district asylums, and it is now uncommon
to find charitable persons aiding the royal asylums by endow¬
ment. Mr. T. YV. L. Spence, Secretary of the General Board
of Lunacy,has reminded us that in 1857 the great bulk of the
insane in Scotland, both of private and pauper patients, so far
as they were in institutions at all, were provided for in royal
asylums, in regard to which the Royal Commissioners expressed
themselves as being gratified “ to be able to report that they
are in many respects in a highly satisfactory state.” A perusal

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620

LUNACY ADMINISTRATION IN SCOTLAND, [Oct.,

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of that report shows clearly that, viewed in the light of their
own time, these asylums were, as a rule, excellent institutions
providing in an enlightened and humane manner for the care
and treatment of the insane committed to them. Some fifty
years ago the directors of Murray’s Royal Asylum found that
the Charter did not permit them to receive paupers, although
they were empowered to admit local patients not belonging to
that class at such unremunerative rates as they might think
fit. Within recent years the Glasgow Royal Asylum has been
similarly set apart for the admission of private patients only,
and the Royal Edinburgh Asylum, by authority of the Court,
has been freed from the incubus of maintaining pauper patients
for less than they cost. There is an equivocal meaning under¬
lying the word “ pauper.” Mr. Spence showed some years ago
that four-fifths of the paupers under cognisance of the board
were reduced to that status solely by reason of their mental
inability. They were obliged to seek relief from parochial
rates for that very reason, so that the burden of insanity falls
upon the people in a manner that can be discriminated from
the ordinary obligations of parish councils. (The inspector of
poor, the official of the parish council, is bound to deal with
the case of any insane person submitted to his notice, whether
rich or poor. Naturally those who are under the protection ■
of their friends and in reasonably good circumstances do not
require the interference of the inspector of poor and the aid of
the parish council, but the law provides this general remedy in
case of difficulties occurring.)

In 1855 it was found that the total capital expenditure
made by the several royal asylums for lands, buildings, and
furniture, amounted to .£352,632. That sum has been steadily
increased year by year, mainly out of surplus revenue derived
from the maintenance of well-to-do patients, until it amounts
to considerably more than a million pounds sterling.

The Elgin District Asylum was also built in a remarkably
public-spirited manner on ground given by the Trustees of
Gray’s Hospital. The proprietors of the county agreed to a
voluntary assessment to defray the expense of the erection of
the asylum, which was opened in the year 1835, and eventually
came under the Lunacy Act of 1857 as a district asylum.
Before that year it was a small public asylum, containing forty-
three patients.

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Original from

PRINCETON UNIVERSITY

i9io.]

BY A. R. URQUHART, M.D.

62 I

About the year 1855 a strenuous attempt was made to
erect an asylum at Inverness, and subscriptions were obtained
to the amount of .£5,000. That money was not used for the
purpose, for the Lunacy Act made provision for the erection of
a district asylum at the cost of the county and the subscriptions
were returned.

Aberdeen Royal Asylum , founded in connection with the
Infirmary, under the same managers ; built by voluntary con¬
tributions. Opened in 1800; later, rebuilt and disjoined from
the Infirmary, which had been unduly benefiting by the joint
management. Consists of four main buildings: (1) The
original house containing both pauper and private patients at
low rates of board ; (2) in the immediate proximity a modern
hospital for acute cases ; (3) the detached establishment for
private patients paying £60 and more per annum; (4) an
estate and mansion in the country at some distance, principally
occupied by working patients. Extent of grounds, 330 acres.
Accommodation, 1,000 beds. The charitable area of the institu¬
tion includes Aberdeenshire. Income from board paid for
patients, assisted by a small charitable fund—total, £30,000 in
1909. Lectures on mental diseases in connection with the
University.

Dumfries Royal Asylum .—The Crichton Royal Institution
was founded by the widow and trustees of the late Mr. James
Crichton of Friar’s Carse, whose name it bears, and the residue
of whose estate was devoted to its endowment. The institu¬
tion was opened in 1839, when the first house, now reserved
for private patients, was completed. A second house, con¬
taining both private and pauper patients, was opened in 1849.
There is a charitable fund from which grants are made to
patients in straitened circumstances belonging to the locality.
The institution was greatly extended by the late Dr. Rutherford
during the last twenty-five years. When he retired the
property extended to 1,300 acres, including the estate of
Friar’s Carse above mentioned, and there were fourteen houses
available for patients. (Since that time, however, Friar’s Carse
has been sold. An appreciative notice of Dr. Rutherford’s life
appeared in the Journal of Mental Science for April, 1910,
and it may be referred to for details regarding this asylum.)
Accommodation, 900 beds. Income from board paid for
patients, £44,292 in 1909.

LVI. 41

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Edinburgh Royal Asylum. —Built by voluntary contributions
aided by a small Government grant. Opened in 1813. Con¬
sists of two main buildings with various succursal houses:
(1) The East House, the original establishment, has been sold,
and is now replaced by New Craig House, on the estate
which lies to the west of the Morningside property and extends
to 62 ‘acres. In 1879 Old Craig House was adapted for
the reception of private patients at the higher rates of board,
and nearly twenty years ago a modern asylum for the same
class of patients was erected in its proximity. The central
building receives about 100 patients, and adjoining it are
detached hospitals and villas of moderate size. (2) The West
House, opened in 1842, receives patients at the lower rates
of board and paupers. Separate wings were adapted for the
reception of acute cases, but that plan is no longer continued.
The whole extent of the grounds is about 120 acres. Accom¬
modation, 900 beds. Income from board paid for patients,
•£5 0 .5 5 2 - The poorer class are assisted from charitable funds,
which amount to a capital sum of £22,388. Lectures on
mental diseases in connection with the University. (Some
account of Dr. Clouston’s work in the Royal Edinburgh
Asylum is given in the Journal of Mental Science for
April, 1910, on the occasion of his being presented with his
portrait by colleagues and friends.)

Glasgow Royal Asylum. —Founded in 1810. Built by
voluntary subscriptions, and opened in 1814. Rebuilt on a
better site and on a more extended scale in 1842. It consists
of two main buildings adjoined. The East House was designed
for pauper patients, while the West House was reserved for
richer private patients. For twenty years the whole establish¬
ment has been devoted to private patients, many of whom are
maintained at very low rates of board, to the great advantage
of the locality. On the foundation stone of the original asylum
were inscribed the words: To restore the use of reason and to
alleviate suffering. That remains the fundamental idea of
the directors. Accommodation, 460 beds. Revenue from
the boards paid for patients, £27,974, aided by a small endow¬
ment. On March 25th, 1908, there were 449 patients in
residence. Of these, 65 paid less than £40 and 155 paid no
more than £40 per annum. Extent of grounds, 66 acres.
Lectures on mental diseases in connection with the University.

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BY A. R. URQUHART, M.D.

623

Montrose Royal Asylum .—Founded in connection with the
infirmary, but with the infirmary and dispensary subsidiary
to the asylum. The infirmary still benefits by this long-
continued connection. Built by voluntary subscription. Opened
in 1782, rebuilt in the country in 1857. The asylum con¬
sists of three main buildings: (1) The original establishment
chiefly devoted to pauper patients ; (2) the hospital, opened
in 1891, for sick and infirm cases ; (3) Carnegie House for the
reception of private patients only, opened in 1899. There are
also two separate villas containing patients at the lower rates.
Extent of the grounds, 270 acres. Accommodation, 70c beds.
The charitable area extends to the counties of Forfar and
Kincardine. Income from boards paid for patients, £23,908.

Perth Royal Asylum .—Founded by the trustees of the late
James Murray, whose name it bears. Opened in 1827.
Consists of two main buildings: (1) The original establish¬
ment enlarged in 1839 and 1889 ; (2) a neighbouring mansion
house for quiet and convalescent patients. There are also four
villas occupied by patients. Extent of grounds, 71 acres.
Accommodation, 157 beds. The charitable area of the institu¬
tion is limited to Perthshire. Income from boards paid for
patients, £1 3,847.

Dmidee Royal Asylum occupies a somewhat anomalous
position at present. It was founded in connection with the
infirmary, and under the same managers, in 1805. Built by
voluntary subscriptions and opened in 1820. Disjoined from
the infirmary and rebuilt in the country in 1882. Private and
pauper patients were received until 1902, when a separate
building, Gowrie House, was opened for private patients only.
The later history of the institution ended in the sale of the
whole property to the District Lunacy Board of Dundee.
The directors derived their authority from the Royal Charter,
and had entered into a contract to receive State-supported
patients, as was the usual practice. The purchase price was
paid to the directors, who administer the funds so obtained in
aid of the poor private insane of the locality. These patients
are still maintained in Gowrie House with an accommodation
of 70 beds. The charitable area of the institution includes
Forfarshire and Fifeshire. Lectures on mental diseases in
connection with the University.

Brief reference may be made to the principal private asylum

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624 LUNACY ADMINISTRATION IN SCOTLAND, [Oct.

of Scotland, New Saughton Hall , which is under the direction
of Sir John Batty Tuke and his son. Circumstances rendered
it imperative that the old mansion house of Saughton Hall should
be surrendered to the City of Edinburgh, and the private
patients resident there were transferred to Mavisbank, which
had been similarly occupied for many years. Additions were
made, and opened in 1907. Accommodation, 90 beds. The
minimum charge is .£105 per annum. Sir John Batty Tuke
resides at Balgreen.

District asylums .—These were erected subsequent to the
passing of the Lunacy Act, which was the result of the
Commission in 1855. It is impossible to enter upon details
regarding these institutions which receive the pauper patients
of the country, and which have been enlarged and multiplied
in accordance with the necessities of the times. The list of
them given on p. 616 shows their distribution and importance.

It will be of some interest, however, to indicate certain
changes which have been evolved, in recognition of important
principles. For instance, take the Inverness District Asylum ,
which was erected in the early years of modern administration,
on a limited area of estate. It was, like the others, an asylum
built on the corridor plan, of the cheapest construction, and in
no way in advance of the times. Under the active manage¬
ment of Dr. Keay it was completely re-organised and
modernised. Hospitals were built, administrative buildings
were added, and the estate was enlarged at a cost of some
£70,000. Thus the most remote asylum will bear comparison
with any of its class. Similarly the Ayr District Asylum has
been enlarged and rendered more effective by the addition of
a separate hospital, which cost only about ^100 a bed. On
the other hand, the enlargement of the Perth District Asylum
was accomplished by the erection of separate villas, the acute
cases being treated in the main buildings. The Stirling
District Asylum had large demands made upon it, and a block
for chronic patients was first added, then a detached hospital
for acute cases, and lastly, a separate house for the nursing
staff.

This represents a remarkable latitude of administration, and
brings us to consideration of the reasons w’hich permitted such
diversity of action. The reasons are not far to seek. As has
been said, the Lunacy Act was the w r ork of men of wisdom and

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BY A. R. URQUHART, M.D.

625

prescience, and the central administration has been maintained
on the lines they laid down. A brief discussion of this matter
will be of interest.

This board consists of a chairman, two paid medical com¬
missioners, two unpaid lawers of eminence, and a paid secretary.
The chairman, who is also unpaid, has always been a man of
public distinction. The deputy-commissioners, two in number,
are medical men paid to visit and report upon the boarded-out
cases. (Sir Arthur Mitchell began his official career as deputy-
commissioner, and some account of his life and work is given
in the Journal of Mental Science for April, 1910.) Scotland
is a small country, and the medical commissioners are not
harassed by the volume of work expected of them. They
know the asylums intimately, and the patients whose cases are
of outstanding importance just as well. They have always
encouraged local administration to develop, to experiment, to
succeed. This is so fully recognised and appreciated that the
Scottish Division of the Medico-Psychological Association
entered the following minute in their proceedings of March
19th, 1908 : “In view of the fact that it is now fifty years
since the Act 20 and 21 Victoriae, Chapter 71, came into
operation, the Scottish Division of the Medico-Psychological
Association resolve to record in their minutes this expression
of their recognition of the great advances which have been
made in Scotland during the last half century in the treatment
of the insane and the scientific investigation of insanity ; their
acknowledgment of the humane, enlightened, and generous
manner in which the asylum boards of the country have pro¬
vided for this most unhappy class of the community, and
their high appreciation of the broad and sympathetic policy
consistently pursued by the Commissioners of the General
Board of Lunacy in their control of Scottish lunacy administra¬
tion, a policy which has not only been fruitful in the protection
and promotion of the best interests of the insane, but has also
done much to encourage and assist those who are more imme¬
diately engaged in carrying out their care and treatment.”

Eras have been marked firstly by the enlargement of liberty
and the avoidance of irksome restrictions, and secondly by a
fuller development of medical ideas in psychiatry. Hopeless
of attaining a true pathology of insanity, and sceptical of pro¬
fessional powers in the early Victorian age, there was a robust

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LUNACY ADMINISTRATION IN SCOTLAND, [Oct.,

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demand for common-sense methods in administration. Greater
liberty was the prime necessity. Mechanical restraint and
seclusion had been discredited, personal comfort had been
ignored. The house had to be set in order. It is true that
Dr. Lauder Lindsay had been on the track of pathological
conditions of the blood in mental disorders, but his apparatus
was imperfect and his conclusions were faulty. The time had
not come. Therefore, administration was largely operative in
more accessible fields of action.

Liberty and industry were obviously remedial in intention and
practice. Sir John Sibbald assumed direction of the Argyll
District Asylum and abolished airing courts with their unneces¬
sary walls and limited area. Sir John Tuke abolished the use
of locked doors when in command of the Fife District Asylum.
Dr. Rutherford, greatly daring, trusted patients of the most
doubtful antecedents with unprecedented freedom, and sent them
to work in the open air using the ordinary tools of agriculture.
He did more than anyone to abolish restraints, to foster
industry, and to accustom Scotland to spend money freely in
the care and treatment of the insane.

It became evident that asylums required land on which to
employ suitable patients. Seventy years ago the directors of
the Perth Royal Asylum embarked on that venture, and sixty
years ago they acquired a succursal house standing in its own
grounds. But the district asylums soon developed the agri¬
cultural ambition, and attained success in the undertaking.

Personally, I do not advocate exclusive use of unlocked
doors ; it seems to me that liberty may be more truly gauged
by the number of patients on parole, but it is certain that the
fewer the number of locked doors the better. There are patients
so dangerous, so regardless of consequences, that certain
avenues must be closed in justice to the patients themselves.
Yet one may walk from one end of the hospital at Bangour to
another, through male and female divisions, without requiring a
key or a nurse to show the way.

While these changes were in progress. Dr. Clouston raised
questions from the point of view of the physician. He pleaded
for the infusion of the medical spirit into our administration,
he advocated the teaching of psychiatry to the students of our
universities, he raised the question of the scientific training of
our nurses. The medical spirit led to a new development.

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BY A. R. URQUHART, M.D.

62 7

Dr. Clouston adapted the old separate wards of the Royal
Edinburgh Asylum so that they might be used as hospitals.
New hospital wings were designed and built at the Perth Royal
Asylum, and the first separate hospital was added to the
resources of the Montrose Royal Asylum. It became a neces¬
sity for the asylums to separate and treat acute cases in this
way. Hospitals are to be found at Edinburgh, Dumfries, Ayr,
Glasgow, Fife, Stirling, Montrose, Aberdeen, and Inverness.
But these were designed for the treatment of mental diseases,
and since that time sanatoria have been found essential for the
reception of tubercular patients. The first erected were at the
Perth Royal Asylum, and since then they have been introduced
at Edinburgh, Dumfries, and Glasgow. At the Glasgow
District Asylum, Gartloch, a sanatorium of sixty beds was
regarded as essential, but the result has been that the number
of tubercular patients has so diminished that it is now too large
by about forty beds.

Years ago at Ville Juif these patients were placed in
sheltered, open-air verandahs, and American experience proved
that many chronic forms of insanity could be treated with
advantage in the open air. Consequently at the Ayr District
Asylum and at Bangour village, and at Glasgow, many patients
of an acute as well as a chronic type are treated in verandahs
on this principle.

The Glasgow District Asylum at Lenzie, under Dr. Hamilton
Marr’s direction, affords a good example of modern detached
additions to the earlier type—a reception house, a hospital, a
house for idiots, a pathological laboratory of a complete
organised design.

Recalling the original inception of such royal asylums as
Aberdeen, Glasgow, and Montrose in connection with the
neighbouring general hospitals, it is somewhat surprising that
the modern return to this ideal was so long delayed.

This brings us back to the district asylums in their latest
development. Aberdeen and Edinburgh embarked on the
newest methods of architecture. These village asylums are
designed on the principle of Alt-Scherbitz, and permit of
classification, and its concomitant personal comfort, in a manner
impossible in crowded barracks.

Medical teaching .—The medical teaching of psychiatry was
systematised by the Medico-Psychological Association, and

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628 LUNACY ADMINISTRATION IN SCOTLAND, [Oct.,

the University lectures in Scotland encouraged many young
doctors to enter for the certificate of the Association. Later it
became an integral part of medical education, and at the present
time we have reason to believe that the universities will grant a
special degree in this subject, such a degree as the Diploma of
Public Health without which no State appointment can now be
held.

The instruction of attendants and nurses has vastly increased
in scope and importance since the early tentative efforts which
produced a handbook on the subject at Perth, written by four
Scottish asylum superintendents, and approved by the Scottish
Division of the Medico-Psychological Association. The Asso¬
ciation heartily approved of these modest beginnings and
formulated a scheme which has resulted in the training and
certification of some 9000 nurses. This success has been
followed by a general movement for the certification of all
properly trained nurses under legislative authority, and it is
probable that we shall not have to wait long before it is in full
working order. The handbook has grown to an important
volume, now in its thirty-third thousand, and under successive
revisions it has taken an assured place in the specialty.

Important changes have occurred in the personnel of the
nursing staff. Dr. Turnbull, in 1895, introduced female nurses
into the hospital for male patients at the Fife District Asylum.
The first Lunacy Commissioners had indicated the desirability
of such a step, and experience in the Copenhagen Hospital had
shown how it could be adopted. The system gained ground,
and the general improvement in nursing was accompanied by a
notable strengthening of the night staff. Once more the
principles originally laid down by the Commissioners were
adopted and developed in detail.

Last year saw one of our wrongs righted—an Act passed
granting assured pensions on a contributory basis to asylum
workers throughout the Kindom. It applies to all institutions
directly supported by rates,and confirms as a right to English and
Irish staffs what had been merely permissive. Scotland had no
such permissive provision for those who had served long and well.

Laboratories .—The last great undertaking which Dr. Clouston
initiated and still supports with unabated skill and energy is
the establishment and maintenance of the joint asylums’
laboratory under the direction of Dr. Ford Robertson. It dates

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BY A. R. URQUHART, M.D.

629

from 1896, when it was opened in Edinburgh, having com¬
manded general and willing help. The advantage of having a
central, accessible laboratory from which reports on special
cases could be obtained, and skilled aid rendered available, was
undoubted, and the work advanced from the examination of
dead tissues to its natural sequel, the investigation of living
processes. Last year, however, a feeling arose that the labora¬
tory was unduly limited in scope, and new arrangements came
into force. It will be understood that there are four universities
of ancient foundation in Scotland—Edinburgh, Glasgow,
Aberdeen, and St. Andrews. The last-named has extended
to Dundee in science. As there are many students of medicine,
especially in Edinburgh and Glasgow, the representatives of
the west came to the conclusion that the clinical material and
the students in their locality required an alteration in the existing
state of matters. The asylums of Glasgow and the neighbour¬
hood (nine) therefore united to institute another laboratory
under the direction of Dr. Ivy Mackenzie, with the name of the
“ Western Asylums Research Institute ” which is in the centre of
some 4,000 patients in the Glasgow area. The same principles
guide the founders as obtain in Edinburgh. It is to carry on
researches into the causation and cure of insanity, to guide the
assistant medical officers of the associated asylums in their
work, to afford post-graduate facilities.

Yet another psychiatrical laboratory is in process of institu¬
tion. The directors of the Dumfries Royal Asylum, with Dr.
Easterbrook, are visiting the laboratories of the Continent of
Europe in order to perfect the arrangements which are being
made at Dumfries.

And, lastly, the Dundee Royal Asylum Directors, who never
contributed to the Joint Laboratory, have agreed to defray the
cost of patients suffering from incipient insanity in the Dundee
Royal Infirmary, having obtained the co-operation of the
College Laboratories. This resembles the ancient connection
between the asylum and the hospital, which has already been
noted, and it should be added that a similar arrangement is
likely to be made in Edinburgh. We have long laboured under
the disadvantage of being scattered workers, out of touch with
the great schools of medicine, and have long endeavoured to
resume that co-operative and helpful association. Neurology
and psychiatry should know no divorce.

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630 DEVIATION OF COMPLEMENT IN MENTAL DISEASES, [Oct.,

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The early treatment of mental diseases is an important
factor in our duty towards the State, and this brief mention of
Dr. Carswell and his great work in Glasgow is imperative.
Glasgow is a great city, equipped with hospitals and various
agencies for dealing with the failures of civilisation, disease and
disaster. The Inspector of Poor reports about a thousand
cases of suspected insanity to Dr. Carswell yearly. He
examines them and deals with them in a similar manner to
that which has long been adopted in Paris. Those manifestly
in need of asylum care are sent to the appropriate institution,
but there are many requiring observation and treatment who
need not be so dealt with. In the city hospitals wards have
been set apart for these cases of incipient and transient insanity
under the care of Dr. Carswell. This method has now long
been in use, and the results have been successful beyond anti¬
cipation. It would require a lengthy discussion to make all
this plain, even to set forth the statistical results. Suffice it to
say that the Glasgow system is well suited to the needs of a
great urban population.

(*) A paper read at the Annual Meeting held in Edinburgh in July, 1910.—
( a ) At the time of writing there is now only one parochial asylum in existence—
Greenock.

The Deviation of Complement in the Mental Diseases
Known as Mania. By Lewis C. Bruce, M.D.,
Medical Superintendent, District Asylum, Murthly.

One of the most obvious impediments to the advance of our
knowledge of mental diseases is the lack of a physical basis
of classification. This deficiency is constantly presenting
itself, and even in such a comparatively simple disease as
mania one is often in doubt as to whether the diagnosis should
be manic-depressive insanity or confusional mania.

Some two years ago it occurred to me that it might be
possible to apply the Bordet-Gengou reaction to assist in the
diagnosis of maniacal conditions. My first series of observa¬
tions were carried out with the streptococcal organisms, which
I had isolated from cases of mania. Broth cultures of these
organisms, with similar cultures of Staphylococcus aureus and
Bacillus coli communis which were used to act as controls, were

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BY LEWIS C. BRUCE, M.D.

631

taken as the antigen or toxin; the serum of the patient in¬
activated by heat was expected to contain the specific anti-body,
while the complement was supplied by the fresh serum of a
rabbit or guinea-pig. Inactivated haemolytic serum together
with *5 c.c. of a 5 per cent, suspension of the appropriate red
blood-corpuscles was used as the indicator. If the serum of the
patient in the presence of the toxin or antigen, supplied by the
broth cultures of the organisms, entered into union with the com¬
plement supplied by the rabbit serum, then upon adding 5 c.c.
of a suspension of red blood-corpuscles plus one dose of haemo¬
lytic serum, no haemolysis would occur, i.e., the complement had
been deviated. If, on the other hand, the serum of the patient
did not enter into combination with the complement in the
presence of the antigen, then upon the addition of the indicator,
the red blood-corpuscles and the haemolytic serum, haemolysis
would take place.

This first series of observations, although interesting, were
not uniform in the results obtained.

The next combination which I tried was as follows: I argued
that if these maniacal conditions were due to toxins circulating
in the blood, that these toxins must be excreted by some
channel, the most probable channel being the urine. I there¬
fore now used the urine as the antigen, the serum of a rabbit
immunised to the before-mentioned streptococci as the immune
serum, while the complement was supplied as before by the
fresh serum of a rabbit or guinea-pig. In this series of observa¬
tions negative results were obtained both with the urine of
maniacal persons and of control persons.

I still thought, however, that the urine was a probable
channel of excretion of toxins, and it occurred to me that in
acutely maniacal conditions the blood should also contain
an appreciable amount of toxin. I therefore immunised a
rabbit with the serum taken from a case of acute mania.
From 8 to 10 c.c. of serum was injected into the rabbit at
intervals of ten days. This injection was repeated three
times, and ten days after the last injection the rabbit was bled
and the serum so obtained was inactivated by heat. The
observations made with this serum were conducted upon the
same lines as the previous ones. The urines of maniacal
patients and control persons were used as the antigens, the
serum of the rabbit immunised to the serum of the maniacal

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To serum of case
of mania (class C. ‘os c.c.
undetermined).

•04 c.c.

■08 c.c.

Control 1.

No deviation
of

complement.

Control 2.

No deviation
of

complement.

Control 3.

^ C

No deviation
of

complement.

Control 4.

Deviation of
complement

up to ’02 c.c.

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To «erum of case
of mania (class C. oa e.c.
undetermined).

■04 c.c.

'08 c.c.

Epileptic.

No deviation
of

complement.

Melancholia.

No deviation
of

complement.

Confusional.

Complete
deviation of
complement.

Mania.

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•04 c.c.

•oS c.c.

To serum of case
of mania (class C. •03 c.c.
undetermined).

Mania

(confusional).

Complete
deviation of
complement.

Mania

(confusional).

Complete
deviation of
complement.

Mania

(confusional).

Complete
deviation of
complement.

Mania

(confusional).

Deviation of
complement
up to ‘04 c.c.

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To serum of case
of mania (class C. '01 c.c.
undetermined).

■04 c.c.

•o3 c.c.

Manic-

depressive.

Deviation of
complement
up to '02 c.c.

Manic-

depressive. 2

No deviation
of

complement.

Manic-

depressive. ^

Deviation of
complement
up to '02 c.c.

Manic-

depressive.

No deviation
of

complement.

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1910.]

BY LEWIS C. BRUCE, M.D.

637

Technique .—The materials required are: (1) The blood-serum
from a patient inactivated by heat. (2) The urine of similar
patients as well as the urine of control persons and of patients
suffering from other forms of insanity. The urines are collected
in J-litre flasks heated to 8o° C. to precipitate albumen and
then passed through a Berkfield filter. (3) A sufficient quantity
of serum obtained from a rabbit or guinea-pig to act as com¬
plement. This serum must not be more than twenty-four hours
old. (4) A haemolytic serum with a 5 per cent, suspension of
washed red blood-corpuscles to be used as an indicator. Before
each observation the complement must be tested with the
haemolytic serum and red blood-corpuscle suspension so as to
estimate the dose of complement required to haemolyse *5 c.c.
of the 5 per cent, suspension of red blood-corpuscles. Urine
which has been boiled may lose its power of deviating com¬
plement. Urine which has stood for any length of time may
lose its power of deviating complement. Urine which contains
a trace of albumen will deviate complement without the inter¬
vention of an immune serum. Samples of urine taken from
the same patient on different days may vary considerably in
their power of deviating complement.

Method of Application of the Test.

Tube

1 .

Urine of mania

•2 c.c.

normal saline .

•3 c.c. +

"02 c.c

2 .

It It • •

■2

•3

tl +

tt •

•2

•3

If +

Serum of mania .

•2

It +

If It • •

•2

II +

6 .

It It •

■2

If +

Urine manic-depressive.

■2

serum of

mania

If +

It It •

•2

»>

If +

It It

■2

If +

10.

Urine confusional mania

If +

11.

It tt

»f

•3

It +

12.

It tt

•2

•3

If +

>3-

Urine control

•2

•3

If +

14.

It • •

•2

If +

15-

It • •

’3

If +

These tubes are then placed in the incubator at 37 0 C. for
ninety minutes, and then to each tube is added '5 c.c. of the
suspension of red blood-corpuscles together with a sufficient
dose of haemolytic serum to haemolyse the red blood-corpuscles
with *oi c.c. of complement. The tubes are then returned to
lvi. 42

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638 DEVIATION OF COMPLEMENT IN MENTAL DISEASES, [Oct.,

the incubator for one hour, allowed to stand at room tempera¬
ture overnight and the results recorded.

Cases tested to serum of confusional

Tested to serum manic-

Control. C.

mania.

•02 c.c. 04 c.c.

08 c.c.

‘02 C.C.

depressive.
•04 c.c.

•08 C.C.

N .

. N

. N .

N .

. N

. —

—

3 •

P .

. N

. N .

4 •

N .

. N

. N .

5 •

P .

. N

. N .

6 .

N .

. N

. P

. N .

7 •

N .

. N

. —

—

8 .

P .

. N

. —

—

9 •

N .

. N

. —

—

P .

. N

. —

—

N .

. N

. —

—

Mania

(confusional).

N .

. N

. N .

P .

. P

. N

. N .

3 •

P .

. P

. N .

4 •

P .

. P

. —

—

5 •

P .

. P

. N

. N .

6 .

N .

. N

. N .

7 •

P .

. P

. —

—

It will be noted that Cases 1 and 6 failed to deviate comple¬
ment with either serum. Both these cases were tested several
times and the same results were obtained. Is it possible that
there are other varieties of mania besides confusional and manic-
depressive ?

Cases tested to serum confusional Tested to serum manic-
mania. depressive.

Mania

(manic- C. '02 c.c. '04 c.c. - o8 c.c. - 02 c.c. ’04 c.c. 'o8. c.c.
depressive).

P .

. N .

P .

. N .

P .

3 •

N .

. N .

P .

4 •

N .

. N .

P .

5 •

N .

. N .

P .

6 ,

N ,

. N .

P •

P .

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Original from

PRINCETON UNIVERSITY

i 9 io.]

BY LEWIS C. BRUCE, M.D.

639

Cases tested to serum confusional
mania.

Tested to serum manic-
depressive.

Melancholia. C. '02 c.c.

Confusional

insanity.

Epileptic.

3 •

General

paralysis.

04 c.c.

■08 c.c.

•02 c.c.

P . —

•04 c.c.

The general paralytic No. 1 was at the time in
acute mania.

08 c.c.

state of

Discussion,

At the Annual Meeting held in Edinburgh, July, 1910.

Dr. McKenzie said it was a difficult matter to discuss the paper, and he would not
criticise work which he had not repeated himself. He thought the results which
Dr. Bruce had found were very interesting and suggestive. There was only one
series of the author's observations which he, Dr. McKenzie, thought he could
explain, namely, the third series. In that series, where he injected the serum first
into a rabbit, and used that rabbit’s serum with the urine of the various patients,
he would get a deviation of complement in every case where the urine of the
patients contained albumen. With regard to the fourth series, he did not think
the albumen itself would be a very disturbing factor as regards destruction of
complement. He knew that Wilson examined 200 cases, finding the presence of
albumen by that method where it was impossible to find it by the ordinary delicate
tests. He did not find albumen so long as it was pure and had any effect on the
complement. He wished to suggest to Dr. Bruce that in confusional cases, or in
cases with a temperature, there was a large amount of other nitrogenous substance,
de-naturalised albumens, amido-acids; and those, if in a sufficiently concentrated
condition, would have a deleterious effect on the complements and give rise to the
appearances which Dr. Bruce explained.

Dr. Mercier said he wished to look at the matter more broadly than from the
standpoint of technique. Were members to understand that when the complement
was deviated in the manner explained, that that indicated that in the blood of the
person there existed the same toxin as was present in the original preparation to
which the blood was added. If it did not show that the same toxin existed in
this person’s blood, what was the use of it ? He would doubt very much, on
a priori grounds, whether a particular toxin necessarily produced in each person
the same symptoms.

Dr. Lewis Bruce, in reply, said one had to be certain that there were none of
the disturbing factors, and that constituted the difficulty in the observation. He
contended that if one had the same toxin in the urine and the anti-body in the
serum, one would get a deviation of complement, and it promised to be a most
valuable method of diagnosis, in the same way as was the Wassermann test. At
present the difficulties of the observation were such that he had asked others to
repeat them.

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640 THE INFECTIVE FOCI IN GENERAL PARALYSIS, [Oct.,

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The Infective Foci in General Paralysis and Tabes
Dorsalis. By W. Ford Robertson, M.D., Pathologist
to the Scottish Asylums.

In previous papers it has been contended by Dr. Douglas
McRae, Dr. Dods Brown and myself, that in cases of general
paralysis there are special bacterial infective foci in the naso¬
pharyngeal and buccal mucous membranes, and that these infec¬
tive foci are of importance in the pathogenesis of the disease;
Dr. McRae and I have also maintained that in cases of tabes
dorsalis there are similar infective foci in the genito-urinary
tract. In this paper I wish to deal with some further investiga¬
tions, the results of which give additional support to these
views. In the fifteen minutes at my disposal it is impossible
for me to describe these investigations in detail. I can only
indicate their chief results and state some of the conclusions
that they seem to me to warrant. All the evidence that I can
lay before the meeting is shown under the ten microscopes on
the tables.

In my experience it is possible, in all cases of advancing
general paralysis, to demonstrate, in direct films of the nasal
secretion, large numbers of small granular bacilli which fre¬
quently show metachromatic granules. In most cases such
bacilli are present in very large numbers. In cultures made
upon the ordinary media these micro-organisms often fail to
grow. I have lately used an agar medium over which there
have been poured some drops of sheep’s serum containing
haemoglobin in solution. In all of sixteen cases of general
paralysis recently examined with the aid of this haemoglobin
medium, I have obtained from the nasal mucosa abundant
growths of a diphtheroid bacillus showing the morphological
characters and bio-chemical reactions, either of the Bacillus
paralyticans longus or of the Bacillus paralyticans brevis. In four
out of six of these cases in which it was possible to test the
virulence, the bacillus proved virulent to mice. I have
endeavoured to get further information regarding this infection
from histological examination of the nasal mucosa and sub¬
jacent tissues in a series of cases of general paralysis and in
various controls. The following are, in brief, the conclusions
that I have been able to draw from this examination. The
nasal mucosa and subjacent tissues of the general paralytic are

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i9io.]

BY W. FORD ROBERTSON, M.D.

641

constantly the seat of well-marked diffuse sclerotic changes and
of localised acute or subacute inflammatory processes. In the
cases in which these active morbid processes are going on, there
is more or less dense aggregation of lymphocytes and great
increase in the number of plasma-cells. Lying amongst the
epithelial cells covering such areas a few diphtheroid bacilli
may generally be detected. Occasionally small areas of epithe¬
lium may be observed in which these bacilli occur in dense
masses ; in these instances they can be seen to be pushing
their way through the thickened basement membrane and
invading the subjacent tissues. Small microscopic ulcers may
occasionally be detected ; their floor generally shows necrotic
tissue, lying in which there are numerous diphtheroid bacilli.
In the lymphatic channels there may frequently be seen more
or less numerous bacilli of a similar kind. In this situation
there are also, in some areas, very abundant and conspicuous
segregations of granules the size of micrococci, larger or
smaller angular fragments, and short rods which stain of a deep
blue or olive-green tint in preparations stained with Loeffler’s
methylene-blue. These bodies are either contained within the
cytoplasm of endothelial cells or lying free in the tissue spaces.
I shall refer to them again. All control cases show, in methy¬
lene-blue preparations, some plasma-cells, more or less numerous
mast-cells, and generally a few aggregations of olive-green
granules. None have shown invading diphtheroid bacilli.

In several cases of general paralysis diphtheroid bacilli have
been found in considerable numbers lying in the lymphatics of
the connective-tissue sheath of the second division of the fifth
nerve as it passes through the foramen rotundum. Examination
of the third division in the foramen ovale has so far given
negative results, but the Gasserian ganglion and neighbouring
dural tissues have in nearly all of the cases been observed to
contain some of these bacilli. In several cases the dura mater
lying over the cribriform plate of the ethmoid and the under
aspect of the olfactory bulbs have been found to contain
numerous diphtheroid bacilli. Experiments in the post-mortem
room have shown that fluids readily pass from the nasal sub¬
mucosa through the cribriform plate of the ethmoid. It is
therefore evident that bacilli that have reached the lymphatics
of the nasal mucous membrane can, and do, pass into the
cranial lymphatic system by way of the cribriform plate of the

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642 THE INFECTIVE FOCI IN GENERAL PARALYSIS, [Oct.,

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ethmoid and foramen rotundum. There are also other possible
channels of cranial invasion from the naso-pharyngeal tissues.

In order if possible to trace the infection further I have, in a
series of cases of general paralysis, examined the pia-arachnoid
in horizontal sections stained with Loeffler’s methylene-blue.
In the majority of cases bacilli with the characteristic morpho¬
logical features have been clearly demonstrated, generally in
small numbers, but occasionally in abundance. In all cases of
general paralysis the pia-arachnoid appears to contain, though
it may be only locally, very numerous aggregations of the blue
and olive-green granules and fragments already described as
occurring in the nasal mucosa. These bodies, in so far as they
have been observed, have probably generally been regarded as
“ tissue granules,” the result of degenerative and disintegrative
processes. In favour of this opinion there are the facts that a
few granular aggregations of a similar appearance may be seen
in control cases, and that in these they can often be clearly
traced from the granules of mast-cells. Against it there are,
however, other facts that deserve consideration. In cases of
general paralysis these aggregations commonly occur, locally
at least, in the nasal tissues and in the pia in very extraordinary
amount; many of the rod-shaped forms have appearances
identical with those presented by the alleged pathogenic bacilli
grown under anaerobic conditions. It has been proved in the
laboratory that these bacilli are capable of living under anaerobic
conditions, and that under such conditions their growth is
extremely slow. Growing out from some of the granular
masses characteristic rod-forms with clubbed extremities have
been detected. Moreover, it has been shown experimentally
that these bacilli when injected into the tissues of the rabbit are
taken up by the endothelial cells and transformed into granular
aggregations very closely resembling those in question. We
cannot, therefore, exclude the possibility that some of these
masses represent altered diphtheroid bacilli, and even a chronic
infection by these micro-organisms growing under semi-anaerobic
conditions. As the question cannot be settled by the staining
methods I have employed, I leave it there for the present. It
remains to add that within the brain of the paralytic diph¬
theroid bacilli can, in my experience, be demonstrated in the
majority of cases. In several instances I have found them to
occur locally in large numbers.

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PRINCETON UNIVERSITY

i9io.]

BY \V. FORD ROBERTSON, M.D.

643

The evidence in support of the view that tabes dorsalis is asso¬
ciated with a special infective focus in the genito-urinary tract
is chiefly bacteriological and therapeutic. In twenty-three
successive cases of tabes I have obtained from the urine or from
the surface of the urethra cultures of a diphtheroid organism
with the bio-chemical reactions of one or other of the two types
to which importance has been attached. In several instances
this bacillus has proved virulent to mice. In every case there
have been other or secondary infections, represented most
commonly by various Gram-fast diplococci, but also frequently
by the Bacillus coli. In three cases of tabo-paralysis the bacilli
have been traced through the pelvic lymphatics to the posterior
root ganglia and the pia-arachnoid of the lumbo-sacral cord,
In the connective tissues around the posterior root ganglia and in
some areas of the membranes of the cord there were found very
numerous, more or less dense, aggregations of blue granules
and rods similar to those observed in the nasal tissues and
cerebral pia-arachnoid in cases of general paralysis. The
therapeutic evidence has consisted in the results obtained from
the administration of autogenous vaccines and anti-serum in a
fairly extensive series of cases. It shows that in early cases of
tabes the symptoms readily yield to such specific treatment. In
advanced cases it is much more difficult to obtain amelioration
of the patient’s condition, yet even in some of these pain has
been relieved, walking has greatly improved, and urinary
troubles have been obviated. It is impossible that such results
could have been obtained if the infections against which the
treatment was directed had nothing to do with the malady. It
has, moreover, frequently been observed that an overdose of one
of these autogenous vaccines is followed within twelve or twenty-
four hours by a characteristic attack of tabetic pains.

Before concluding I desire to say a few words regarding the
origin of these infective foci. In my opinion sufficient evidence
has now accumulated to show that general paralysis is, as
a rule, a venereal disease, not only in respect of its common
aetiological relationship to previous syphilis, but also in respect
to the source of the bacterial infection which experimental
evidence has shown to be capable of producing many of the
essential phenomena of the disease. The source of this infec¬
tion is commonly a bacillary endometritis. The man gets
a urethral infection usually before marriage; he accidentally

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644 THE INFECTIVE foci in general paralysis, [Oct.,

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infects his nasal mucosa and invasion of the local lymphatics
begins. He may, however, convey the infection to his wife;
her uterus provides a suitable anaerobic culture medium. The
virulence of the organism gradually rises, and in this more
virulent form the bacillus is returned to the husband. Every
asylum physician is aware of the fact that if he allows a man
who suffers from general paralysis, and who has improved
under asylum treatment, to go home, the rule is that the patient
is brought back within six weeks suffering from a serious relapse.
What has happened ? In some instances, at least, he has
become re-infected by a virulent strain of the bacillus. I have
made great efforts to have some of these “ carriers ” investigated
bacteriologically. Thanks to the kindness of two gynaecologists
I have succeeded in two cases. The first case was that of a
lady whose health was greatly undermined by severe endo¬
metritis. Cultures were made for me by Dr. Haultain from
the interior of the uterus, and portions of the endometrium
were also obtained. There developed in the cultures numerous
colonies of a Bacillus paralyticans longus , identical with that
previously obtained from the urethra and nose of the patient’s
husband, and sections of the endometrium showed the bacilli
in the tissues. The patient consented to undergo vaccine
treatment, and in preparing the vaccines I used the bacillus
isolated from the husband. Each ordinary dose produced next
day a definite reaction in the form of a severe and characteristic
attack of endometritic pain. Subsequently this w r as obviated
by the administration of anti-serum.

The second case was that of the wife of another general
paralytic, whose nasal cavities and urethra were loaded with
a virulent strain of the Bacillus paralyticans brevis. In this case
the uterine lesion was so severe that the specialist feared at
first that the patient was suffering from carcinoma. Direct
films made from a scraping from the interior of the uterus
showed abundant diphtheroid bacilli, with metachromatic
granules. Cultures upon haemoglobin agar yielded growths of
the same organism as that previously obtained from the
husband. I tested in the usual way the virulence of three
separate growths. Out of six mice two died within twenty-four
hours, two within five days, one within eleven days, and the
last succumbed after two months.

It is clearly established, from certain features of the disease

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PRINCETON UNIVERSITY

i9io.]

BY W. FORD ROBERTSON, M.D.

645

when it occurs in early life, that syphilis specially tends to
damage the nasal tissues. These highly virulent bacilli that are
associated with a particular form of endometritis may find a
specially suitable nidus in a nasal mucous membrane that is
weakened in its defences by a syphilitic sclerosis. It is certain,
at least, that these virulent diphtheroid organisms do invade the
nasal mucosa of the general paralytic, and that they pass along
the lymphatics to the intra-cranial cavity, whilst experimental
evidence now obtained by five observers has shown that they
are a sufficient cause of the characteristic histological lesions
of the disease.

The relation of the urethral infection in tabes to a bacillary
endometritis is not so clear. I have no direct evidence on the
subject. In cases of tabes, as has been established by exten¬
sive statistics, a history of acute urethritis occurs in over 90
per cent. This previous acute infection is probably a far more
important step in the pathogenesis of locomotor ataxia than is
at present believed. It permits of various secondary urethral
infections becoming established, and among others those by
the neurotoxic diphtheroid bacilli. Such bacillary infection of
the urethra may undoubtedly exist without tabes, but if the
patient has had syphilis and has suffered from a slight syphilitic
spinal meningitis he may be much more susceptible than others
to the action of the toxins carried to the spinal canal by the
pelvic lymphatics. He may also be less able to inhibit the
multiplication of living bacilli that reach the lymph-stream.
There is, however, no proof that syphilis is a constant ante¬
cedent of tabes. Many of the characteristic phenomena of the
disease can certainly be produced in lower animals by the
action of these neurotoxic bacilli alone.

I have to express my special indebtedness to Dr. Keay
and to Dr. Muncaster, Pathologist at Bangour Asylum, for
having given me facilities for obtaining nasal tissues, and my
similar obligations to Dr. Muirhead, Dr. David Orr, and Dr.
A. L. Taylor. I am also indebted to Dr. M. C. W. Young for
valuable help in the histological work.

References.

Rev. of Neurol, and Psych., February, March, and April, 1906.
Journal of Mental Science , January, 1909.

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646 THE INFECTIVE FOCI IN GENERAL PARALYSIS. [OcL,

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Discussion,

At the Annual Meeting held in Edinburgh in July, 1910.

The President thanked Dr. Ford Robertson for his paper.

Dr. Robert Jones asked whether the bacilli had been found in the cerebro-spinal
fluid. He understood Dr. Robertson to say the bacilli were found in the brain in
many cases of general paralysis. He supposed that did not apply to all cases.

Dr. Ivy Mackenzie asked whether the micro-organisms were injected sub¬
cutaneously.

Dr. Percy Smith said he would like to make a remark from a clinical point
of view. He spoke because he had seen one of the cases referred to by Dr. Ford
Robertson, a general paralytic, whose wife had endometritis, and in the secretion
therefrom the Bacillus paralyticans was said to have been found. He had been
treated with vaccines in Edinburgh, and returned to London in January last,
when he was considered to be quite well; at any rate he had a remission. In
February he had retention of urine, unequal pupils, which did not react to light,
exaggerated knee-jerks, hesitation of speech, confusion of mind. It seemed
evident it was the third stage of general paralysis. After returning home from
Scotland Dr. Smith believed he had been treated by his own practitioner with
vaccines which Dr. Ford Robertson supplied. Dr. Robertson appeared to have
been asked about the case when the symptoms recurred, and he expressed the
opinion that there must have been a reinfection of the patient, either from his
wife, or from some other woman. But it was ascertained, as a positive fact, that
the patient had had no intercourse of the kind. He feared that, from the clinical
point of view, he must regard it as merely a remission of symptoms, and that, in
spite of the vaccine treatment, the disease had followed its ordinary course. From
his standpoint, the vaccine seemed not to have done any good in that case. He
was very sceptical about the relationship of the Bacillus paralylicans longus found
in the endometritis secretion to the disease.

Dr. Winifred Muirhead remarked that Dr. Ford Robertson had said he was
able to get tabetic symptoms in rabbits by inoculating those rabbits with the diph¬
theroid organism. She had produced similar symptoms in rabbits after inoculating
them with ordinary Bacillus coli culture, or the streptococcus. The inoculations
were done into the spinal canal, and there was a lesion of the spinal cord from the
various inoculations. She had used both the Bacillus coli and the streptococcus,
and her results from those were much more marked than with the diphtheroid
organism, using two or three different strains of the latter.

Dr. Robertson, in reply to Dr. Jones, said that Dr. McRae, Dr. Dods Brown,
and he, had obtained cultures from the cerebro-spinal fluid of the living general
paralytic in several cases, as had been recorded in their published papers; and Dr.
John D. O’Brien had obtained growths in 70 per cent, of cases in a series extending
to over 160. He did not agree with the statement of Dr. Percy Smith; the patient
had left him in good health, with no evidence of active disease. What happened
afterwards he did not fully know, but he had information that strongly supported
the view that the patient did go back to the original source of infection. He
would not, however, follow Dr. Percy Smith in expressing his absolute conviction
upon a point that could only be one of conjecture. In reply to Dr. Mackenzie, he
said that the virulence test was applied in the usual way; 1 c.c. of a twenty-four
to forty-eight hours’ broth culture was injected subcutaneously.

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PRINCETON UNIVERSITY

IQIO.] A BACTERIOLOGICAL INVESTIGATION.

647

A Bacteriological Investigation into General Paralysis
of the Insane . By Henry Lind, formerly Assistant
Physician to the Department for Nervous and Mental
Diseases at the Kommunehospitalet, Copenhagen.

The very interesting publications by Dr. Ford Robertson
and his pupils on the discovery of a bacillus as the cause of
general paralysis of the insane have given rise to the following
research.

This aetiological hypothesis having been adopted by one
observer only (O’Brien in America), and several others not
having been able to confirm it, it will be perhaps of interest
that similar investigations are carried out also on the continent.

The research to be mentioned was undertaken in the Danish
State Serum Institute, upon cases from the Department for
Nervous and Mental Diseases at the Kommunehospitalet,
Copenhagen, and from the Aarhus Lunatic Asylum in Jutland.
The cases examined were all well-marked general paralytics,
and in all of them the Wassermann reaction was positive.

Blood, cerebro-spinal fluid, scrapings from the nose and the
naso-pharynx were bacteriologically examined, and in some
cases the urine and scrapings from the urethra. In addition,
the complement-deviation test (Bordet-Gengou) was tried.
Cultures of the Bacillus paralyticans longus and brevis , kindly
sent to the Institute by Dr. Ford Robertson, were used as
“ antigen.”

The results will be stated briefly.

In 18 cases of general paralysis the blood was examined
for bacilli. It was drawn aseptically from the median basilic
vein, and 5 c.c. were immediately placed in 50 c.c. of a 1 per
cent, glucose 1 ^ per cent, peptone bouillon (to which was added
4 per cent, sodium oxalate and 2 per cent, sodium tartate in
order to prevent clotting), this broth having proved itself a
good medium for the bacilli. Two c.c. of blood were placed
in ordinary 1 ^ per cent, peptone bouillon and 2 c.c. in glucose
peptone bouillon. The tubes were kept at 3 7 0 C., the two
former under aerobic, the latter under anaerobic conditions.

In 10 of these cases (once the blood was obtained during
a seizure) the tubes remained sterile. The remaining 8 showed
streptococci or staphylococci. In 7 of the 18 cases the
cerebro-spinal fluid was also examined, and in 15 others the

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PRINCETON UNIVERSITY

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648 A BACTERIOLOGICAL INVESTIGATION. [Oct,

cerehro-spinal fluid only. The fluid was either directly drawn
into the tubes or placed there a few hours afterwards, and then
kept at 37 0 C., one of each under aerobic and another under
anaerobic conditions.

Out of these 22 cases 10 remained sterile and 12 showed
streptococci or staphylococci.

The Bacillus paralyticans was not obtained in any of these
cases, either in cultures from the blood or from the cerebro¬
spinal fluid.

As to the micro-organisms obtained, it may be suggested
that at least in some cases they may be due to contamination.

In 15 of the cases mentioned scrapings from the vestibule
of the nose, the nasal fossae, and the naso-pharynx were
examined. In 8 cases micro-organisms showing morpho¬
logical resemblance to the Bacillus paralyticans (brevis ) were
obtained, but only once a bacillus having both its morphological
and bio-chemical features.

In this case the complement-deviation test was applied,
a culture of the bacillus obtained being used as “antigen,” but
no inhibition of haemolysis took place.

Scrapings from the urethra and cultures from the urine in
six cases showed various micro-organisms, which were not the
Bacillus paralyticans.

In all the cases above mentioned and in some others, fifty
altogether, the complement-deviation test was applied.
Bouillon cultures of the Bacillus paralyticans , longus and brevis
were used as “ antigen ” in a quantity of 0*4 c.c., this having
been proved not to inhibit haemolysis in the absence of the
serum to be examined.

The method was that commonly used in this Institute.
Sheep erythrocytes, rabbit-immune serum and fresh guinea-
pigs serum were employed. Of the immune serum two and a
half times the volume necessary for total haemolysis was used,
1 c.c. of a 5 per cent, suspension of washed erythrocytes and
O'1 c.c. of complement; o '2 c.c. of the patient’s serum was
employed, which was inactivated by heating at 56° C. for
thirty minutes.

In five out of the fifty cases a slight inhibition of haemo¬
lysis was observed with cultures of Bacillus paralyticans longus
as “ antigen.”

Thirty-four samples of the cerebro-spinal fluid of general

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PRINCETON UNIVERSITY

THE WASSERMANN REACTION.

I9IO.]

649

paralytics were tested in the same way, but no inhibition of
haemolysis occurred in any case.

In addition the complement-deviation test was tried in four
cases, using an antiformin extract of the bacilli as “ antigen.”
A positive reaction was observed in none of them.

As controls ninety cases of recent syphilis and positive
Wassermann reaction were tested, cultures of the bacilli being
used as “ antigen.” A slight deviation of the complement
took place in nine cases, in seven of them only when cultures
of the Bacillus paralyticans longus were used, in the remaining
two also with cultures of the Bacillus paralyticans brevis. The
number of positive reactions, then, is seen to be proportionally
the same in these control cases as in the general paralytics.

Finally, fifty-two other cases especially of nervous and
mental diseases were tested. In two cases a slight deviation
of the complement was observed, namely, dementia praecox
and acne in epilepsy. In the latter case a repetition of the
test, however, turned out to be negative.

The specificity of the Bacillus paralyticans has, then, not been
confirmed by this research.

Before concluding I wish to express my thanks to Dr.
Thorvald Madsen, director of the Danish State Serum Insti¬
tute, for his kind permission in allowing me to undertake these
investigations and for his valuable advice during the research.

I have also to thank Professor Friedenreich, staff physician
to the department for nervous and mental diseases at the
Kommunehospitalet, Copenhagen, and Dr. Hallager, medical
superintendent at the Aarhus Lunatic Asylum in Jutland, for
permission to examine the cases.

The Wassermann Reaction in the Blood and Cerebro¬
spinal Fluid , and the Examination of the Cerebro¬
spinal Fluid in General Paralysis and other Forms
of Insanity. By Winifred Muirhead, L.R.C.P. Edin.,
Pathologist, Royal Asylum, Edinburgh.

The brief summary of the results stated in this paper is
based upon an examination of thirty-five cases of general para¬
lysis and seventy-seven cases of psychoses other than general
paralysis.

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65O THE WASSERMANN REACTION, [Oct,

Wassermann Reaction.

In the examination the original method of Wassermann was
employed, and a quantitative estimation of the amount of com¬
plement deviated was ascertained, the technique used being that
recommended by Mackenzie.(i) Alcoholic extract of syphilitic
foetal liver and of guinea-pig liver were used as antigen, and
the haemolytic serum was that of ox-rabbit, the complement
being supplied by fresh guinea-pig serum, and the blood-
corpuscle suspension was made up to 5 per cent, in normal
saline solution. In each case the blood-serum and cerebro¬
spinal fluid were examined.

In the cases of general paralysis the serum was positive in
767 per cent., the cerebro-spinal fluid in 71*4 per cent., and a
partially positive reaction was obtained in the spinal fluid in
two instances, or 57 per cent.

In the other psychoses the Wassermann reaction was nega¬
tive in seventy-six cases, or 987 per cent., and in the remaining
case, where the insanity was associated with Addison’s disease
and who was markedly tuberculous, a partially positive reac¬
tion was obtained in both the serum and spinal fluid.

Proteid Reaction.

The proteid reaction of the cerebro-spinal fluid was ascer¬
tained by means of two tests, namely, Noguchi’s (2) butyric acid
reaction and Ernest Jones’s (3) modification of Nissl-Nonne’s
saturated ammonium sulphate reaction. They are both
precipitation reactions and demonstrate the presence of globulin.
The results obtained by these two tests were identical; possibly,
however, for practical purposes the ammonium sulphate method
is the easier to perform.

In thirty-three cases of general paralysis this reaction was
markedly positive and in the remaining two cases was partially
positive. The intensity or delicacy of the proteid reaction was
found to bear no relationship to the Wassermann reaction.

In the seventy-seven other cases of insanity this proteid
reaction was positive in two instances only, or 27 per cent., one
of these was a case of well-marked epileptic insanity, and the
other was a case of insanity associated with myxcedema. In

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1910 .] BY WINIFRED MUIRHEAD, L.R.C.P. 65 I

fourteen cases, or i8’i per cent., the reaction was partially posi¬
tive. The various types of insanities and the results obtained
in them have been differentiated in the following table:

Table showing Wassermann Reaction, Protcid Reaction, and
Lymphocytosis in 35 Cases of General Paralysis and in 77
Cases of other Psychoses.

Type* of insanity.

Wassermann reaction.

Proteid

reaction.

Lympho¬
cytosis .

No.

Blood

serum.

No.

c. s.

fluid.

No.

c. s.

fluid.

No.

General paralysis, 3.S C

cases }

□

(

—

Delirious insanity, 13 C

...

cases (3 alcoholic). ]

...

(

—

■ |

—

«3

—

Acute melancholia, 9 (

...

cases . . . i

...

(

—

Mania, 14 cases . ;

□

...

—

Epileptic insanity, q (

...

cases . . . ]

...

—

Paranoia, 5 cases . )

...

□

...

(

—

Dementia praecox, 13 f

...

cases . . j

...

□

...

(

—

«3

—

Senile dementia, 7 C

...

cases . . . j

...

□

...

(

—

Congenital imbecility, (

...

5 cases ... 5

...

□

...

Insanity associated r

—

with myxoedema, 1 3

case . . £

Insanity associated r

with Addison’s dis- 5

□

ease, 1 case . . (,

...

—

+ Positive. □ Partial. - Negative.

It will be seen from this table that two cases of mania, both
in an excited state, three cases of well-marked epileptic insanity,
one case of paranoia, four cases of marked dementia praecox,

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THE WASSERMANN REACTION.

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two cases of senile dementia with arterio-sclerosis, two cases of
congenital imbecility, one case each of insanity associated with
myxoedema and Addison’s disease respectively gave a proteid
reaction more or less marked. In these patients no history of
syphilis was obtained and no symptoms of syphilis, congenital
or acquired, were present.

Estimation of A Ibumen.

The quantitative estimation of the proteid present in the
spinal fluid was ascertained by Aufrecht’s albumenimeter in
seventeen cases of general paralysis and in forty-four cases of
other psychoses. The amount was much increased in the
former disease, varying between o*i and 0*35 per cent., the
average being 0*2 per cent., whilst in the other psychoses
the quantity only twice reached o’i per cent.; sixteen cases
gave 0*025 per cent., nineteen cases gave 0*05 per cent., and seven
cases gave 0^075 per cent. It was found that the quantity of
albumen present in the spinal fluid did not necessarily coincide
with a positive or partially positive proteid reaction.

Lymphocytosis.

The cytological examination revealed a constant increase of
lymphocytes in the cerebro-spinal fluid of all cases of general
paralysis, which in number bore no relationship either to the
intensity of the proteid reaction or to the Wassermann reaction.
A differential count of the cells was not made. In the case of
other insanities an increase of lymphocytes was never found—
that is, 100 per cent, negative—and in each case the cell count
was calculated by Ernest Jones’s (4) field method.

Fehling's Solution.

In the total 112 cases examined the substance reducing
Fehling’s solution was never absent, and its reducing power
was found to vary in other insanities as well as in general
paralysis, but on the whole was more diminished in this
disease. An accurate quantitative estimation was not made.

Conclusions.

(1) The Wassermann reaction has been found positive in
the blood-serum and spinal fluid in a large percentage of

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CERTAIN INSANE CONDITIONS.

653

cases of general paralysis and negative in all other cases of
insanity examined, therefore its presence is a valuable addition
to establish the diagnosis of general paralysis, but its absence
does not negative that the case in question may be one of this
disease.

(2) The proteid reaction, more or less marked, is present in
all cases of general paralysis, and was obtained in sixteen out
of seventy-seven cases of other psychoses, although the intensity
of the reaction was much less marked. It must be concluded,
therefore, that this reaction is not absolutely specific for
general paralysis, and demonstrates that in other insanities
chemical changes are present in the cerebro-spinal fluid.

The quantity of proteid in the spinal fluid is much increased
in general paralysis compared with any other type of insanity.

(3) An increase of lymphocytes was found constantly present
in general paralysis and in no other case of insanity examined ;
thus, according to these observations, the presence of a
lymphocytosis is the most reliable sign of this disease.

(4) The substance reducing Fehling’s solution, although
varying in its power of reduction, was never absent in all cases
of insanity examined.

References.

(1) Journal of Pathology and Bacteriology , January, 1909.

(2) Journal of Experimental Medicine, January, 1909.

(3) Review of Neurology and Psychiatry , June, 1909.

(4) Ibid ., July, 1907.

Certain Insane Conditions amongst the Criminal
Classes. By James P. Sturrock, M.A., M.D., Medical
Superintendent, Criminal Lunatic Asylum, Perth.

It is not surprising that weakmindedness should be common
amongst the habitual frequenters of prison, but the proportion
of those who become certifiably insane is small. How very
few are there of our ordinary asylum patients who come from
the slums, or at least the criminal class. Is it that, in these
less cultured individuals, crime and alcoholic excess take the
place of insanity, each of them being a signpost marking
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distinct paths of degeneration, or does insanity exist, but is not
recognisable as such ? The unavoidable importance placed
upon conduct in determining insanity amid the ordinary respect¬
able conditions of life may prove misleading in the case of those
in whom what is commonly called bad conduct is a normal
condition. A distinguished alienist tells how he was once
called to see a lady, and on being introduced to her she spat in
his face. Without more ado he sat down and certified her. It
may be that many amongst the criminal classes suffer from
there being no possible obverse to this picture. I have seen
men sent into an asylum suffering from delusions of long
standing whose condition never caused their friends a serious
thought till some Monday morning they refused to go to work,
and before next pay-day they were certified. I have seen men
sent to prison for habitual failure to support their wives or for
neglect of their children where there seemed to be distinct
mental enfceblement, not certifiably obtrusive like a delusion,
but in the particular circumstances as potent a factor in the
lapse of conduct.

The actual relationship between mental enfeeblement and
crime is always difficult to determine. Besides, we must be
very careful in diagnosing mental enfeeblement amongst
habitual offenders. A hurried conversation with an illiterate
tramp may be very misleading, and a full appreciation of right
and wrong may, and does develop quite apart from the
intricacies of a Board school education. Apparently, as with
drink, so with mental enfeeblement; in many cases, much to
the detriment of statistics, putting aside the ordinary breaches
of the peace due to drink, which cannot properly be called
crime, the drunken man and the defective are, when bent
on crime, more easily found out. Many cases of sexual crimes
would be certifiable were it not so evident that nearly all the
uncommon and revolting perversions become active, or at least
prominent, under the influence of alcohol. It may be that we
should not look for any complex symptoms in the insane
criminal, and that the weak-minded should be as certifiable for
care and treatment as the more highly organised individual
who suffers from melancholia or paranoia.

Even though the conditions that have tended to dissociate
the old-time relationship between the prison and the asylum
have been more especially at work during the forty years since

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1910.] BY JAMES P. STURROCK,’ M.D. 655

Bruce Thomson wrote that “ 12 per cent . of prisoners at Perth
require special observation on account of mental disorder
exclusive of those who become insane,” we must expect to find
a large number of mentally defective in prison. I wish here to
draw attention to certain cases that emphasise to my mind the
difficulties of determining the proper provision to be made for
some of the mentally defective. The late Dr. Milsom Rhodes
stated that 10 per cent, of prisoners are weakminded, and that
almost all of those who violate the prison regulations belong to
this category. I doubt if any prison official would agree
entirely with the latter statement, but it is in this direction of
resistance to discipline and intolerance of regulations that
much mental enfeeblement is thrown into prominence. Much
has been said of the effects of prison discipline and solitary
confinement upon the degenerate mind. Solitary confinement
is probably not good for any mind, but we must be cautious
before we accept such a statement regarding order and discipline,
as that the sane criminal respects the regulations, while the defec¬
tive reveals himself by breaking them. We must not forget that
in the great class in which defectives are to be looked for, cases
of repeated breaches of the peace, common house-breaking,
petty thefts, and assaults, we have individuals whose prospects
and aims are of the lowest order, and who look forward to their
liberation, not as the end of a period of deserved punishment,
but as the regaining of that liberty which to them only means
licence. That liberty, which so many troublesome habituals
constantly talk about, is simply the craving to be at large to do as
they please in contra-distinction to the liberty of the law-abiding
subject, which is really a complex observance of the laws of
custom and decency, and a studied adherence to the social order.
Hence we must be careful not to place any undue pathological
significance upon conduct during those repeated terms of
imprisonment which, in a modern prison, are only irksome in
that they are interruptions of this undisciplined freedom. In
certain cases, however, this attitude, whether it be acquired or
due to constitutional defect, leads to conduct of a more or less
insane character.

The following cases illustrate, I hope, what I mean : No. 1
was at school till he was twelve, but was always amongst bad
companions. His mother died at his birth; his father was a
heavy drinker, and used, he says, to tie him to a chest and beat

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him till he was black and blue. He spent some years on a
training ship and was discharged from the navy for stealing.
At eighteen he was a known thief. He has on several occasions
assaulted policemen, prison warders and others. His own
words best describe his condition when he drinks: “ If you see
me drunk you are better to keep out of my way.” Previous to
his present sentence he made his sister support him while he
loafed about amongst his old companions because he could
only get work at ten shillings a week, and that “ would only
pay his board.” He is a good worker in prison, probably
because otherwise his gratuity suffers, and one day, while
working in a gallery, he had a dispute with a fellow prisoner.
Had they been at large they would no doubt have fought to a
finish and probably been good friends, but a warder, to quell
the disturbance, had of necessity to send both to their cells.
No. 1 immediately broke every pane of glass in his window.
His reason was that the other prisoner was in the wrong and
there was no use being locked up for nothing. He continued
to behave violently for days, once attempting suicide, and
finally, setting fire to his mattress, was found in a state of
terror shouting for help, after which he did well to the end of his
sentence. The suicidal attempt was of that peculiar kind that
one meets with on occasion amongst imbeciles in asylums,
more the result of peevish resentment than of mental depression,
and apparently conceived by a childish process of reasoning to
pay off some grievance. He tied his neckerchief in a single
knot round his neck and lay quiet holding the ends till he heard
the step of the warder coming to inspect him, and then pulled
them as tightly as he could. He showed none of the ordinary'
signs of mental enfeeblement, and in his most destructive and
violent moods I could always get him to desist and sit up to con¬
verse quietly with me. His conversation always showed a per¬
manent undercurrent of irritation as if he felt that, whatever
he did, the whole world was against him. He never, however,
had any of the constant suspicion of warders and officials which
some others show, and which seems to be just a further stage of
this irritable mental resistiveness. He says he does not sleep
soundly in prison but he has no complaints of this when he is
doing well. He broke up his cell three days after his last
admission, again as a protest against a regulation, and said it
was partly because he had not slept for three nights for think-

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1910 .] BY JAMES P. STURROCK, M.D. 657

ing of being caught, probably because he knew he was likely to
get a convict sentence this time. This man appears to differ
only in the intensity of the reaction from many cases of simple
bad temper in the face of discipline, and in judging of the
sanity of his acts, we must keep in mind the level at which his
whole career has been carried on.

No. 2, with a similar history, attempted suicide by drowning
at the age of ten because his father had thrashed him for mis¬
conduct. He was one day sent to his cell, after being twice
cautioned by a warder for speaking to his neighbour in the
workshed. Some few hours later he attempted to hang himself
just at a time when he must have known from experience and
the noise in the gallery that his cell-door was about to be
opened by a warder to put in his food. Placed in an observa¬
tion cell, he unfastened from his bed over a score of screw-nails
and swallowed them. In hospital, where he was for some weeks
under constant observation, he obtained a small iron knob from
his night-stool and swallowed that, showing his disposition at
the same time by telling me that he got it at the infirmary,
where he was X-rayed, through the warders leaving him
unwatched for a little—a statement which was proved to be
quite false. He seemed astonished that he recovered, as he
knew a companion who once swallowed one nail by mistake
and died. His reason for his conduct was that he was no good
in the world, but this statement was expressed in a peevish,
resistive, somewhat insolent manner, and far from showing the
depression to be looked for in ordinary melancholia. He
thoroughly enjoyed himself in hospital, reading amusing and
exciting literature, while he continued to threaten further
attempts when he got out. He is still in prison, free from
observation, contented and most industrious when he is given
some task that touches his vanity, such as collecting and
arranging the work of the other prisoners. He is ready to do
anything cunning or smart, particularly if it involves some
display of bravado. Yet it would be difficult, I think, for any¬
one to define any mental enfeeblement in him, much as one
feels it is there.

No. 3 is a female inebriate. She has a long list of convictions
for assaults, breach of the peace, etc., and is a very good
example of the many cases of neuro-instability where reforma¬
tion is not to be effected by curing an alcoholic craving. She

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lived a “ cat-and-dog ” life with her husband, whom she married
at seventeen, even before she took to drink, and one glass of
whisky sends her out looking for a fight. In her case the out¬
bursts of resentment are not kindled by ordinary prison restric¬
tions, for, in the State Reformatory, she has practically the
freedom and treatment of an asylum, and the attention of a
staff which, for patience and tact, cannot, I am sure, be
excelled. Her own reason for her outbursts of wild fury is
that of many of her type—continually increasing resentment at
being confined three years for what she calls a “ simple drunk.”
She is a highly strung, excitable woman, who as a rule works
nervously hard. Though illiterate and of low upbringing and
habits, she is remarkably tidy in person, somewhat vain and
conceited, and seems to think herself much better than the
other inmates. She applies repeatedly for liberation on licence.
What is actually a determinate sentence becomes for her that
fear of all the criminal class—an indeterminate one, because
she sees other inmates having their sentences reduced by vary¬
ing periods of conditional liberation. She becomes more and
more nervous—sometimes applying to me for a sedative—
sleepless and irritable. A refusal of her request for liberation
or some trifling misunderstanding with an inmate or official is
then sufficient to cause her to attack someone or go to her room
and smash up. Sometimes, when she is known to be excitable
and is perhaps being kept well in view, she will accuse the
warders of suspecting her of stealing. She has repeated attacks
of palpitation, sometimes with praecordial pain and great
anxiety, but these never occur till her irritation is well on the
way from some other cause. Isolation or solitary confinement
has no part in the origin of these conditions, except the wider
isolation from freedom, for this woman never exhibited conduct
of this kind until she was first sent to a reformatory. When at
liberty her irritability probably drives her to drink and expends
itself more easily in her freer circumstances.

Another typical case, sulky and irritable, had been teetotal
and well-behaved for six years, till her mother, against whose
wishes she had married, visited her one day and reproved her
for some trifling fault, when she at once went off and forthwith
began her degraded career again.

Nos. 4 and 5 differ from the others chiefly in that they are
in the lunatic department. No. 4, born of respectable working-

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659

class parents, drifted like the others into low company and
dissolute habits as soon as he reached his teens. He served
twelve sentences for housebreaking or assault and robbery, and
had numerous reports in prison for insolence, refusal to work,
etc. He stabbed a warder who had sent him to his cell for inso¬
lence. He said he felt he had been unjustly dealt with in being
sent to his cell, and, seeing the knife, he used it in his anger
without thinking of the consequences. He was afterwards
removed to an asylum, certified as having delusions of persecu¬
tion and suspicion, taking fits of passion without occasion of
any sort, being uncontrollable and smashing his cell furniture
and tearing his clothes. He was sentenced to H.M. pleasure,
and since his admission he has had a constant succession of
these outbursts. I cannot say that he has no occasion for them ;
every furious outburst has its starting-point in his misinterpreta¬
tion, not necessarily insane, of discipline and order. When he
breaks out his resentment lasts for days, he tears everything to
pieces, and he has carried out destruction which would scarcely
be credited. He will then pace his room all night shouting about
being unjustly treated by the warder whose order was the cause
of his resentment. These are not ordinary delusions of perse¬
cution. If I refuse to allow him free scope because he has
lifted a knife from the table with which to attack the charge
warder, I do not call it a delusion of persecution if he
spends the night threatening to murder me because I do not
give him justice. Every outburst is similar in origin to the
following : He handed me a letter, after he had for some time
persistently refused to exercise in the observation ward, pre¬
ferring to remain in the corridor, in which he asked to be
allowed to spend the afternoon in the large yard for the quiet
privileged patients, telling me that if I did not grant his
request and I wanted destruction he would give me my fill of
it. With special arrangements his request was granted, and
he was quite happy, seeking out for his companions men of his
own habits. Then came the inevitable request to be allowed
to stay on while the garden workers played bowls and half the
staff were at tea. He was told this also would be granted as
much as possible, but on the day he made the request he was
kindly asked to go to the ward for a little as the staff was
short. Five minutes afterwards the warder went to bring him
back, but he was already threatening and began at once to tear

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up, took to his bed and to his usual degraded habit of first
breaking his night vessel and then defiling the floor. On one
occasion he tore up everything because I would not let him
have his melodeon in his room at night. When he quietened
down it was returned to him during the day, but he dashed it
through the roof-light, and threatened me for weeks because it
could not be mended. He has, when excited, scratched his
throat very slightly with a piece of iron wrenched from his
door, and then thrust it through the inspection hole as a
warder looked in with the intention of injuring the warder’s
eye. When he is quiet he is perfectly rational, pleasant and
intelligent, and could he have a villa and six attendants pre¬
pared to humour him in everything I doubt if he would have
many outbursts. It is interesting, in determining the exact
significance of this man’s conduct, to recall the nature of his
crimes when at liberty. He is well known to the police as a lazy
corner-boy of the worst type. A policeman had occasion to be
constantly moving him and his companions from a certain
entry in town. One day, after this man had been moved on
several times, he secreted a piece of railing in the stair, and
when the policeman next appeared and followed him into the
entry he was savagely assaulted and injured with the weapon.
This is the same reaction under different circumstances as when
here, on his best behaviour, he one day lifted a dinner knife
and hid it in the lavatory, saying afterwards he put it there for
the charge warder if he could not manage him with his hands.
I have a patient very similar in type, always suspicious of
warders, but who has not yet broken out, sentenced to King’s
pleasure as being insane, whose crime consisted in following
an elderly gentleman into a stair, garrotting him and stealing
his purse. Such conduct, however, in these men should not
influence the diagnosis of insanity, but it has a most important
bearing upon their treatment.

No. 5 pled guilty to a murder charge and threatened to
commit suicide if he were reprieved. His conduct is similar to
that of No 4, except that he carries the degrading features of
his outbursts further, which is not to be wondered at from his
disposition. His character is low, his ordinary conduct cunning,
but in its general sequence the latter reveals a constantly vary¬
ing emotional condition and a peevish, childish determination,
which, if it is not mental enfeeblement, is certainly the starting-

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1910.] BY JAMES P. STURROCK, M.D. 66 1

point of his excited attacks. He can be trusted more than the
last case, his excitement seldom taking the form of assaults and
being easily anticipated, so that in general he is working in the
garden or in the ward. At work he goes at high pressure,
insists on hoeing three drills of potatoes for every one of the
others, has bursts of religious pretensions varied with filthy
language and most unchristian acts, and is invariably kind to
helpless inmates. There is no trace of other intellectual
enfeeblement about him, but the following incident shows some¬
thing of his peculiar mental state. He is very fond of concerts
and attends every one. Recently he was prepared with a
bouquet of flowers for the lady who was giving an entertain¬
ment to which he had been eagerly looking forward. Unfor¬
tunately she did not at once notice him when she came in, and
he was much downcast and left looking fit to cry. His disposition
prompted him at once to write to the authorities complaining
that the inmates’ leisure time was being stolen from them to
give concerts which no one ever wanted to attend. It would
take too long to show by daily examples of this sort how much
of this man’s conduct is due to a mental twist of some kind.
He tore up one day because he did not get his clothes at once
in the morning, after having promised me to keep his bed for
a day on account of a sore knee. When he is in one of his
destructive, dirty moods he lies in bed reading his newspaper,
laughs and discusses quite sanely with me the sporting news,
all the while his walls are decorated with filth, and he tells
me he does it all to fight me for his rights. For many
months now he has been continually studied and humoured like
a child in spite of repeated troublesome sane conduct, but he is
not so well on the whole as he used to be for a long period after
he had an outburst. The charge warder constantly assures me
what I feel is quite true that the man would be better if he had
a burst, just as if our treatment of him had the same effect
on his emotional centres as bromide has upon the motor areas
of many asylum epileptics. Dr. Macpherson, who has seen this
man at his worst, says he has never seen conditions so closely
resembling acute mania as these outbursts, and yet he could
not characterise them as such. I am certain from close obser¬
vations that there is no mental confusion present in any of these
outbursts. This man often threatens suicide in an angry,
resentful way, but he only once attempted it, running his

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head against the door in one of his tempers and desisting the
moment he felt it sore. There seems little doubt that he was
unfit for convict discipline, but there is a doubt as to whether,
if he were at liberty now, his conduct would ever take a form
that would suggest insanity. When he drinks he is said to be
quite wild and erratic, impossible to please whatever attitude is
adopted towards him.

Wherein lies the mental defect in these cases ? The term
“ explosive ” I think well expresses the condition in that it is
not so much the conduct after an outburst that constitutes the
defect—that varies very much with the disposition and ordinary
habits—but rather the mental instability which is so easily
kindled into uncontrollable impulse. I have not seen any periodi¬
city about these attacks ; frequent they may be, but in view of
the history of the outbursts in these cases which typify the group,
no periodicity need be looked for. I do not think the term
“ explosive ” need be restricted to cases of destructive habits
or violence but have included the suicidal case No. 2 as I con¬
sider the underlying mental state to be similar in all of them.
Very many cases of homicidal impulse now in the lunatic
departments at Perth show, after recovery, this same disposi¬
tion without perhaps the baser accompaniments. Mental
resistiveness, childish petulance, aggravated jealousy, disposi¬
tions that will not brook contradiction are so common in
otherwise recovered puerperal cases as to throw much light upon
the undercurrent of their impulsive acts, though when we meet
these same characteristics in the ordinary prisoner we may
overlook them in face of the more evident criminal pro¬
pensities.

It may be argued that these are simply cases of ungovernable
temper in persons of bad habits and criminal instincts, that the
treatment they need is not mental care but rigid discipline and
moral training. I might, however, point out that the theory
of congenital mental defect is supported by the early age at
which all of them began to show perverted habits amid varying
grades of home circumstances and example, and by the fact
that, with few exceptions, the cases I have met have had
reformatory training without result. It may even be said that
some of the men are merely hooligans fostered by the modern
humane treatment in prison and out of it. True it is that the
prison punishments now inflict no bodily pain, and that to an

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663

ordinary habitual a day’s bread and water and the complex
administrative machinery with which the ignorant offender
finds himself in conflict after a simple offence seem in some
cases to act as mere irritants. But corporal punishment is not
likely to affect the least defective of these. The condition is
not a recent creation; in former days they were less scientifi¬
cally known as “prison breakers,” and from all accounts they
were far more numerous than they are to-day. Fifty years
ago one notorious case who was seen in consultation by a
mental specialist and pronounced of perfectly sound mind used
to “ bring her head against the wall with a sickening series of
cracks and wrench up the flooring of her dark cell, battering
away with the planks at the door till the whole prison seemed
to be coming down.”

In another group of cases this same mental resistiveness,
with its resulting irritability, appears in association with
peculiar illusions and ideas of suspicion and persecution
directed against prison officials and referred to the prisoners’
surroundings. Here we touch upon the possible effects of
solitary confinement producing insane ideas by the introspec¬
tion which it favours. I do not here refer, however, to those
cases that approximate to paranoia, but to certain forms where
the insane ideas are of a very fleeting and changing type, and
seem to have a causal connection with the mental irritability
awakened in defective cases by prison restrictions.

The simplest form is shown in a prisoner, a young man who
has led a career of crime since he was twelve. Although he
talks intelligently enough for his education, and has a ready
speech, as befits his occasional occupation of a street flower-
seller, most experienced people would say there is some
enfeeblement about him. He broke his dinner-dishes one day
because his soup was “ poisoned.” He said he knew it was
tampered with because of the bad taste in his mouth, and I am
sure that at the time he believed it. He suffers from a slight
chronic dyspepsia, and his breath is always foul. He has only
made this complaint twice, and on both occasions he was at
the time under report for an offence against the regulations.
The connection between his irritation against the warders, his
mental enfeeblement, dyspepsia, ideas of poisoning and dish¬
breaking is not difficult to make. Though he has no complaints
of such a nature at any other time, he still insists that on both

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these occasions something was put in his food. In conditions
such as this we must remember the part that ignorance plays
in the causation of the many absurd ideas that prisoners express
regarding warders and others. I had a woman under observa¬
tion who was illiterate and ignorant, but not, in my opinion,
at all defective. In the middle of the night she rang the bell;
the matron who visited her found her sitting on the edge of her
bed, having almost certainly jumped up in a nightmare. She
insisted till the day she went away that she was pulled out of
her bed, for she wakened in a fright to find herself sitting up.

These prisoners are all right when at liberty and amongst
people and rules they understand, and the man whose soup was
“ poisoned ” is not likely to be certified out of prison, apart
from his slight enfeeblement.

Transient delusional states are common. There is a case of
homicide, while insane, now practically well, except that at
very long intervals, and always after not sleeping well for a
night, he excitedly tells me in the morning that the night
patrol, while going his rounds, was kicking up the gravel as he
passed beneath his window just to annoy him. He may be
perfectly well afterwards for months, except for an irritable
display of temper, but with no trace of suspicion or delusion
against anyone till this neurasthenic crisis recurs.

The most difficult and interesting cases are in the convict
prison. Those that I have investigated show invariably the
following sequence : the breaking of some regulation, a report
to the Governor, and perhaps a mild punishment—the worst is
deprivation of good conduct marks, as that prolongs the
sentence—smashing up of cell furniture or windows, and then
a referring of the whole incident to some persecution practised
upon them. The origin of these ideas of suspicion is very doubt¬
ful. Most of the cases seem undoubtedly enfeebled mentally.
In many instances there are merely constantly reiterated
grumblings superimposed upon ignorance and mental defect
and not amounting to delusions. In some cases the ideas are
nothing more than degenerate romance, reminding one very
much of cases met with in ordinary life, where some highly im¬
probable personal incident is often related and embellished by an
individual so that he appears to believe it, though none of his
audience ever do. There is also ample evidence to prove that
the ideas are borrowed by one convict from another. There is

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nothing mystical about the delusions. If a prisoner has been
reported by a warder, his food has been “tampered with ” by
that warder. There is a constant air of suspicion about most
prisoners which is not necessarily insane but very much the
result of their own habits. So that it is not difficult for a
mentally defective convict to evolve absurd ideas out of trifling
acts of observation and discipline which a warder has to
exercise under a strict and silent penal system.

I have at present under observation a convict who began to
steal at the age of ten, has been out of and in prisons ever since,
and has served long sentences at Peterhead. There is no
doubt that he is mildly imbecile, but he has had an extra¬
ordinary career. He has a most powerful imagination; he will
keep me listening for hours to accounts of his treatment in
Peterhead, interspersed with impossible tales of his life out of
prison which make me certain that the whole thing is degenerate
romance. He has been for some months under my care, and
probably because of the relaxation of the discipline and the
granting of almost every addition to his diet in reason there is
no delusion forthcoming regarding his treatment here. He will
give the exact dates for years back of the occasions when gas
was blown into his cell, poison or some medicine from the
doctor was put into his food, etc. He tells tales of detectives
watching him when at liberty—which they no doubt did—
embellished into something very like certain forms of juvenile
literature and the most extraordinary stories of hospitals he has
been in, not delusions, but absolutely impossible romances, con¬
cerning the conduct of the staff from the doctors downwards.
His character since he first entered a prison is that of an incor¬
rigible chatterbox, and it is no wonder that he was continually
in trouble at Peterhead. If he was asking extra coffee for supper
and was refused he would, on the first occasion of punishment,
say he was getting a “ tampered ” supper. Similarly with many
other cases. Mental enfeeblement, ignorance, resentment to
discipline, vicious tendencies, and anti-social habits and ideas
are the foundation of these quasi-delusional states, which are
of a fleeting nature, are not accompanied by true hallucinations,
and are more or less evident according to the behaviour of the
prisoner and the amount of indulgence that is given him on
account of his defect. The last case well illustrates the diffi¬
culties of providing suitable treatment for such defectives under

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any circumstances. Under the slightest pressure of disciplined
restrictions he is constantly, and is likely always to be, at war,
while his disposition and habits lead him to take such advantage
of every allowance and indulgence made for his mental deficiency
as to render order an absurdity if these privileges are to be
carried to the fullest extent necessary to please and keep him
quiet under detention.

One outstanding fact is that these ideas disappear entirely
when the sentence is ended. The circumstances are altered to
the prisoner’s entire satisfaction, and in his normal surroundings
mental enfeeblement of itself is not obtrusive. I do not think
that any of the cases I have seen had any thought of malinger¬
ing insanity. That is a highly intellectual process, I think—
quite above the level of the prisoners in whom these delusional
states are found. I have learned from old prisoners in asylums
that they would much rather have a sentence and be done with
it than be certified. It is the grievance of many King’s pleasure
cases who are detained for ordinary crimes of which they have
been acquitted on the grounds of insanity.

The only radical treatment for these cases would be the
approximation as far as possible of their conditions during
detention to those they enjoy at liberty, and the difficulties of
that treatment are self-evident. Association in place of solitary’
confinement must be looked at not only in the light of history’
on the state of matters that prevailed before the long-sought-for
solitary system was instituted, but also with a complete know¬
ledge of the disposition and conduct of certain convicts, which
are undoubtedly more serious matters than many people
suppose. The methods of indulgence that must be employed
to keep these outbursts under are not likely to cure the mental
defect, and I have tried every form of drug for the explosive
conditions without much good results. If the inherent defect,
then, is an ineradicable quantity and these cases are unfit to be
at large, which will not, I think, be doubted, whatever be the
view taken of their mental condition, there are two extremes
of treatment available. The most natural, or rather primitive,
and the one that would probably commend itself to the
prisoners, would be to remove all artificial restrictions and
supervision, giving them the liberty they desire in a community
cut off from the social system, so that they could indulge their
primitive instincts, settle their difficulties in their own fashion.

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and on the principle of the survival of the fittest, probably
evolve a better type. But that is not in accordance with
modern standards. The other extreme is the expensive method
of depriving them of their liberty, whether by an indeterminate
sentence or a medical certificate matters not, and, as compensa¬
tion, providing such extensive supervision as will ensure the
safety of the public and at the same time afford the maximum
amount of freedom. The ideal system would, of course, be to
associate each individual with good companions, and whatever
system be adopted for these defectives it will be expensive in
proportion to its success. The difficulties of treatment are
evidenced by the experience of the State Inebriate Reformatory
and Lunatic Department. In the latter the lunatic criminal is
not yet very largely represented, but the treacherous combination
of several semi-sane convicts would require, in a fully associated
system, attendants possessed not only of patience that would
be difficult to procure in any very large quantity, but of some¬
thing more than “ second-sight.”

A difficult problem is the ultimate disposal of such cases.
Apart from the difficulty of deciding whether or not all these
cases are to be put under restraint and undergo treatment
entirely based upon the recognition of a mental defect, there is
the substantial difficulty of obtaining a certificate of their
insanity on their discharge from prison. It is remarkable how
even a truly delusional prisoner can pull himself together as
liberation approaches. I discharged lately a very rough, dan¬
gerous character, defective, ignorant, suspicious, and certifiably
insane from his conduct during his short imprisonment for
culpable homicide. On his liberation it was found impossible
to get out of him, after the most careful examination, one
single fact to justify a certificate of insanity. It may be that
the next we hear of him will be another assault, when his
history will probably be recalled and he will be sentenced to
H.M. pleasure.

If a prisoner be certified insane while undergoing imprison¬
ment, whether he finishes his sentence in the lunatic depart¬
ments or not, his ultimate destination, if he does not recover,
must be an asylum. No one will deny that whatever the pro¬
vision made for him, it should be entirely free of prison regime.
If the treatment of the cases I have mentioned is to be based
upon mental defect it should also be of an asylum character

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in the first place, though discipline and even punishments of
the better type—the deprivation or granting of privileges that
tend to instil self-control and habits of work—must have a
place. Whatever may have been the career of a prisoner it is
only common humanity that his mental condition should
receive proper treatment. There are obvious disadvantages to
his being treated at first amongst the better-behaved inmates
of an asylum, but there is no justice in keeping him in the
vicinity of a prison whatever methods may have to be employed
for his care and treatment. Many cases, though unfit to be at
large on account of their vicious habits, become otherwise so
well after a stay in an asylum that they cannot be detained,
and they are no sooner out than the whole process begins its
round again. Some of these are then, at the first offence, sent
to the criminal lunatic department, There are obvious objec¬
tions to this method. It intensifies all the conduct which in
the inmate is associated with his attitude to prison, even
although the treatment is purely asylum in character. The
indefinite sentence, the association with, and conversation
of, some of his fellow inmates all tend to discontent instead
of submission to treatment. There are as good objections,
too, to mixing up vicious defectives with the many respect¬
able inmates in the State asylum as in an ordinary asylum.
There is also the objection of the defective but mild offender to
his being sent, and that for an indefinite period, to associate
with homicidal cases. Legislation for the mentally defective
who are not, according to law, certifiably insane, may make
many of these questions clearer. When it does come, the mass
of criminal defectives and their proper disposal in those com¬
paratively unrestricted circumstances, which I believe will
alone combine treatment, safety and contentment, will be a
difficult problem indeed.

Discussion,

At the Annual Meeting held in Edinburgh in July, 1910 .

Dr. Dunlop desired to express his high appreciation of Dr. Sturrock’s paper,
which was of great interest to all. He had had ten or twelve years’ experience of
the class spoken of, and after a considerable acquaintance with the subject and
hearing much evidence on the Commission to inquire as to the feeble-minded, he
might be allowed to say a word. Dr. Sturrock’s main conclusion was one which
nobody could controvert; everybody who had been interested in the subject had
arrived at the same conclusion. Those unfortunates of the class referred to, who
went in and out of prison, required to be segregated, as they were not fit to be at
liberty. Their conduct was dependent upon mental deficiency. The author had

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selected some very difficult cases, and he would like to say, by way of warning to
others present, that some of the cases met with in prison, which were habitually in
and out of prisons, were more exaggerated cases of insanity than Dr. Sturrock had
given an idea of. For instance, one man, a paranoic, spent fourteen years in prison
out of seventeen years ; he imagined that there was a phantom running up and down
and interfering with his getting work, and in order to procure something to eat he
got into stables and stole clippings of horsehair, which he sold for a few pence.
Among dements there were several instructive cases which he had known during
the last ten years. One was that of a respectable woman who, unfortunately,
became insane. She was treated three times for long periods in asylums, and then
discharged in a condition fit for liberty if she had had friends and relatives to care
for her. But she was not of the class who had anyone to care for her, and ever
since then she had been spending her life in and out of prison—short sentences
each time. Certainly her downfall dated from her discharge from the asylum. He
mentioned that in order to show the great necessity of having some machinery for
securing the care of the unfortunates who got into our prisons. But how that was
to be brought about was a very difficult question. The Commission of which he
had the honour to be a member, in its report advised that it should be the duty
of county councils in England, or of the district lunacy boards in Scotland. His
own opinion was that it was a matter for the State or the Crown to deal with. And
more especially was this so in Scotland, which is only a small country, and the
total number of such persons there was comparatively trifling; he believed there
were not more than three hundred of them all told. If those were collected into
one State asylum—in which the patients would be maintained at the local cost, other¬
wise it would be open to abuse—the whole matter would be satisfactorily dealt with.
He had for years felt the necessity of something being done, and he thoroughly
appreciated the paper in drawing further attention to that class.

Dr. Percy Smith said he had been very pleased to hear the paper, as he was
familiar with the cases written about, being one of the Board of Visitors of the
State Inebriate Reformatory at Aylesbury, where there were large numbers of
persons of the type described, persons who probably had never in their lives exer¬
cised, or been capable, of self-control. They were irrelevant in conversation and
were unable to accept an answer to anything as final. They were explosive, irri¬
table, and often violent on the least occasion, when they would instantly seize
wardresses by the hair. There were cases who had periodical outbursts of extreme
fury with destructiveness. They were like cases of acute mania, but, as the author
said, they were not confused at the time, but always knew exactly what they were
doing. The outburst generally passed off in a short time and was usually due to
some slight correctional, disciplinary measure. The practical difficulty was, that
even with those who, by careful observation, were considered insane and certified
and sent to asylums, the asylum people would not keep them. As Dr. Dunlop
said, the patient was sent to the asylum a semi-criminal. After a short time he
behaved well and went out, and his last stage was worse than his first. There was
considerable difficulty at present in the State reformatory in that the London
magistrates would not send the people there for sufficiently long periods. Three
years kept them out of mischief and in fairly good health, but probably this period
was not long enough. Many of the patients required re-detention, and that should
be possible on the least relapse without any formality. The London magistrates
were now largely reverting to the old practice of sending patients who were drunk
and disorderly to Holloway for three days. But often they were back again in a
week in the same condition. Whether detention in an inebriate reformatory did
good or not, a sentence of three days, resulting in the prisoner being back again in
a week, did no good at all. Probably some permanent seclusion from the com¬
munity was necessary for many of the people under discussion.

Dr. Robert Jones said that as one of those who received the people under
discussion he could support what had been said about them. They were most
difficult people to control in a ward; they upset the discipline of the whole ward
or block of the asylum. It was very creditable to a public body, the Commission
for the Feeble-minded, that it had discovered the moral imbecile. He had had
many such cases, and in one he had careful post-mortem notes made. The brain
was simply ill-developed, with scarcely any complexity. He was more and more
convinced that the chief power of the cerebral cortex was inhibition. As these

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persons had defective inhibition they were most difficult to direct and control.
He did not think there was anything to be done for them, except what was suggested
by the Commission on the Feeble-minded, namely, keeping them in some definite
place for education and encouragement. But it would need to be a large asylum
to contain them all, as in one large asylum he had had there would probably be
hundreds of them. He would refer to the committee which the Association had
formed, and which it was suggested should be enlarged, namely, one to work with
the school medical officer. It was important that these moral imbeciles should be
discovered early, and something made of them, if possible.

Dr. Briscoe asked if Dr. Dunlop would say whether alcohol played any part in
the cases described. The Salvation Army got hold of a lot of those people, and
its officers said that if they could keep alcohol away from some cases these would
be all right.

Dr. Dunlop, replying to Dr. Briscoe, said alcohol was a frequent element; but
in many cases stoppage of the alcohol did not stop the occurrence of the out¬
bursts.

Dr. Sturrock, in replying on the discussion, said the estimate of the lack of
the power of inhibition had been exaggerated in many cases, and the difficulty of
treating such cases was not always due to the defective inhibition. He had one
man who was suspicious of warders; he was working as a tailor, and had been
wearing his slippers, but one morning he put his boots on, and it was ascertained
that he was expecting a fight. He was a defective. His crime before he came in
consisted of waylaying an old gentleman in an entry and stealing his pocket-
book. Much of his conduct was dependent on that temperament, not on lack of
inhibition. The moment one began to apply freer methods to them, one required
a huge body of attendants; and it would be a very expensive matter if the whole
of the mental defectives were to be placed under the amount of supervision
necessary to keep them not only sane, but contented. Then would probably
come about that state in which the inhabitants of the British Isles would make a
living by taking in each other’s lunatics.

Eugenics and Degeneracy. By C. T. Ewart, M.D., Senior
Assistant Medical Officer, Claybury Asylum.

The object of this paper is to consider whether it is
necessary or advisable to introduce ordinances for the dis¬
couragement of parenthood on the part of the “ unfit,” and the
encouragement of large families on the part of the “ fit,” in
fact the eugenic principle, and to those who believe that the
only true cure of insanity is its prevention, the subject must
be of vast importance.

If we recall for a moment the history of the rise, progress,
and fall of the various nations which have been pre-eminent in
the past, we find that the same course has been experienced by
each : there has been a period of hardship and energy, accom¬
panied by development, followed by a period of luxurious
quiescence during the supremacy, and this has been succeeded
by a decline and fall, a study of events during these periods
showing us that it is by the interference of civilisation with

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the process of natural selection that the decline and fall is
brought about. So soon as the necessity for striving and
struggling is past, there is no longer the extermination of the
weaker members, and their proportion steadily increases, the
standard of the whole country is lowered, and there is a
diminution in the mental, moral, and bodily powers, and an
increase in the numbers of those who are unable to properly
fulfil the duties of citizenship, until finally there is a pre¬
ponderance of the latter, and the doom of that country is
sealed.

Two explanations, each falsely asserting itself to be rooted
in biological fact, have long been cited, and are still cited in
order to account for these supreme tragedies of history. The
first may claim Plato and Aristotle as its founders, and consists
of an argument from analogy. Races may be conceived in
similar terms to individuals, and just as the individual is
mortal, so is the race. Each has its beginning, its periods of
youth and growth, its maturity, and finally its decadence,
senility, and death. Biology, however, declares that whilst
the individual is doomed to die from inherent causes, the
germ-plasm is immortal, and has no inherent tendency to
cease to exist. Species now flourish which are millions of
years older than mankind, and the Jews have survived one
empire after another of their oppressors, so that it is not races
that die, but civilisations and empires.

The second false interpretation widely credited is that in
consequence of success a people become rich, idle, and luxurious,
and that these acquired characters are transmitted to succeeding
generations, so that finally there is produced a degenerate race
unable to bear the burden of empire, and then comes the
crash, but this theory of Lamarck of the transmission of
acquired habits of luxury and sloth from parent to child, the
modern study of heredity empowers us to repudiate.

What theory of this alleged degeneration is there to offer in
their place, and especially, what theory which explains racial
degeneration amongst, not the conquered, but the conquerers
amongst the successful, the imperial, the cultured, the well
cared for in all respects, mentally and bodily? Why is it that
not enslaved, but imperial peoples degenerate ? Why is it that
nothing fails like success ? The reason is that no race or
species, vegetable, animal, or human, can maintain its organic

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level, let alone raise it, unless its best be selected for parentage.
When a race is making its early way, by force, selection is
stringent. The weak, diseased, and stupid are ruthlessly
expunged from generation to generation. As civilisation
advances, another ethical standard is reached : the diseased and
feeble-minded are no longer left to pay the penalty sternly
exacted by Nature for unfitness ; they are allowed to survive,
which is well, and to multiply, which is ill. Babylon lasted
4,000 years, and yet, at last, it fell. If selection had been
operating throughout that time, would Babylon have fallen ?

Without selection races must deteriorate, the lower indi¬
viduals multiplying more rapidly than the higher in accordance
with Spencer’s law, that the higher the type of the individual
the less rapidly does he increase, and the race which is not
advancing is retrograding as Gibbon declared (Saleeby).

From the evidence given before the Royal Commission we
learn that in England and Wales 271,607 persons are suffering
from mental defect, that 120,000 are certified lunatics, and
150,000 are not sane, but are not certifiable, while 66,000
urgently need proper supervision. Of the inmates of the Poor
Law Institutions, excluding pauper lunatics, from 12 to 18
per cent, are mentally defective. In the elementary schools
35,000 children are mentally defective, and in our prisons
there are to be found every day from 3,000 to 4,000 mental
defectives.

From these figures it is evident we have in our midst a
class of persons contributing to the degeneracy of the race.
But that is not all. The problem of the feeble-minded is
intimately associated with the problem of insanity, epilepsy,
alcoholism, and consumption. Again, such questions as the
housing, feeding, and remuneration of the working classes,
infantile mortality, teaching, employment, and pauperism are
in urgent need of attention, but measures to deal with these
matters cannot solve the problem of national degeneracy.
National progress can only take place when means are taken to
increase the fit and decrease the unfit. The establishment of
suitable farm and industrial colonies is the only method whereby
society can be protected from the feeble-minded. There they
would be far happier than in the outside world and would con¬
tribute to their own support. Nothing is more wasteful than
this army of degenerates who, when they are not living at the

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cost of the taxpayer in workhouses or prisons, are wandering
at large, idling, pilfering, injuring property, and polluting the
stream of national health by throwing into it human rubbish in
the shape of lunatics, idiots, and criminals.

Dr. Ettie Sayer, in the course of her work for the London
County Council, studied the family history of 100 normal
families and 100 families where mental defectives were found.
The normal family averaged five in number, while families
showing abnormality averaged 7‘6, or nearly one-third as many
more ; 42 per cent, of the abnormal families, compared with
6 per cent, of the normal, showed parental drunkenness ; I 3 per
cent. } as compared with 3 per cent. y showed consumption, whilst
insanity, suicide, epilepsy, and other diseases were also shown
in excess amongst families of aments. In a group of 100
normal and 100 abnormal children examined by Birmingham
doctors the contrast between the family histories was very
marked ; twenty-eight abnormals had an insane, feeble-minded,
or epileptic history, compared with 10 per cent, among the
normals ; in forty-three of the abnormals a consumptive history
was found, which appeared in only 17 per cent, of the normals ;
41 per cent, of the abnormals owned an alcoholic family history,
as compared with 22 per cent, of the normal.

Of our diseased and defective population almost every
individual is maintained either by charity or the State. To
these families belong the recipients of half the doles of free
boots, free meals, and indiscriminate charity of the neighbour¬
hood. In short, we are looking on at a process of selective
degeneration carried out on an extensive scale by State and
private philanthropy. For the purposes of the Royal Com¬
mission the National Association instituted an inquiry in con¬
nection with all the larger Magdalen Homes in England. One
hundred homes sent answers, which showed that 14,725 inmates
had passed through the hundred homes in the course of three
years, and of these 2,521 were stated to be feeble-minded.
These feeble-minded women were known to have added 1,000
illegitimate children to the population.

We fail to see that we must educate both sexes. It is of
little use that a girl had played centre forward at hockey or
had been a wrangler if she could neither produce a baby nor
nurse it. Education which teaches a girl to despise mother¬
hood, whilst making her incapable of it, is not “ higher ” but

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“ lower ” education. The whole theory of eugenics rests on the
distinction between the right to live and the right to become
a parent. It does not propose to kill anyone, and it hails ever)'
political party and every reform which contributes to its end.
No eugenist believes in the theories of Plato, namely, that the
bridegrooms and brides are to be mated by lot, and the lots to
be so manipulated by officials as to bring together superior
persons of each sex and to keep apart the inferior, who were
to mate with each other, the offspring of the first set of unions
to be regarded as “ children of the State,” and the children of
the other unions to be put away.

What makes the science of eugenics possible is the law of
heredity that “ like tends to produce like,” not “ that like pro¬
duces like.” It is common experience that superior persons
produce inferior children, and that inferior persons, though much
less often, produce superior children. Eugenics deals with
averages, and in the average the law of heredity acts with
practical certainty, and all race questions are questions of
average. With regard to heritable diseases, what is meant is
not the transference of the disease itself, but the transmission
of a predisposition to it, and this is effected through the medium
of the germ-cells. Negative eugenics teaches us what to pre¬
vent, positive what to encourage. The “ fittest to survive ” are
those who possess sound health, energy, and a well-balanced
brain. These would be most likely to be useful to themselves
and to the community. The greater part of feeble-mindedness,
insanity, and criminality could be eliminated by segregation in
one generation.

So little attention has been given by the State to the physical
development of the people that, unlike those continental nations
which have adopted universal military service, it has, at the
present time, no physical standard whereby the male youth of
corresponding ages could be compared. The Army Medical
Report for 1907 gives 59,393 as the total number of medically
inspected; of these, 17,513 were found unfit within three
months of enlistment, making the rejection ratio 294'83 per
1,000 examined. In this calculation no account is taken of
candidates so manifestly unfit that they were not submitted by
the recruiting officials to the medical staff for examination.
The average age of the medically inspected was 19^2 years,
average height 65 6 inches, average weight I22'2 lb., while

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the average height of males of the general population between
eighteen and nineteen years of age is 67£ inches, and their
average weight 1384 lb. These figures do not, however,
convey the whole truth, for the average height and weight of
males of the strata from which the recruits are drawn are still
lower and the recruit is the “ fittest of the unfit of the people.”
Of all diseases there is none more intimately associated with
impaired nutrition and with lowered vitality than heart disease,
which, therefore, with other circulatory diseases, affords an index
of national health and of racial quality not otherwise obtainable.
In 1907 the total number of rejections on enlistment for these
diseases was 2,337, a ratio of 39*35 per 1,000 medically
examined.

Table showing Cardiac Affections. Ratios per 1,000 of Strength.

United

Kingdom,

1907.

France,

'905.

Germany,

■9«>S-

Austro-

Hungary,

1906.

3'9

United

States,

1906.

3'37

Russia,

■9°5-

When it is considered that the mortality from diseases of the
heart and of the blood-vessels of the civil population in England
and Wales in 1907 was more than one-seventh of all the deaths,
the importance of this question cannot be over-rated. Unfortu¬
nately the responsibility of the State for national health relates
to environment, the notification of infectious diseases, Poor Law
relief, and partially to the care of children during school life.
In all other respects, excepting criminal offences and the cus¬
tody of the insane, the individual is subject to no supervision.(')
In the problems of heredity we see as yet but as in a glass
darkly, but it is gradually dawning on many that the proper
study of man is mankind. In our wise and beneficent search
for better conditions of life we should not forget other influences,
which even more than environment goes to make personality.
To improve the conditions in which life is passed and by which
it is moulded is but to deal with the lesser part of the problem.
The deeper question, the conscious solution of which is opening
out to all civilised nations, is how to maintain and, if possible, to
improve the innate quality and character of life itself. The
average quality of a race is but the average quality of the
individuals composing it. If by increased medical knowledge the
feeble-minded and weak-bodied stocks be allowed to survive,

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and if, as it seems to be the case at present, they reproduce
themselves faster than the better strains, the relative numbers
of such persons in the country must increase and the average
quality of the race deteriorate. If by economic and social
conditions children be made too heavy a burden on the more
desirable elements of the population, there is danger that the
thrifty and far-seeing members of the community will postpone
marriage, and when married restrict the number of their
offspring. Thus while the weak and careless elements grow at
an increasing rate, the good stocks of the people check their
growth and the selective deterioration of the race is hastened
in two ways.

We learn from the Registrar-General’s returns that in order
that a population should maintain its numbers unaltered, four
children must be born to each marriage; of these four, on the
average of large numbers, two will either die early or have no
children, and the other two will be left to continue the race in
the place of their parents.( 2 ) Certain large classes now pro¬
duce an average of only three children to each fertile marriage,
that is, only three-quarters of the births necessary to maintain
their numbers unaltered. If their death-rate be taken at 15 per
1,000 their birth-rate must be three-quarters of 15, or rather
more than 11, that is, about 4 less than the 15 needed to replace
the deaths. At the end of a century—three short generations—
each 1,000 will be represented by only 6S7 and in 200 years by
472.

The birth-rate of other sections of our people is still 33 per
1,000, or 13 more than are needed to balance their higher death-
rate of about 20. At the end of 100 years each 1,000 will
become 3,600 and in 200 years about 13,000. Since 1875 a
serious change has arisen. Large families are rare in the
upper and middle classes and also among the higher ranks of
the skilled artisans, but they are still usual in the thriftless
ranks of unskilled labour and among the feeble-minded in our
midst. Only one generation has yet suffered and the results
are only now appearing, but the calculation of the numerical
effect of a selective birth-rate shows that no time is to be lost
if the quality of the race is not to deteriorate with ever-increasing
rapidity to the lowest types. The Hearts of Oak Friendly
Society is formed by an upper class of skilled labour, and it
provides a benefit of thirty shillings for each birth of a child to

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1910.]

its members. From 1866 to 1880 the claims rose from 1,176
to 2,472 per 10,000; from 1891 to 1904 they fell from 2,472 to
1,165, a decline of more than half. A similar friendly society
gives a decline of 56 per cent. If the prosperous artisan
member of these two societies alone had maintained their rate
of reproduction in 1904 as in 1880, nearly 70,000 children
would have been born to them instead of 32,000, and these
children would in all human probability have become sound,
healthy, and useful citizens.

In taking the class represented in the peerage and baronetage
it is found that marriages taking place between 1831 and 1840
gave an average of 7*1 births to each fertile couple; from
1841 to i860 the average for each decade remained constant
at 6‘i; from 1871 to 1880 there were 4^36 births to each
marriage; from 1881 to i8go 3 - i3 births are recorded. Thus
during the past fifty years our stable upper classes in this
section have reduced their birth-rate by more than one-half and
have passed well below the point at which the number of births
compensates for the number of deaths, and their virtual extinc¬
tion is only a matter of a few generations. In Who's Who
there are biographical details of some 20,000 men and women
who may be taken as representing the upper, official, profes¬
sional, and commercial classes. Fertile marriages of 143 lay¬
men before 1870 resulted in an average of 5‘2 to each couple,
after 1870 the average is 3'o8. In clerical families before 1870
the average of the children was 4*99, after 1870 an average of
4'2. Taking marriages of those who have served in the army
and have attained to the rank of captain, before 1870 the aver¬
age was 4*98, after 1870 the average was 2'oy. In the statistics
relating to Roman Catholics and tabulated from Who's Who
and the Landed Gentry, the average of children from 1871 to
1890 was 6’6 to each fertile marriage.

If men represent the income to be used and spent freely by
each succeeding generation, women must be considered as
capital to be spent sparingly in the present and to be husbanded
carefully for the future, and for the welfare of the race it is
important to watch zealously the employment of women in the
industrial sections of the people. From the reports issued by
two of the women’s colleges at Oxford and Cambridge, and
excluding those who have left within three years, out of some
3,000 only about 22 per cent, subsequently married, but there is

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no record of the number of children born, which is most likely
very small. The proportion of marriage is distinctly higher
among those who do not take the final examination or fail to
obtain honours. Does this mean that exceptionally capable
women are rendered unfit or unwilling to discharge their
natural functions ? The problem of “ cause or effect ” is of
the gravest import. We have clear evidence that the birth-rate
among married women teaching in the elementary and secon¬
dary schools is very far below the average rate of the classes to
which they belong, and for the race the ability of the mothers
is at least of as much importance as that of the fathers.

The importance of heredity in the animal kingdom is never
for a moment doubted. By careful selection and marking
special breeds are obtained—in horses, speed, endurance, and
strength ; in cattle, size and dairy qualities ; in sheep, the
texture of the wool; these being only a few examples of what
can be attained by taking into consideration the parentage.
Are the physical and mental characters of man inherited to the
same extent ? The answer to this question is given by Professor
Karl Pearson, and it is based on observations made on between
5,000 and 6,000 school children. It was shown that the degree
of resemblance of members of the same stock for eight mental
and moral characters and for eight physical characters, in the
case of pairs of brothers, pairs of sisters, and pairs of sisters
and brothers, is sensibly identical.

A king of France discovered an ancient man engaged unre¬
mittingly in the planting of date-kernels : “ Why,” he asked,
“ do you grow the seeds of a tree of such tardy growth, seeing
that the dates will not ripen till a hundred years be passed?”
The old man answered, “ Am I not then eating the fruit of
trees planted by my forefathers, who took thought for those
who were to come, and shall I not do like unto them ? ” Our
duty of all duties is to transmit the sacred torch of life un¬
dimmed, and if possible a little brightened to our children, and
the basis of the new biological ethics of to-day and of the
future is that everything is right that makes for the welfare of
the yet unborn and all is wrong that injures them, and to do so
is the unpardonable sin.

Many thoughtful observers are coming to believe that one of
the greatest advances of the near future will be the recognition
that education must more directly include preparation for the

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679

supreme civic duty of parenthood, and that all wisdom of what¬
ever order must be justified in the children of the generations
that are to be. When woman perceives that to her is entrusted
the greatest of all human assets, the child during those impres¬
sionable years, consecrated to character, formation and physical
development, it will be like a trumpet call to awaken her to her
weighty obligations, imperial, domestic and social, for the web
of civilised life is woven by woman, and it is her concern to
raise the tone of life in all its relations, it is her privilege to
maintain the health of every human being, and upon her
standard depends the manners and morals of her country.

Lecturing the other day at the Sorbonne on the subject of
national virtues Mr. Roosevelt observed: “ A nation’s chief
blessing was that it should leave its seed to inherit the
land. No refinement of life, no delicacy of taste, no material
progress, no sordid heaping up of riches, no sensuous develop¬
ments of art and literature can in any way compensate for
the loss of the great fundamental virtues, and of these great
fundamental virtues the greatest is the race’s power to per¬
petuate the race.”

Considering we are a dominant race, that we possess the
greatest empire the world has ever seen, that we plant our
stock all over the world and lay the foundation of the capacities
of future millions of the human race, to no other nation is the
question of improvement more important. It is possible that
even with a stationary population a race may continue to hold
its own, provided its stock be sound and physically and mentally
vigorous, but it cannot survive if diseases such as insanity,
epilepsy, and imbecility are rampant in its midst.

As long as man was speechless he advanced no faster than
other animals, but with speech, writing, and printing, came the
transmission of acquirements in a special sense, and these
would produce traditional or acquired progress. The past
education of a mother will not enlarge the brain of the infant,
but she can teach her child what she has learnt and so the
child can begin where she has left off. A dwarf can see further
than a giant if he sits on a giant’s shoulders, yet he is a dwarf
and the other a giant: any schoolboy knows more than
Aristotle, but the schoolboy is a dwarf, and Aristotle a giant.
If the race degenerates, the time will come when its heritage
is too great for it, and neither battleships, Free Trade nor Tariff

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Reform, nor anything else will save it. The bigger the empire,
the stronger must be the race; the larger the superstructure, the
stronger must be the foundations. The citizens must be healthy,
thrifty, sober, industrious, and patriotic. Their virtue must
not be of the cloistered idealist kind; it must be full of virility
and vigour, ready to face the rude shocks of a tempestuous
world, always prepared to defend itself against aggression by
trained, effective, and remorseless force. The man who is too
tame to become a soldier, the woman who is too self-indulgent
to become a mother are no worthy citizens of a great empire.
Hardness of heart is a great evil, softness of head a greater.
That which I wish to point out is that so long as the natural
man increases and multiplies, so long will peace and industry
necessitate a struggle for existence as sharp as any that ever
went on under the regime of war. About every hundred
seconds a new claimant to a share in the common stock of
maintenance presents him or herself among us. At the present
time the produce of the soil does not suffice to feed half its
population; the other moiety has to be supplied with food
which must be bought from the people of food-producing
countries. We desire nothing but that which is in itself
innocent and praiseworthy—the enjoyment of the fruits of the
earth and the reward of industry—and lo ! in spite of ourselves
we are in reality engaged in an internecine struggle for existence
with our presumably no less peaceful and well-meaning
neighbours.

However shocking to the moral sense this eternal competition
of man against man, of nation against nation, this state of
things does exist. How can we help to prevent the crowding
of men, women, and children into dens wherein decency is
abolished and the most ordinary conditions of healthful exis¬
tence are impossible of attainment, in which the pleasures
within reach are reduced to bestiality and drunkenness, in
which the pains accumulate at compound interest in the shape
of starvation, disease, stunted development, and moral degrada¬
tion—in which the prospect of even steady and honest industry
is a life of unsuccessful battling with hunger, rounded off by a
pauper’s grave ? This is the riddle of the Sphinx, and every
nation which does not solve it will cease to exist. I take it to
be a mere plain truth that throughout Great Britain there is
not a single large manufacturing town which is free from a

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vast mass of people whose condition is exactly that described,
and from a greater mass who, living just on the edge of the
social swamp, are liable to be precipitated into it by any lack
of demand for their produce.

If we are able to get away from the busy haunts of men and
the din of machinery, and visit the lonely sea-shore or lie on
the quiet moorland, tented by the blue sky and draped with the
horizon, or sit in the silent glade of an extensive forest, we
are ready to think that here, at any rate, is peace. Yet we can
rest assured that in every one of the sacred temples of life
there are to be seen the blood-red footprints of the same
murderous competition. Arguments can hardly be needful to
make it clear that no society, in which the elements of decom¬
position are thus swiftly and surely accumulating, can hope to
win in the race of industries. Intelligence, knowledge, and
skill are undoubtedly conditions of success; but of what avail
are they likely to be unless they are backed up by honesty,
goodwill, energy, and all the physical and moral faculties that
go to the making of manhood, and unless they are stimulated
by hope of such reward as men may fairly look to ? What
dweller in the slough of want, dwarfed in body and soul,
demoralised and hopeless, can reasonably be expected to
possess these qualities ?

Any permanent development of the productive powers of a
nation must be based upon a social organisation which will
secure a high amount of physical and moral welfare to that
race, and I do not believe that a stable society made up of
healthy, vigorous, instructed people would ever run any risk of
falling through hideous misery and degradation to utter ruin,
for they would be so highly equipped that they could safely be
trusted to find ways of holding their own (Huxley).

Now, how does this affect us? I believe we are travelling
fairly rapidly in the direction of the fall, and this I consider is
mainly due to the fertility of the unfit. Most persons agree
that there should be no breeding from lunatics, epileptics,
habitual criminals, idiots, imbeciles, and other mental defectives.
Some hold that natural selection would prevent a race being
contaminated, but as this law, which would remorselessly sweep
away the unfit, is not allowed normal sway, it cannot be relied
upon, and the only true alternative is compulsory segregation
in colonies with rigid separation of the sexes. A plan which

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EUGENICS AND DEGENERACY,

[Oct.,

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might be adapted would be compulsory notification by medical
men of all cases of mental deficiency to some authority created
to deal with such cases, and these could then be very readily
classified : the more degraded to colonies for life ; the others,
not being criminal, might be given the choice of segregation or
sterilisation. I hold no brief for sterilisation, but after mature
consideration I am convinced that if segregation is adopted
voluntary sterilisation should follow. Many of the high-grade
type of feeble-mindedness are capable of earning their own
living under favourable circumstances, although, perhaps, not
of competing on equal terms with their normal fellow beings,
and if they have no vicious or criminal propensities why should
they not be allowed to try. Their only danger to the nation
would be their probable inability of producing healthy children.
Think for one moment of the cruel injustice which would be
meted out to these unfortunate cases by locking them up for
life in colonies, even of the most beautiful type of the Garden
City. Would any of us hesitate as to the choice ? The
enormous power which religious and quasi-religious customs
obtain over a community is illustrated by every tribe and nation
throughout the world, and if the vital importance of preventing
the race from being contaminated in its mental and physical
conditions was branded into the minds of our youth with all
the fervour that springs of religious convictions, it is more
than probable that the degenerates would themselves insist
upon operative measures.

If closing the flood-gates through which has poured a
devastating torrent of degraded humanity be not adopted, the
only other plan is to favour the increase of good stock. If
having and rearing children is a private matter, then no one
has a right to revile small families ; if it is a public service, then
the parent is justified in looking to the State to recognise that
service and offer some compensation for the worldly dis¬
advantages it entails. Parents capable of producing healthy
children and possessing the requisite knowledge to train them
into useful citizens should be endowed, for the most precious
gifts citizens can present to their country are healthy, robust,
and vigorous children. Modern conditions conspire to put
a heavy handicap upon parenthood and an enormous premium
upon the partial or complete evasion of offspring, and that is
where the clue to the trouble lies. Our social arrangements

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discourage parenthood very heavily, and the rational thing for
a statesman to do in the matter is not to grow eloquent, but to
do intelligent things, to minimise that discouragement. People
who spend £100 a year on a child should have a large proportion
of it returned, and those who spend 5s. a week should be treated
in a similar manner. There should be a special tax, and each
social stratum would pay according to its prosperity, and the
childless people of each class would pay for the children of that
class (Wells).

The Government has made a beginning and discriminated in
the incidence of income tax on small incomes in favour of
parents. This action might safely go much further, and a
scheme might be adopted exempting from income tax all money
spent in maintenance and educating families of good stock, and
this would tend to throw some of the additional financial burden
on those who escape this national form of service. In past days
wealthy men founded almshouses and hospitals for the old and
weak, and why should we not hope in the future for endowments
for healthy and capable parents, who could be chosen by trustees
who should look solely to the probable quality of the offspring?
Something in this direction is commonly but unconsciously
done by many great landowners, whose employments for man
and wife, together with good cottages, are given to exceptionally
deserving couples. The advantage of being connected with a
great and liberally managed estate being widely appreciated,
there are more applicants than vacancies, so selection can be
exercised. It might well become a point of honour for wealthy
families to gather fine specimens of humanity around them as
it is to procure and maintain fine breeds of cattle (Galton).

The State might honour and reward those in all ranks of life
who produce healthy and able children, instead of penalising as
at present the reproduction of the best elements of the people»
and assuring the burdens of those alone who are least likely
to give birth to useful members of society. The duty of the
State to support the falling has been so much emphasised that
its still more important duty to the able and competent has
been obscured, yet it is they who are the real national asset of
worth, and it is essential to secure that their action should
not be hampered and their value sterilised by the jealousy and
obstruction of the failures. The incompetent have to be sup¬
ported partially or wholly by the competent, and for their own

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good it would be worth while for the incompetent to encourage
the preponderant reproduction of the abler and more successful
stocks, as it is only where such stocks abound that the nation
is able to support and carry along the heavy load of incom¬
petence kept alive by modern civilisation.

There is plenty of good stock in Great Britain and Ireland,
and an appreciation of its value and of its necessity to the
nation will force us to find ways of encouraging its reproduction
and checking that of the evil strains. We must learn to honour
those who, sound in body and mind, bring up well a large
family, and not less those who avoid marriage for fear of per¬
petuating their own infirmities. A man who will not earn his
own living, a woman who neglects her household and refuses to
perform her maternal duties, and a nation which will take no
thought for the morrow, must all be classed among the failures
of civilisation (Whetham).

A novel experiment is now being made in the town of Schon-
berg, about two miles south of Berlin, a favourite residence of
the Anglo-American community having business in that capital.
The municipality has lately instituted a system of bounties for
such of its employees as are the fathers of large families. The
experiment is made on distinctly eugenic lines, since those
fathers who are the most steady, healthy, and efficient men are
to be preferred. The scale of bonuses is as follows :

In addition to their regular wages the heads of families of
three children will receive an extra monthly payment of 10s. 2d.,
for four children 12s. 6 d., for five children 15s. id., for six
children 17s. 6 d., for seven or more £1. These bounties will be
paid only to fathers whose children are under sixteen years of age
and who can produce satisfactory evidence that the children are
entirely dependent upon them. Payments begin with the first
day of the month in which the man enters the municipality's
employ and end when the man’s service is over. If the work¬
man leaves during the month payment will be made for the
entire month. Contrast the practice largely adopted in
England, as appears from the advertisements in the press, of
giving a preference to “ no encumbrances ” over a sound,
steady man with a healthy wife and family. It will be in¬
teresting to watch the experiment, for if successful the precedent
will probably be contagious.

In France, where the birth-rate is steadily falling, it is pro-

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posed to impose extra military obligations on all bachelors over
twenty-eight years of age. Men who do not serve the State in
the capacity of fathers of families should, it is argued, be made to
compensate for this in the national defence. Another suggestion
is that all healthy civil servants should be compelled to marry at
or before the age of twenty-five. As the salaries of young civil
servants are not in many cases sufficient for the support of
families, it is proposed that increases be granted in proportion
to each man’s family, and that men who have at least three
children should receive preference over seniors with smaller
families when promotions are made.

Parents should grasp that when they have given birth to a
new citizen, this involves on the one hand a duty towards the
community in respect of his health, mental and physical, and a
claim on the other hand of the parents on the State that the
latter shall make the conditions of life favourable to the rearing
of healthy, mentally vigorous men and women. Gladstone
defined as the noblest work of the statesman that which is done
to raise the standard of public health, and Ruskin stated that
the veins of wealth are purple, and that the divine intent of all
wealth is the production of a sturdy race (Karl Pearson).

To the medical profession as a whole public opinion entrusts
the welfare of the race, and through this welfare the destiny of
the nation, not only for the present but also for the future,
and proper attention by us to prevent evil conditions will have
a profound effect in reducing the gravity of the problems which
the physician, the sociologist, and the statesman of the future
will be called upon to solve.

I do not for an instant intend to question the righteousness
of the endeavours of civilised man on behalf of his afflicted
brothers ; one cannot but admire the beauty of the unselfish
spirit which prompts his action, but it is right to point out that
by these means disease is propagated, the contamination of
the race assured, and the care of useless citizens made a very
heavy charge on the community. Pity is the highest and most
exquisite of human emotions, and surely it teaches that the
prevention of suffering is more noble than its creation.

( l ) Lieut.-Col. Hill-Climo.—( 3 ) These statistics are extracted from the Family
and the Nation (Whetham).

LVI.

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The Viscosity of the Blood in Epilepsy. By R. Dods
Brown, M.D., M.R.C.P.E., D.P.H., Senior Assistant
Physician, Royal Asylum, Edinburgh.

i. Historical.

It is only within the last few years that any serious attempt
has been made to investigate the viscosity of the blood and to
find out what importance, if any, could be attached to the varia¬
tions in the fluid friction of the blood in health and disease.
Prior to this period a few physiologists did pay attention
to this subject, but many of their results have been ignored
on account of the difficulty encountered by the coagulation
of the blood. Defibrinated blood or blood to which an anti¬
coagulator had been added was used in later investigations.

In 1896 Nicolls, working with defibrinated blood, confirmed
the results of Ewald, who stated that the blood viscosity was
about five times that of water. In the following year Lewy gave
the value as three and a half times that of water. It will be
noticed later that the results of different authorities vary con¬
siderably.

Denning and Watson carried out an elaborate research, and
they stated that an increase in the number of the corpuscles
causes an increase in the viscosity, and that certain chemical
substances increase it, while others lessen it.

Hess found that the mean viscosity value in healthy indivi¬
duals was 4'5 times that of water, with a tendency at the
extremes of life to be less than in the middle-age periods.
This is confirmed by Bachmann, who thought that nourishment
and exercise caused changes in the blood.

The researches of Weber and Watson show that the number
of erythrocytes is not without influence. Rotky, on the other
hand, is not of the same opinion, and the works of Bence and
Determann confirm this. The latter states that the changes
are due not to the number but chiefly to the size and form of
the corpuscles, which hold substances which determine the
degree of viscosity under different circumstances. Osmotic
tension between them and the plasma is also important.

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Determann showed that when the blood is laked the viscosity
is greatly increased. This is due to the corpuscles being
destroyed and the viscous substances being set free. The
variations in the viscosity of the serum are much less than those
of the blood.

Venous blood is more viscous than arterial blood, and that
is thought to be due to an increase in the size of the corpuscles,
to their giving out their highly viscous substances, and to their
taking up H 2 0 from the plasma.

C 0 2 passed into blood-plasma makes very little difference in
the value of the viscosity.

Rotky, Hirsch and Beck found the mean average viscosity
value to be 5*1, but they took the blood from a vein. Bence put
the value at 5*4, and Determann at 47 in men and 4’5 in women.

Hess states that the results obtained by these observers are
too high, and that the hirudin they used to prevent coagulation
retards the flow of blood.

Neither in the specific gravity nor in the haemoglobin count
is there a safe analogy of the inner friction of the blood, although
Blanschy says that if the percentage of haemoglobin be divided
by the viscosity value it gives an indication if a pathological
condition is present. The result, he says, should be between
17 and 21 in a normal person. The viscosity is not affected by
the blood-pressure.

2. Viscosity in Some Morbid Physical Conditions.

In pneumonia the viscosity is lower after the crisis than before
it, and this has been ascribed by some to the C 0 3 in the blood,
but it has been pointed out that frequently it is much higher in
mild cases than in severe cases. Oxygen inhalations have been
found to diminish the value of the fluid friction in these cases,
and in one observed by Ferrari there was a great lowering of
the viscosity without a decrease in the number of the corpuscles.
Sodium iodide, however, had been given to this patient for two
days.

in chronic interstitial nephritis the viscosity values are low,
and this is due to hydraemia which is present.

Rotky found in a case of acute nephritis an increase both
of the blood and of the plasma. This he thought might be due
to waste products circulating in the blood.

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Naturally a considerable amount of work has been done in
blood diseases, and it has been found that in most cases of
ana;mia there is a definite lowering of the viscosity, but the red
corpuscles do not always show a corresponding reduction in
number, nor is there a constant lowering of the plasma viscosity
in these cases.

Where there is a very high leucocyte count, as in cases of
leukaemia, the viscosity is raised, but Bence was unable to find
any increase in a case of leucopasnia during the leucocytosis of
digestion.

In jaundice the fluid friction value is high, and in cases of
heart disease with valvular lesion it is raised when the patient
is allowed out of bed.

Graham Brown carried out a series of observations which
show that with a rise of temperature the rate of the flow of
blood is increased. He accordingly suggests that “ a febrile
temperature may be considered as a boon to the organism in
that it will either allow the blood to circulate faster or it will
save the work of the heart.”

There is no uniformity of opinion as to the viscosity before
and after food.

It is of interest to note what Fano and Rossi pointed out
that removal of the thyroid gland brought about only a slight
increase in the viscosity, but when the parathyroids were
removed the viscosity rapidly increased. They assume that
this property of the blood is normally affected very largely by
the internal secretion of these-glands.

3. Viscosity in Epilepsy.

From what has been said it is evident that there is not known
any one factor which influences the blood viscosity. It has
been suggested by some that toxins, metabolic or otherwise,
may play an important part in its value, and as epilepsy is con¬
sidered toxic in origin it may be interesting to note what is
found in this disease.

The viscosimeter which I used is that invented by Hess, and
is described in the appendix.

With the assistance of Dr. Scott Watson a series of obser¬
vations was carried out almost daily for several weeks on fifteen

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PRINCETON UNIVERSITY

BY R. DODS BROWN, M.D.

689

I9IO.]

cases of epilepsy, on thirty-five cases of various forms of mental
diseases, and on six members of the staff, i.c., a total of fifty-six,
twenty-nine of whom were males and twenty-seven females.

These were done in the wards and the temperature of the
room never varied more than a few degrees, so that this had no
influence on the reading of the viscosity.

Table I gives the average reading of the different diseases.

Table I.

Showing Average Viscosities in Fifty-six Cases Examined.

15 cases of epileptic insanity .... 4’8

2 „ general paralysis.4'4

9 „ melancholia...... 4^3

13 „ dementia praecox..... 4^2

1 „ mild delirious insanity . . . 4*2

3 ,, simple mania ..... 4*2

5 ,, secondary or organic dementia . . 4*1

2 ,, delusional insanity .... 4

6 ,, healthy persons ..... 4^2

In 46‘6 per cent, of epileptics viscosity was from 5 to ^g.
In 2‘4 per cent, of all the other cases viscosity was 5*3.

Of all these diseases epilepsy was the one which gave the
most interesting results. Its mean viscosity value was 4‘8.
While seven of the fifteen cases gave results varying from 5 to
5‘9, only one of all the other cases examined— i. e., forty-one in
number—had a viscosity higher than five times that of water.
In other words, 4C6 per cent, of epileptics had a viscosity above
5, and only 2’4 of all the others gave a similar result.

Moreover, not only was the blood value in these epileptics
high, independently of fits, but it was very evident that it rose
to a very high level prior to a fit in very many of these cases,
although not in all. This is seen in Table II.

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690 THE VISCOSITY OF THE BLOOD IN EPILEPSY, [Oct.,

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Table II.
Case I.

Average viscosity
45 minutes before a fit
20 minutes after fit

Case II.

Average viscosity
2 hours before severe fit

Case III.

Average viscosity

11 a.m..

2 hours later and just before fit .
1 hour later . . . .

4.4

3-8

4‘9

4’4

4’5

4’ 1

The viscosity value was highest in those epileptics in whom
the seizures were most severe and most frequent. Indeed, in
those patients who had a very occasional fit it was only slightly
higher than that of a healthy person. That this condition was
not dependent on the bromide which was administered to the
epileptic patients was proved, because if the drug were stopped
the viscosity remained high even after many weeks, and
because the same high value was not found in other classes of
patients to whom was given a similar dose of bromide.

Although a large series of blood-counts was made I have
not been able to observe any connection between the number
of the red or white corpuscles, or the haemoglobin and the
viscosity, or between it and the blood-pressure.

I examined the blood of only two general paralytics, and
found the average to be 4^4, but in one of these it was as high
as 5’8 about half an hour after a congestive seizure.

In regard to cases of dementia prascox, I have not been able
to observe any noteworthy facts in the different types of the
disease. In this the rate of flow was 4 - 2 times that of water.

It is of great interest to find that among the cases of mania
and melancholia the viscosity was highest in those who were
acutely ill, c.g., the average reading in the former class was
4‘2, and the two patients who exhibited the greatest degree

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PRINCETON UNIVERSITY

i9io.]

BY R. DODS BROWN, M.D.

691

of mental excitement gave average results of 4^5 and 4'6
respectively. The mean among the melancholiacs was 4‘3, but
4*6 and 4‘8 were the viscosity values of those whose condition
was most acute.

In these cases, also, blood-counts were made, but the number
of the corpuscles did not appear to influence the viscosity
results.

4. Conclusions.

It seems to me, therefore, from the examination of the blood
of these fifty-six cases, that one is justified in affirming that in
epilepsy there is present in the blood some factor affecting its
viscosity, and that this is absent from the blood of other cases,
or is present in a much smaller amount. The most probable
explanation, I think, is that this is a toxin, bacterial or meta¬
bolic, circulating in the blood, and this is in conformity with
the view held by many regarding the causation of this disease.

This toxin, it will be noted, then, is present in the blood of
epileptics to a far greater extent than in any other class of case
examined; that it is most abundant in those suffering from
frequent and severe fits; and that the toxicity of the blood
increases to a very marked extent prior to the onset of a
seizure.

Description of Instrument.

Two parallel glass tubes A and B of unequal length are fixed
to an opalescent glass stage c, and though open and separate
at one end, at the other they are connected by a U-shaped piece
D, which joins them at right angles to the stage upon which
they lie.

To this U-shaped piece there is fixed a rubber tube P, which
is attached to a rubber ball K by means of a glass joint s. This
glass piece has an opening n, which can be closed by one’s
finger, and so by means of the bulb suction is obtained.

Thus it will be clear that whatever pressure the bulb exerts
acts equally on both glass tubes; but the apparatus has a stop¬
cock F near the longer of the two tubes, by which it can be shut
off from the pressure of the bulb, which then acts only on the
shorter tube, i.e., on the one used for blood. The longer tube
is used for water.

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PRINCETON UNIVERSITY

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692 THE VISCOSITY OF THE BLOOD IN EPILEPSY. [OcL,

For a little less than a third of its length tube a is graduated,
as is also tube B. The graduation begins at o in both tubes
and at exactly the same level. In the tube for water, i.c., tube
a, the graduation extends up to 8, each unit being divided
into tenths.

In tube B, however, it is carried up to 2, and only the first
unit is subdivided into a quarter and a half. The mark 2 of
the blood tube corresponds to 4*3 on the water tube.

The calibre of these two tubes is not the same throughout.
In tube A the finest bore is found in the middle third, while in
tube B the non-graduated portion has the smaller lumen.
Between the two tubes is placed a themometer M for registering
the temperature of the air at the time the observations are
taken.

There is a metal clip h for holding a capillary blood tube R.

Modus Opcrandi.

Pure distilled water is used for these observations. Some is
taken into a small glass tube, and with the stop-cock vertical is
sucked up to mark o of tube A. The stop-cock is then turned
horizontally, so shutting the water tube off from the action of
the bulb. Some blood is now taken from the finger or ear of
the patient in the special capillary tube, whose funnel-shaped end
is placed against the free end of tube b and is held there by
means of clip H. The blood is immediately sucked up to
mark o. Now both blood and water stand at the same level.
The stop-cock is opened, thus allowing both fluids to come
under the influence of the bulb. Blood and water are then
sucked up until the blood reaches the mark 1. The level at
which the water stands indicates the viscosity of that specimen
of blood.

It is only after much practice that accurate results can be
obtained, and great care is required to prevent coagulation of
the blood in the tube.

Bibliography.

Lewy.— Arch. Physiol., Bonn, vol. lxx, 1897.

Denning and Watson.— Proc. Roy. Soc., lxxviii, 1906.
Hess.— Deutsch. Arch. f. klin. Med., Leipzig, xciv, 1908
Bence.— Deutsch. f. klin. Med., Berlin, lviii, 1906.

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PRINCETON UNIVERSITY

1910.] ANAESTHESIA, MENTAL CONFUSION, AND MOODS. 693

Determann.— Idem., lix, 1906.

Hirsch and Beck.— Deutsch. Arch. f. klin. Med., lxix, 1901.
Blanschy.— Dissertation , Zurich, 1908.

Burton Opitz.— -Journ. of Physiol., xxxii, 1905.

Burton Opitz.— -Jourti. of Exper. Med., 1906.

Graham Brown.— Edirt. Hosp. Report, 1894.

Ferrai.— Arch, di Fisiol., i, 1904.

Fano and Rossi.— Idem., ii, 1905.

A Clinical Study of A nccsthcsia, Mental Confusion,
and Moods, in Epilepsy, Confusional Insanity and
Hysteria. By Leonard D. H. Baugii, M.B., Ch.B.
Edin., Senior Assistant Medical Officer, Glasgow District
Mental Hospital, Gartloch.

Manifestations of anaesthesia, mental confusion, and
moods are frequently met with in general medicine and
psychiatry. Their occurrence is not confined to pathological
states; in normal people it must be studied in the domains of
physiology and psychology. It is by no means always easy to
differentiate the physiological from the pathological, or in
psychology the normal from the abnormal. This difficulty in
demarcation has tended to render investigation arduous and
the findings imperfect.

In dealing with the subject from the clinical aspect, the
avenues of approach and the paths explorable are limited; more
markedly is this the case when observations are carried on
amongst the alienated.

In this study consideration is concentrated on the pheno¬
mena observed in epilepsy, confusional insanity, and hysteria,
as a degree of relationship appears to be present, and, it is
hoped, will be demonstrated. The interest of the study, the
careful observance of manifestations, and the relationship
referred to, are the only justification for such a paper as is here
submitted.

The disturbances of sensation are not limited to regional
anaesthesia, but in many, owing to the mental state, the
reaction to a painful stimulus (pin-prick) is the only reliable
test. The variations are striking. While in confusional
insanity the same altered state lasts for days or weeks, in

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694 ANAESTHESIA, MENTAL CONFUSION, AND MOODS, [Oct.,

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epilepsy and hysteria the changes may be sudden and of short
duration.

Prodromal anaesthesia, although often present, cannot be
said to be constant in epileptics; it may be that in some it is
transient, or limited in extent, and has been missed. It
disappears in several a few minutes after the epileptic discharge.
When associated with serial epilepsy it appears to be more
constant as a prodroma, and often persists for a considerable
time after the fits have ceased. It has been noted that some
cases have shown the rapid disappearance of analgesia after a
single fit or other epileptic discharge, and the slow regaining of
pain perception after a series.

Muskens (i) has drawn attention to the disappearance of
the disturbance in sensation after an epileptic discharge, usually
abrupt, but not necessarily a fit, and suggests the desirability
of directing the discharge along the least harmful lines. In
1908 it was stated (2) that prophylactic treatment by large
enema minimised tendency to serial fits; since then in these
observations it has more than once been found that where
analgesia was present sensation returned, without the occur¬
rence of fit or jerks, after the bowel had been washed out and
the patient kept in bed and given milk for a day.

It has occasionally been observed, particularly in one female
patient, E. F—, that prodromata—analgesia, etc.—have disap¬
peared after the manifestation of a psychic equivalent.

The following extract shows well this point:

E. F— was well and had all her sensations on the 15th, and
that night slept from 10.30 p.m. She, on the 16th, wakened
without any jerking, etc. Before breakfast at 8 she appeared
sulky, complained of headache and dimness of vision ; eyes
were glassy; right eye showed internal strabismus; analgesia
was complete. Until 10 she worked well, then refused to tidy
and showed irritability. On the charge nurse's attempting to
tidy her, E. F— scolded, then sat and cried for a little; she
was left alone but closely watched. At about 11.30 she seemed
brighter (got up and appeared about her normal), and had no
recollection of scolding nurse, of whom she was very fond. By
5 p.m. all her sensations had returned. She then continued
well until, on the 23rd, prodromata, anaesthesia, etc., were noted
at 9 a.m.; these culminated in a series of ten fits at 5.15 a.m.
on the 26th.

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i 9 io.]

BY LEONARD D. II. BAUGH, M.B.

695

The manifestations of epileptic discharge, which vary from
fit state to phenomena purely psychic in character, are easier
of explanation, if one recalls C. Besta’s (3) conclusion—that
the manifestations are the result of an irritant, mechanical or
toxic, acting on the central nervous system, and to which the
nerve-centres react independently of one another. The extract
from E. F—’s case showed an extreme form of confusion, viz.,
amnesia. Amnesia and other symptoms of confusion favour the
contention of a toxic irritant, as much of the research recently
done has tended to show that confusional insanity is, speaking
generally, the result of toxins acting on more or less unstable
nerve-cells.

The association of disorientation or other phases of mental
confusion with anaesthesia is as typical of hysteria and many con¬
fusional insanities as it is of epilepsy. An attempt to ascertain
if there is any definite relationship in this association has been
made. There appears to be an association, but I do not feel
competent to explain the connection, and the number of
observations made do not warrant a definite statement. It
may be said, in the cases examined a relationship was present,
both in regard to the development of, and emergence from, the
symptoms of analgesia and mental confusion.

In cases of epilepsy and hysteria anaesthesia was, time and
again, evident before the onset of confusion ; usually, but not so
constantly, sensation was regained before emergence from the
confused state. Confusional insanities have come under treat¬
ment when both symptoms were established, but two chronic
exophthalmic goitre cases, at the time of relapse, have shown
alteration of sensation previous to becoming confused. In
another thyroid case in whom there are numerous alternations
of the mental state, there is anaesthesia before torpor and during
transient delirium, and after the latter, marked general hyper-
aesthesia and intense hallucination. As a rule, in acute
confusional cases analgesia disappears before the confusion
does. In some, after sensibility to painful stimuli is regained
and during the period of slow mental clearing, formication and
other variations of abnormal sensation are present, and appear
to form the bases of hallucinations. These variations (formica¬
tion, etc.) sometimes persist for a while after mental clearness has
been re-established and the hallucinations are forgotten or can
be laughed at. In these observations anaesthesia was oftenest

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696 ANESTHESIA, MENTAL CONFUSION, AND MOODS, [Oct.,

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evident amongst the cases of confusional insanity in whom
auto-intoxication, possibly metabolic, appeared largely causative.
The association of hallucination with analgesia and confusion,
although frequent in confusional insanity, has not been found
to be as constant as Stoddart (4) stated.

The incidence of moods of an obsessional type has been
observed in cases of epilepsy and hysteria. This incidence
occurs while they are analgesic and confused. Hallucinations,
obsessional in character, appear in some acute confusionals.
The occurrence of these hallucinations appears analogous to the
moods noted in epilepsy and hysteria, and I have come to regard
them as the equivalent of a mood.(5)

The following chart indicates the general relationship existing
between the phenomena that have been under consideration.
The confusional insanity is charted from the second day of
delirium (post-febrile of measles) when she was admitted ; the
rash was then fading and the urine loaded with albumen. The
hallucinations were at times obsessional; history, elicited after¬
wards, substantiated the impression that they originated from a
remote, intense, suppressed “ complex.”(6) The persistence of
altered sensations lasted about ten days more than the chart
shows—in other words, nearly all through the period of slow,
gradual emergence from confusion into mental well-being. The
epileptic (G. G—) illustrates well pre- and post-fit analgesia; at
her normal she is alert, a good worker, and can differentiate sensa¬
tions. In the hysterique (Me. G—), when well, no sensor}'
anomalies could be detected. In some cases of profound
confusion moods seem to be the only incidents remembered
after recovery ; this feature has been noticed in both confusional
insanity and epilepsy. In hysteria the repetition of the same
mood, usually a repetition of, or a conversion from, some domi¬
nant impression, is sometimes a good illustration of the defence
resistance of Freud (6); an analogy to this has been noticed in
two obsessionally hallucinated cases of confusional insanity.

A somnambulistic state (Janet termed it “ deliria ”) was on
several occasions manifested by A. C. S— when under observa¬
tion for over two years. A certain mood always preceded the
state in which she re-lived two days. Those around were
called by names taken from that period of the past, and she
was anaesthetic, hallucinated, and oblivious to everything else.
She conversed freely in response to hallucinatory stimuli, and

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PRINCETON UNIVERSITY

1910.

BY LEONARD D. H. BAUGH, M.B.

697

Chart Shewing

Analgesia Altered and Normal Sensations

Mental State ■ -

Mood in Confl/sional Insanity - Epileps -- Hysteria

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698 ANAESTHESIA, MENTAL CONFUSION, AND MOODS, [Oct.,

appeared frank up to a certain point, and then resistant and
reserved. This phase of defence resistance was never really
overcome, although other phases could as a rule be interpreted
and relieved. Curiously, hepatic disorder from metabolic
upset (? is it a constitutional predisposition) often seemed to
fill the role of “ mechanism of symbolisation,” which led to the
mood antecedent to the state. In the mood, to still further
adopt the language of Freud and Janet, “ censure ” broke
down, “ repression ” was lost, and then the deliria of Janet (7).

Before concluding, some opinions arrived at by various
writers should be referred to. That a definite cause is often
not assigned is not a matter for surprise, for the vagueness of
the subject and the difficulty of interpretation are very soon
realised when such a study is attempted.

The conclusions of Bouchard (8), Krainsky (9), Voisin and
Peron (10), Bruce (n), A. Turner (12), Clark and Prout (13),
and Besta (3), with regard to epilepsy, and of Macpherson (14),
Bruce (n), Gilmour (15), Orr (16), G. Turner (17), Korsa¬
koff (18), and Soukhanoff (19), Giachetti and Pilcz (20) on
mental confusion, to refer to only some of the workers, all
point to a toxaemia. Many points from those referred to, and
from personal observations (21) on confusional insanity and
epilepsy, suggest that the rdle of metabolism in the production
of these phenomena is on many occasions of importance.
That in many there is hereditary nervous instability must
always be recollected. Kauffmann (22) has suggested that this
factor from heredity leads in epileptics to the excessive pro¬
duction of such substances as indoxyl, and that they at times
act as toxins of metabolic origin. Kauffmann’s (22) theory is
worthy of consideration, and some clinical observations support
it. Mental confusion, the outstanding feature in confusional
insanity, is accepted as a symptom which, if not resultant from,
is at least always associated with, toxaemia; the frequent
association with it of analgesia is at least suggestive.

In hysteria the opinions of Freud (6), Janet (7), Sollier (23),
etc., are really not as antagonistic as at first sight they appear.
The remark about nervous instability is equally applicable to
hysteria, and certainly the association with metabolic deficiency
seems borne out in some. There is no desire to draw deduc¬
tions from the statement of this juxtaposition ; such a step, in
the light of our present knowledge, would be open to the charge

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1910.] BY LEONARD D. II. BAUGII, M.B. 699

“ circulus in probando,” but current literature on the subject
shows a gradual tendency to no longer regard the manifestations
of hysteria as purely psychic in origin. So far we have no
explanation of what is “constitutional predisposition,” and it
is only by observance that we can learn.

In conclusion, I must thank Dr. Parker, the Superintendent
of Gartloch, for freely affording me facilities for carrying out
observations, and must express my appreciation of the interest
shown and the care taken in work outside the routine by
certain members of the past and present staff.

It is hoped that the study, despite, so to speak, dealing with
only the fringes of the subject, has shown, however imperfectly,
the relationship of the phenomena, and that the paper has not
been devoid of interest.

References.

(1) “ Prodromal, Motor Sensory, and other Symptoms,” Epilepsia,
fasc. i, 1909.

(2) “Observations on Insane Epileptics,” Journal of Mental Science,
July, 1908.

(3) “ Research on Blood-Pressure, etc., in Epilepsy,” review, ibid.,
April, 1907.

(4) Mind and its Disorders.

(5) The Changes of Mood in Epileptics, Aschaffenburg, Halle, 1906.

(6) Brill’s Translation of Freud’s Selected Papers on Hysteria.

(7) “ L’hyst^rie maladie mentale,” Congres Amsterdam, September,
1907.

(8) Auto-intoxication, trans., 1894.

(9) Memoires Courounes, 1901.

(10) Arch, de Neurol., vol. xxiv.

(1 x) Studies in Clinical Psychiatry, 1906.

(12) Epilepsy, 1907.

(13) Amer. Journ. of Insanity, vol. lix, No. 2, 1902.

(14) Mental Affections, 1899; Morison Lectures, 1905.

(15) “ Mental Symptoms of Exophthalmic Goitre,” Journal of Mental
Science, October, 1909.

(16) Discussion on (15).

(17) “Alcoholic Insanity,” Journal of Mental Science, January, 1910.

(18) Quoted by J. Turner, ibid., October, 1903.

(19) “Contribution to Study of Sensation in General Paralysis,”
abstract, ibid., July, 1906.

(20) “ Meynert’s Amentia,” abstract, ibid., January, 1909.

(21) “Confusional Insanity,” i?r/Y. Med. Journ., October 14th, 1905,
and “ Observations on \L\n\tt\rt\cs,” Journal of Mental Science, July, 1910.

(22) “ Beitrage zur Pathologic des Staffwechsels bei Pychosen,” Die
Epilepsie, Jena, 1908.

(23) “ 1 -Iysterie et Sommeil,” Arch, de Neurol., 1907.

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Treatment of Mental Excitement in Asylums. By
George M. Robertson, M.B., Physician Super¬
intendent, Royal Asylum, Morningside, Edinburgh.

1 HAVE been asked by the President to open a discussion
on the “ Treatment of Mental Excitement in Asylums.” The
subject is a very important and practical one, and goes to the
root of many of the most difficult problems connected with the
management of the insane. Of cases of mental excitement in
asylums it may be said, “ they are always with us,” and the
manner in which they are treated and the success attending
their treatment may be taken as tests of the good manage¬
ment of an asylum. The difference between the state of the
madhouses of the past and of the mental hospitals of the
present day is largely the result of better methods of dealing
with it.

I shall endeavour to treat the subject in as practical a manner
as I can, but I must begin by subjecting mental excitement to
analysis. It can be divided into two kinds. There is on the
one hand the mental excitement which is directly due to dis¬
ease, as of the person who suffers from acute mania. This is a
primary or essential excitement, a symptom of disease, and it
runs a course which corresponds in intensity and duration to
the morbid process. It is a more or less continuous form of
excitement, and it is amenable only to those kinds of treatment
which have an effect on the disease. There is, on the other
hand, the mental excitement which is a reaction to some irrita¬
tion in the environment acting upon excitable patients. This
excitement is secondary and non-essential, it is temporary in
character and paroxysmal, and with the removal of the irrita¬
tion it exhausts itself and naturally subsides. The obvious
treatment for this secondary excitement in excitable patients is
preventive.

Although these two forms of excitement met in asylums are
on analysis so different, yet in practice the distinction is easily
overlooked and suitable treatment cannot then be adopted.
For example, if an excitable patient be kept in an irritating
environment, the reactions may follow one another so closely,
that there is apparently continuous excitement. The symptoms
may thus be regarded as mainly due to mania and be treated

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701

by sedatives, which under these circumstances would not be
good treatment. On the other hand, it may not be realised
that in cases of acute mania the patients are excitable as well
as excited, and that a part of their excitement, the exact pro¬
portion depending on their environment and treatment, is a
reaction to irritation, and is not an essential symptom of the
disease. There is no doubt that the better treatment given
nowadays to cases of acute mania as compared with the past is
the chief reason why the disease now appears to be of a milder
type than in the past. A large part of the excitement in
former days was mainly a reaction to the harsh and irritating
treatment the patients then received, and naturally this has
disappeared in consequence of the removal of the exciting
cause.

The practical importance of the distinction I have drawn is
seen to be very great when one comes to consider the details
of treatment. The treatment of the essential excitement of
mania is directed towards the disease, and consists of remedies
and measures which influence the morbid process, such as the
use of sedative drugs, of baths, and of rest in bed, and of
general treatment, such as tonics, nourishing food, fresh air, and
moderate exercise, which improve the general nutrition and
enable the patient to throw off the disease. The treatment of
secondary excitement in the excitable, on the other hand, is, as
I have already said, mainly preventive. It is, of course, true
that excitability may be a direct symptom of active disease,
just as primary excitement is, and in these cases its treatment
should be on similar lines, but in asylums excitability is usually
found as a fixed mental attribute in a considerable prop«r-
tion of our patients. The rational treatment of excitement
in those cases is, therefore, not to attempt the impossible
by removing a brain quality, but to guard the possessor of a
brain with defective powers of self-control from all sources of
irritation.

I intend in the first place to refer briefly to the treatment of
mental excitement, which is a direct symptom of such diseases
as acute mania, agitated melancholia, and delirious insanity.
In these diseases sedative drugs are often employed, and as
their use is condemned by some, the advantages and disad¬
vantages of their employment may be mentioned. It is
admitted by all that their employment is undesirable, and that

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when used for their sedative effects, it is on the principle of the
choice of the lesser evil. It is also admitted that they are
liable to abuse, that they should never be given at the will of
nurses or attendants, and that their effects should always be
supervised by medical men. They should never be administered
in increasing doses with the object of completely controlling all
signs of excitement, but they should be used merely to tone
down the symptoms within manageable or safe limits, and they
should only be administered for short periods to tide over a
dangerous or acute exacerbation. With these precautions I
have not hesitated to employ sedatives, but there are some who
totally abstain from doing so. It appears to me that the toxic
theory of the causation of insanity which is now being so widely
accepted does not support a policy of abstention, for if there be
a circulation in the blood of toxic agents acting injuriously
on the brain, surely it is in accord with the fundamental
principles and practice of medicine to administer an antidote,
either chemical or pharmacological.

The prolonged bath at the temperature of the body is a most
useful calmative, and it has none of the objections alleged
against sedative drugs. It is a mistake to suppose that it
is dangerous or has a debilitating effect, as it tends to raise
the blood-pressure, and in imagining these evils, as some do,
they are confounding it with a hot bath, which is relaxing and
distinctly dangerous if prolonged.

Rest in bed has also a calming effect in acute mania. The
bed treatment of the acutely insane has many advantages
which it is impossible to refer to at the present time, but there is
no doubt that by its suggestion of rest and invalidity and by its
physiological effects on the nervous system and blood-pressure,
it has a distinctly calming influence on acute excitement.

All measures directed to improvement of the general health
of the patient act indirectly on excitement by tending to
shorten the course of the disease. Attention has to be paid
to digestion and the alimentary tract, to the appetite and the
supply of a sufficiency, but not an excess, of simple nutritious
food, and it may be necessary to administer tonics and con¬
structive drugs. Sleep has also to be obtained, and in the
acute stages of the disease it may be necessary to have recourse
to hypnotic drugs. These should not be given for more than
two nights consecutively, and they should be constantly varied

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so as not to establish a drug habit. In the less acute stages
it will be found that exercise and life in the open air all day
long favour sleep and are usually sufficient to produce it.

I now pass to discuss in greater detail the measures for the
prevention of secondary excitement, or in other words, the
management of irritability and excitability. This is a much
more important problem than the treatment of the essential
excitement of disease. In the first place the number of excit¬
able patients in an asylum is greatly in excess of those who
are continuously excited from disease, and it is probable that
the latter do not amount to more than 3 per cent. It is diffi¬
cult to guess the proportion of the former, but this much may
be said, with truth—it has been very much under-estimated in
the past. Mental nurses are warned, and are fully aware from
personal observation of the marked irritability and excitability
of epileptic patients. A greater or lesser degree of this
irritability exists also in large numbers of patients suffering
from other mental disorders, and if these were only treated with
the same caution and tact that is bestowed by nurses on their
relations with epileptics, the amount of excitement in asylums
would appreciably diminish. In every asylum this preventable
excitement is in excess of what it should be—and in the past
it was very largely so. If a well-directed attempt be made
to grapple with this problem the reward is great, and the
benefits follow so speedily that the relationship of cause and
effect is obvious to all. The lines of treatment are not so purely
medical as in the case of excitement from disease, and it is to
be feared that medical men have not interested themselves so
much in them. The subject is, however, too important to be
handed over entirely to the nursing staff, and if thoroughly
done will test to the utmost the originality and resource, the
powers of observation, and the knowledge of mental disease and
of human nature of any medical man.

I desire to point out in the first place that the sources of
irritation to excitable patients are innumerable. In this
respect the volume of excitement that may result in a mis¬
managed asylum reminds one of a mighty river, for like the
river, it may have its origin in a thousand different little
sources. It is thus obvious that success in the prevention of
this mass of excitement cannot be effected by one measure
alone, however heroic. Human nature always craves for “ a

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Royal road to success,” but in this instance, as in most others,
we find that success is attained by persistent attention to many
details.

Since the days of Gardiner Hill and Connolly much has
been done to ameliorate the lot of the insane, and by removing
causes of irritation these measures have largely reduced the
amount of preventable excitement in asylums. This work is
not complete, and we must carry it on with greater thoroughness
by attending to details and refinements unthought of, and,
indeed, impossible to our predecessors. Innumerable ways in
which the feelings of excitable patients may be spared will
occur to any thoughtful observer who studies the habits and
environment of his patients, and the following are some impor¬
tant points which I think worthy of consideration.

One of the worst manifestations of excitement is noisiness,
and it is not sufficiently realised and acted upon that noise in
an asylum is as infectious as measles in a preparatory school.
One noisy patient in a full ward will in a few minutes excite two
or three others to be nearly as noisy as himself, and a day of
noise will try the nerves and exhaust the self-control of every¬
one, with the exception of the deaf and demented. It is therefore
necessary to start a crusade against noise if one desires to
abolish excitement in an asylum. Even shouting out requests
or directions by the staff should not be permitted, and I have
to record that I came to regret the day when I had furnished
every ward in the Stirling District Asylum with a piano, on
account of the exciting influence of music as usually played in
an asylum. Now what should be done with a noisily excited
patient ? He, or as is more often the case, she, should at once,
without a moment’s delay, be removed to a room where she
cannot disturb her excitable fellow patients. Such a case
should be placed in seclusion, so that in the quiet of retreat
she may calm down, and when segregated she may not inflame
the excitement of others. She should, of course, be treated
with special consideration, as any insult or tactlessness in
this condition would only add fuel to her excitement and
provoke resentment, which would make her future control
more difficult than formerly. There should therefore be
attached to every ward where there are excitable patients a
small sitting-room, called a seclusion room, simply furnished,
but with specially comfortable chairs, where an excited patient

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could come with a nurse, or, if she preferred it, without this
companion, who should nevertheless be at hand. It may be
necessary to have more than one room of this kind in con¬
nection with some wards. Anyone who desires to read of the
beneficial effects of seclusion in the noblest language ever
written on this subject by a physician, may do so in the pages
of Connolly. Connolly obtained the advantages he mentions
by locking up his patients and by placing them in bare, unfur¬
nished bedrooms. This “ locking up ” is quite unnecessary, as
I know from a very extended experience, and very much
better and more lasting results can be obtained by removing
all such indignity from the practice of seclusion. The sur¬
roundings of “ seclusion ” should be more, not less, pleasing
and comfortable than the ordinary wards, and there should be
no trace of anything penal in the measure, but the reverse.
When calmness is restored the patient should return to the
ward in no spirit of rebellion, or with a bitter feeling of having
been wronged. A moral stigma may be allowed to be present,
for this is of value in increasing the self-control of the patient
if there be any self-respect present.

Some may imagine that to provide special nurses for all
excited patients enjoying the effects of seclusion is an impossi¬
bility. In many instances they may be dispensed with, and if
the seclusion sitting-rooms be conveniently situated, suitable
observation of the patients can be maintained without difficulty.
Moreover, if the prevention of excitement be systematically
carried out, the number of cases actually excited among the
excitable becomes very small and can be overtaken.

The treatment of the noisily excited, who are so from acute
insanity, must be carried on in a slightly different way. Seclu¬
sion prevents their excitement becoming aggravated, but it does
not calm down in an hour or two or a day at most as in the
case of the excitable. I have known such an acute case sing
“ The Lord’s my Shepherd ” for three days and nights on end
practically without a break. Such excitement is not of a pre¬
ventable kind, and these cases require the provision of a series of
apartments where they may be segregated, and where suitable
observation and treatment of the disease they labour under may
be carried out day and night by a specially numerous staff. I
believe that in the past the night treatment of these patients
has been very defective.

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Owing to the fact that much of the excitement found in
asylums has not been recognised to be preventable, little
trouble has been taken to find an external cause for it with the
object of removing the exciting cause or of avoiding it in future.
If one found, for example, a patient excited,and was told that
she was an epileptic, that was too often assumed to be a suffi¬
cient explanation of the whole condition. Inquiry should not,
however, cease here, for a careful investigation will often be
rewarded by an explanation from which a valuable lesson for
prevention in the future can be learnt. I remember on one
occasion an epileptic woman being so excited that she broke a
large pane of glass and occupied a seclusion sitting-room for
nearly a whole day before her excitement calmed down. I
could make nothing out of her story, as she derived more
satisfaction from abusing the nurses than in assisting me in
making a careful analysis of what had actually happened. I found
out afterwards that she had started the day very well and had
been sewing. She had then asked a nurse for some coloured
ribbon and was told it was to be found in a particular place.
She said it wasn’t and the nurse said it was. She then asked
the nurse to look for it and was told to find it herself. The
language then became less polite, and culminated in an attack
of excitement, lasting, as I have said, nearly a day. With
improper treatment and with a sequence of irritations it might
possibly have lasted a week. Tact here on the part of the
nurse at an early stage would have prevented this excitement
altogether, and the more carefully one inquires into the history
of these occurrences the more numerous do these cases of pre¬
ventable excitement seem. If the lesson they teach of the
evil consequences of want of tact on the part of officials could
only be thoughtfully applied to the management of every
excitable case, excitement would be greatly reduced. This
may be a doctrine of perfection, but much more could be done
than is done at present.

In cases of excitement where the patient is confused,
demented, or imbecile, the task of finding out the exciting
cause is more difficult, but it should nevertheless be regarded
as a duty, for even in these cases, although apparently hope¬
less, much of the excitement is preventable. Attendants and
nurses, for example, often make a mistake of holding con¬
fusedly excited cases too much. These cases do not under-

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stand why they are being held, but they instinctively feel, as a
wild animal would feel, that they are in the grip of an enemy.
They therefore continue struggling, so long as they are held,
till they are exhausted, whereas, if they be left alone, they are
often too confused to do anything purposeful. Sometimes it
is a delirious idea which is the cause of the excitement. An
assistant of mine was once called to four nurses who were
holding a struggling woman. He found out that the patient
thought she was in her own house and that all the gas taps
were open, and that they were in imminent danger of an
explosion. He told her he would go and see, and, coming
back in a few minutes after, informed her that all the gas
burners were turned off and that she might go to sleep in
safety. The patient slept and gave no more trouble that
night.

Patients suffering from dementia and imbecility can give no
help in investigations of this kind. In this respect they are
on a level with infants who cannot talk, and, as it is usually
found that a restless and crying infant is suffering discomfort,
so dements and imbeciles are noisy and restless from similar
reasons. I have known a noisy imbecile become quiet when
the decayed stumps of his teeth, which had apparently caused
neuralgia, were removed. Another patient was very noisy
every night, and nothing that was done by the nursing staff
with the object of soothing her had any effect whatever. The
night superintendent by chance one night offered her a biscuit
and thought she snatched it rather greedily. She gave her more
and she was quiet that night, and afterwards she got a regular
supply of biscuits at night and continued quiet. I must assume
that this patient felt the discomfort of hunger, and expressed
her feelings in noisy cries as an infant would have done in
similar circumstances. We made a lucky discovery in this
case, but how many other cases of preventable excitement
from a similar cause have been overlooked and misunderstood.
Even when the cause cannot be found in these cases, it may
be possible by expedients of various simple kinds to diminish
excitement and noise. Every charge-nurse, especially on the
female side, should have a supply of sweets for this purpose,
while on the male side the tobacco-pipe becomes literally
“ a pipe of peace.” Troublesome females, too, have been
pacified by giving them rag dolls to nurse. Occupations are,

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of course universally recognised to have a quieting influence,
and I think it is Dr. Clouston who records the history of an
insane tinsmith who was a most unruly and violent inmate till
he was allowed to expend his energy by hammering tin in the
workshop. For six days in the week he was now a useful and
peacable man, but on the seventh—the day of rest—he relapsed
into habits of violence and pugnacity and became a “ flaming
tinman ” again.

Another source of preventable excitement in asylums is the
incompatible position sometimes taken up by patients and
young attendants to one another, which inevitably leads to
trouble if not rectified. Most patients naturally resent being
kept in the asylum, since they consider themselves sane, and it
is galling to them to receive orders from anyone. Some young
attendants, on the other hand, enjoy a sense of authority, and
are inclined to order the patients under their charge to
do things in a somewhat peremptory manner. If examples of
these two classes come together there is sure to be friction
and trouble, and the interesting point about it is, that each
thinks he has been wronged by the other, and is uncon¬
scious of his own wrongdoing. If one investigates an unfor¬
tunate incident between the two, the attendant affirms that the
trouble began because the patient refused to do something, and
struck him, and that he, the attendant, had to defend himself.
The patient’s story of the aggression always goes a stage further
back than that of the attendant, and he states that the attendant
ordered him to do something as if he were speaking to a dog,
and as he could not stand this kind of treatment he naturally
retaliated. The antagonistic attitude of the two is the under¬
lying cause of the trouble, but the tactless language of the
attendant is the exciting cause. Were it less peremptory, as
is usually the case when experience has been gained, then
many of these violent incidents would be avoided. In these
cases the attendant who has unconsciously erred requires to
have it gently explained to him that the incident would not
have arisen had the patient not been irritated by his manner
and tone.

Violent assaults on the part of irritable male patients result¬
ing in the use of an unnecessary degree of controlling force by
the male attendants are the features of excitement on the male
side which give rise to most anxiety to asylum administrators.

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It is not too much to say that nine-tenths of the really serious
incidents (excluding suicides) which the authorities have to
investigate are of this nature. With the general improvement
in efficiency which has taken place by the training of the staff,
by more reliable supervision, and by higher ideals of care and
treatment, violence of conduct has diminished very greatly in
recent years. To my certain knowledge no single factor
exerts a more powerful influence in restraining this violence
and intemperate language than the presence and influence of
female nurses in the male wards. That this should be so is
only what one would naturally expect, and this is the reason
why during seventy years innumerable but only partially
successful attempts have been made to employ women in this
manner. This system has now been successfully inaugurated
by the superintendents of the Scotch asylums, with the warm
approval and encouragement of the Commissioners in Lunacy.
They are chiefly employed in nursing the sick and infirm, but
suitable acute cases are in most asylums placed undertheir charge
as well. The honour of being the first, however, to employ
women in male wards, as far as my reading goes, belongs to
an Englishman, a most interesting man, Dr. Samuel Hitch,
the “ First Secretary and Chief Organiser ” of our Medico-
Psychological Association, when he was Superintendent of the
Gloucester General Lunatic Asylum in 1841. I was lately
informed by his widow that he was led to do so because of the
harsh manner in which male attendants were then disposed to
treat the patients. This statement is confirmed by the
minutes of the Asylum, in which it is recorded that the first
woman was employed in the “ refractory ward,” and she was
the wife of the charge attendant of the ward. It is sometimes
said that the male side of an asylum is not a suitable place for
women. If that be so in the present year of grace then the
sooner a change in the habits and organisation of the male side
takes place the better will it be for the patients treated there.
The statement has, however, been absolutely disproved by our
experience in Scotland.

There is one more point I must refer to, and that is the
education, or, to be more accurate, the re-education, of our
unrecovered patients after the acute stage of their illness has
passed away. In the old days a patient who had become
demented steadily deteriorated in his habits because he was

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neglected and left to himself. In the course of time many of
these—the chronic inmates of our asylums—became very
degraded, and very troublesome and disorderly. They formed
a considerable proportion of the excited cases, and they were
the source of much irritation to others. They are now a
steadily diminishing band, as unrecovered patients are now
closely supervised and their insane tendencies are checked at
the beginning before they are formed into habits. They are,
moreover, re-educated into habits of decency and good order,
and in course of time the best of these patients can be
safely boarded out with guardians in the country. If this
policy of re-education be steadily pursued, it checks the source
of the supply of many of the most excited and troublesome
patients to be found in asylums.

Gentlemen, the subject the President has asked me to
discuss is an important one, and goes to the very foundations
of asylum management. It is also a very extensive one and
there is much that has been left unsaid. I have omitted, for
example, the well-known fact that large wards are unsuitable
for excitable patients ; and that abundant elbow-room is a
most potent agent in producing quiet. I have, however,
brought together some points which I consider of importance
and which may form the basis of your discussion. Of these I
would emphasise two : In the first place, that the greater
proportion of the excitement found in asylums is of the prevent¬
able kind ; and secondly, that this excitement can be prevented
by removing its cause.

Discussion,

At the Annual Meeting held at Edinburgh in July, 1910.

The President said all would agree that the paper was an admirably practical
one. If any member wished to discuss the treatment of excitement by means of
drugs the meeting would be pleased to hear him.

Dr. Briscoe said the paper which had just been presented by Dr. Robertson was
a most interesting one and the subject appealed to every psychological expert. He
wished to ask Dr. Robertson whether there was anything in the colour treatment
of excitement. At some of the asylums he had been into the windows were painted
primary red, blue, or yellow. He believed that in England the Commissioners
approved of yellow.

Dr. Clouston said he proposed to follow the President’s hint and limit his
remarks to one definite branch of the treatment of mental excitement, namely, the
treatment by drugs. In other respects he would not differ from Dr. Robertson's
thesis. He thought there was a distinct field for the treatment of mental excite¬
ment by pure therapeutic measures. If one was treating a patient at home in a
private house, it was his experience that the use of sedative drugs was compulsory.
The question then arose as to what drugs should be used; what was the effect of

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the continuous use for a month or two, or three months, of certain sedative drugs
on the explosive condition of pathological excitement? He thought he could
speak with some certitude on that aspect of the subject. No doctor who had to
treat a case in a villa or even in the country could allow the patient to be noisy
or to attract public attention. Sedative drugs were then used to control the
excitement in such a way as to take the edge off the symptoms and to diminish
the duration of the excitable period. He could say with some dogmatic force that
there were some cases in which one could use sedative drugs, especially in com¬
bination with warm baths, in such a way as to control excitement and limit the
duration of the attack. What drugs were best in this respect? He came back
to his old thesis, as the result of a great deal of experimenting in the earlier days,
and said that one must use the bromides in nearly every case, but not alone. To
bromide of potassium he gave the preference. Bromide of sodium was not so
reliable a sedative, but that and bromide of ammonium could be employed to a limited
extent. Bromide of potassium should be used in combination with certain other
sedative drugs. Sulphonal might be used with it and the dose should be reduced to
below ten grains. Some people wholly condemned sulphonal, but he thought they
were quite wrong in doing so. He had kept scores of senile cases with delusional
excitement out of asylums by the use of, perhaps, thirty grains of bromide and
four to seven grains of sulphonal combined, given twice a day, the last dose at
night, and with no bad effect on the nutrition or in the formation of a drug habit.
The next best drug to combine with the bromide was veronal. One did not yet
quite know its risks; it played tricks with one sometimes; but thirty, or even up to
sixty, grains of bromide combined with five to ten grains of veronal would produce
a sound, refreshing sleep, which was quite free from any traceable disadvantages.
Trional had received a bad name, but it did not deserve half as bad a character as
itreceived. Should one continue with the same combination always ? No; change
to trional, still using the bromides; change to veronal, to sulphonal, giving them
for two or three days at a time. Bromide was a cumulative drug, but if its effects
were watched bad results would not ensue. He had treated cases not by the day
and week only, but by the month, and those cases had improved in weight, got a
better expression in the face, they could be got out into the fresh air, and many
had recovered, not necessarily directly because of the drug treatment, but he was
satisfied that the recovery had been hastened by keeping down the excitement
and preventing fresh attacks of it. The morbid reactiveness of the mental cortex
was diminished by bromides. One could get bromides circulating in the blood
just as in the case of the epileptic, and with no bad result in regard to recovery.
With regard to sleep, he adhered to his view that paraldehyde was the best pure
hypnotic. With good nursing and attention to the general health one could obtain
by drug treatment a good result in a certain number of cases without any of the
destructive effects which some people spoke of.

Dr. Drapes said that Dr. Robertson's paper was an admirable one, as it gave
the leading thoughts on which the hearer could act at once. He was well able to
confirm his opinion as to the effect of the absence of tact, and the occurrence of
noisy conduct on the part of attendants in increasing the amount of excitement in
a ward. He had found attendants shouting at patients, and he had told them
not to do so, and showed those attendants that by talking quietly the patients
themselves became quieter. With regard to seclusion, he thought it was unfor¬
tunate the Commissioners put in their reports so many hours’ seclusion for this
patient and that, because he regarded it as a slur upon asylums. (“ No.”)
Seclusion was a remedial measure, and had a good effect upon the patients, as
well as relieving patients in the wards. An excitable patient often upset other
patients. He had been very glad to hear what Dr. Clouston said, because when
that gentleman spoke in the morning he seemed to have almost forsaken his
original optimism as to treatment by drugs. But as one got older one lost faith
somewhat in drugs and trusted more to general hygienic measures. But too great
stress could not be laid on Dr. Clouston’s experience; he knew of no more reliable
opinion than Dr. Clouston’s. He used veronal largely at his asylum, and found
it an admirable drug; rarely had he found unpleasant effects. No mention had
been made of hyoscine. That had been condemned for many years, but, he con¬
sidered, unjustly. When there was sudden excitement the effect of hyoscine was
immediate, i.e., gr. of it. With £ gr. morphia and gr. hyoscine he had

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seen patients quieted rapidly, with practically no after-effects. Noisy dements
were some of the most trying of all cases.

Dr. Bedford Pierce hoped that reprints of portions of Dr. Robertson’s paper
would be available for circulation amongst the staff of our hospitals for the insane.
His views of the best way of managing excited patients would be of great value if
widely known by nurses. When a new edition of the handbook is required he
hoped that Dr. Robertson would be asked to write a chapter on the subject some¬
what on the lines of his paper. With reference to the drug treatment of excitement
it pained him to say anything in opposition to Dr. Clouston, but he thought the
other side of the question required to be stated. Bortham Park, York, was
managed by an apostle of the doctrine that drugs should not be used merely to
quell excitement, and Dr. Hitchcock had for many years preached and taught that
drugs were useless and even harmful in dealing with excited patients. That
institution was one of the quietest and most orderly he knew. Much the same
practice was followed at " The Retreat,” sedative drugs were very little used, and
he thought the results justified the procedure. On d priori grounds, one could
see that the cure of acute mental disturbance was a process of repair. The drugs
in question were known to lessen protoplasmic activity; and one could fairly
infer that anything which lessened protoplasmic activity would lessen the process
of repair. He would not go as far as Dr. Hitchcock and say such drugs were
never useful; but he thought that in asylum administration very few should be
employed, and great caution should be observed in regard to them.

Dr. Haves Newington said that in order to be thoroughly useful the discussion
of the subject required dividing up. One ; needed to consider the stage or time
of the case. What was good for reducing the excitement of the chronic case
might be dangerous in the acute case. As to bromide, it was a dangerous drug
indeed, the most insidiously dangerous drug there was, and one did not always
see what followed its administration. He had always had a dislike to the old-
fashioned means of reducing excitement in recent curable cases, Dr. Skae's
teaching being that they tended to protract the acute stage. Opium and antimony
were especially tabooed, but in regard to the latter he had in his colleague's
practice seen remarkably good results from it in old-standing cases, i gr. two
or three times a day; it was particularly good in cases of excitement which had
recurring attacks every few months. Those cases then not only became quieted
by day, but the drug predisposed to restful nights.

Dr. Oswald said the Association was very much indebted for such a practical
paper, and especially for having it pointed out that mental excitement was divisible
into two classes—one preventable, and the other not. The lesson which he had
learned from Dr. Robertson’s paper was that every effort should be made to get at
the real cause of the excitement. The tendency when a patient became excited
was to have recourse to drugs to subdue that excitement, without ascertaining, and
therefore without removing, the underlying cause, which might or might not be a
removable one. He had been very glad to hear Dr. Robertson speak of seclusion.
When he said he put a patient out of the ward because he was excited he thought
Dr. Robertson would have used the term “isolation room but he was glad he
had had the courage to speak of it as a seclusion room. It meant that such excit¬
able patients were put into a separate room in charge of competent nurses and
attendants. He thought it was wise to divide the subject into two classes: patho¬
logical excitement, to be treated by drugs, and non-pathological excitement. The
former could be discussed for quite a long time. He agreed with Dr. Robertson
in almost everything he said. Many of the cases of excitement occurring among
chronic cases in asylums were preventable. They were due to lack of knowledge
on the part of the attendants; irritation was not wilfully caused to patients.
With the improved training now received by nurses, excitement had become less
frequent, and the whole tone of even chronic cases and wards was now better than
it was ten years ago.

Dr. Hubert Bond said he would like to associate himself with those who had
expressed their fascination and admiration at the subject-matter of Dr. Robertson’s
address. He did not propose to join in the discussion at any length, because of
the immense programme, but when he saw Dr. Newington get up he thought that
gentleman would speak about certain arrangements with which he (Dr. Newington)
was intimately associated, if, indeed, he were not the actual prompter, at the New

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Sussex Asylum. There a detached hospital formed a feature of the plans, and he
knew Dr. Newington was instrumental in arranging for the design of several
rooms, on the lines urged by Dr. Robertson, namely, to set aside people who were
actually excited, either from a pathological cause, or a purely irritative one. He
would ask whether Dr. Newington could say what had been the result of those
rooms. There were many things in the paper which deserved full discussion,
but the programme was so lengthy that he contented himself with asking that
question.

Dr. Newington said he could not answer Dr. Bond’s question, except to say
that Dr. Taylor found the rooms were very useful for the purpose of separating off
excitable patients.

Dr. Mackenzie (Inverness) expressed his thanks to Dr. Robertson. He was
glad to hear him lay such stress on the value of seclusion and solitude. Seclusion
rooms were important and interesting, but they involved structural alterations, for
which suitable arrangements did not exist in many asylums. An alternative
arrangement was to have a small day dormitory to which such excited patients
might be removed ; and if it had three or four rooms opening out of it that would
be an additional advantage. He had had an experience bearing on the point at
the Aberdeen Royal Asylum, where there were three wards recently constructed,
female wards containing a hundred patients, who had formerly been in much
smaller wards, and subjected to considerable overcrowding. There had been con¬
siderable excitement of the kind which Dr. Robertson had described as preventable.
He found that the removal of twelve or fifteen excited patients to the dormitory,
where they rested during the day, was of great assistance, and caused the wards
to be much quieter. Dr. Robertson did not refer to work and exercise as a sedative.
He regarded that as one of the best means of controlling excitement, especially if
the employment were out of doors. He was not competent to say much about the
effect of drugs, but he found that the addition of whisky to the sulphonal was
often very beneficial. With regard to hyoscine, in impulsive, wild, uncontrollable
excitement his practice was what Dr. Drapes alluded to as his, to give one-
hundredth of a grain, with one-sixth or one-eighth of a grain of morphia. Those
drugs combined produced a quietening 6f what was otherwise uncontrollable
excitement, and very often gave the patient a sound sleep, from which the patient
awakened very much better. With regard to Dr. Robertson’s remark as to the
effect of having pianos in the ward, he, Dr. Mackenzie, had not found the same
result from the music in Inverness. As Dr. Robertson had an infusion of the
Celtic element in the Morningside Asylum, he might try the effect of the national
instrument.

Dr. Seymour Tuke desired to say a word as a representative from the south,
to express the delight with which those from the other side of the Border had
listened to so many papers and so many well-expressed opinions from their
brethren in the north. He could assure the latter that the eyes of those in the
South were turned very much towards them just now, expecting a good deal of
hard work and practical results. Most of the matters dealt with in Dr. Robertson’s
paper were as familiar to those in England as household words, and they did try
to act up to the spirit of Dr. Robertson’s paper. He was very pleased that the
author had laid stress on the open treatment, in which he, the speaker, was a very
firm believer. He had very often seen cases brought from single care and from
confinement in lodgings, which immediately improved when taken out of them¬
selves and placed in the open air. There was also general physical repair and
much better sleep. In his asylum they did not talk of seclusion rooms, though
what they did came to practically the same thing. An excitable patient was
always removed, if possible at once, from the room where the other patients were ;
there was often an immediate amelioration in the patient's condition when that
was done. He would congratulate Dr. Robertson very much on his paper, which
he, Dr. Tuke, regarded as the most practical paper of the Session. One always
felt so much the importance of practical papers in the Association ; there had
been somewhat of a tendency in the last ten years to lose sight of the clinical
side of the question of insanity. But the Association was really founded as a
practical body for the discussion of the best means of ameliorating the lot of the
insane. Perhaps he spoke in regard to that matter feelingly, because he had a
kind of link with the past; the blood of Connolly ran in his veins, and he had
been brought up in his best traditions by his son-in-law.

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Dr. Stoddart said he wished to give his support to the reader of the paper. He
was very pleased to accord it, not only &propos of removing all causes of excitement
from excitable patients, but also as supporting Dr. Robertson’s contention that
rest was essential in the treatment of cases of mental excitement, as, indeed, in the
treatment of every other kind of mental disease. He would also say a word about
the drug treatment. While he supported Dr. Robertson in that, he was not against
Dr. Clouston's expressed views. He thought the combination of the removal of
the source of the excitement, with rest and a certain amount of drug treatment,
was the ideal method. Small doses should be given, not doses which were
intended to give a knock-down blow to patients suffering from excitement. As
Dr. Clouston had said, the way in which one could secure minimal doses of a drug
was by combining it with another. That was the method which he had adopted
for some years. Dr. Clouston suggested bromides as the basis of all sedatives, but
he, Dr. Stoddart, had adopted other modes of combination—veronal-sulphonal,
and so on. There was, however, one drug which he relegated to the veriest limbo
of Hades, and that was trional, which he found had a very deleterious effect on
patients. For the moment it was a good sedative and good hypnotic for old
people, but if one looked through cases which had been given trional for more
than a very limited period, it would be seen that they seldom showed any tendency
to recover. Moreover, Soukanoff had made certain observations, not ostensibly
for discovering anything about the drug, which showed that trional was the most
effective agent he could employ for causing desired degeneration of the neurons
in animal experimentation. Since he had learned that he had been the more
determined to relegate trional to the dust-heap.

Dr. George Robertson, in reply, thanked those who had participated in the
discussion for the manner in which they had received his paper. His object had
been to make it as practical as possible. It was not necessary for him to say very
much, but one or two sentences were desirable in reference to the points raised.
With regard to the colour treatment of insanity, he did not think the Scottish
temperament was influenced by colour, though on the more excitable temperaments
he believed it had a slight effect. With regard to the use of drugs, many would
remember how the meetings, ten years ago, degenerated into meetings in praise of
sulphonal, and shortly after that it was found that many of the cases died with
hrematoporphyrinuria. He had seen accounts of cases of the kind on the
Continent, and some of them he had himself seen. He felt very averse to using
that drug at all. Recently he had not seen reports of deaths after the use of this
drug, and if h^, could be persuaded that there were not harmful effects from its
use no one would be better pleased at it, as it was so effective. But, in a general
way, the use of drugs was objectionable if the patient could be treated in any other
way. Dr. Stoddart had mentioned the important point that trional produced
degeneration of neurons in the lower animals, and if the doctor added a poison of
that kind to those already circulating there, harm was being done to the patient.
A drug which had been much employed for the purpose was cannabis indica;
there was no drug so powerful in causing hallucinations, so that the employment
of that drug for people who were subject to hallucinations was a very great mistake.
With regard to seclusion, he objected very strongly to seclusion as usually
employed, namely, locking the patient up into a single room ; it was very un¬
fortunate that that beautiful term should be given such a meaning. The benefits
of seclusion could be obtained without locking the patient up; there should not be
solitary confinement.

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Occasional Notes.

British Medical Association, Annual Meeting, 1910.

At the Annual Meeting of the British Medical Association at
Belfast last year it was resolved that the scope of the Section of
Psychological Medicine should be extended to embrace Neuro¬
logy. That this was a wise step was clearly demonstrated by
the successful meetings of the Section of Psychological Medicine
and Neurology held in London on July 27th, 28th, and 29th,
under the presidency of Dr. Theo. Bulkeley Hyslop. The
papers have gained in interest, and the sectional meetings,
formerly rather sparsely attended, were crowded on each day,
On the first day, after Dr. Hyslop had delivered an able Presi¬
dential Address upon the general philosophy of the subject-
matter with which the Section had to deal, being in the main a
survey of the various hypotheses which have been advanced to
explain the concomitance or connection of mind and body, a
discussion upon the “ Treatment of Tabes Dorsalis ” was
opened by Dr. Risien Russell. Convinced that there was only
one rational treatment for this disease, and having frequently
seen patients who had been under treatment for years but in
whom the treatment for syphilis had been altogether neglected,
or so imperfectly carried out as to be quite useless, Dr. Russell
purposely confined his remarks to anti-syphilitic treatment with
the hope of awakening the profession to its importance. As to
the method of treatment the speaker had found the best results
obtained from mercurial inunction, as carried out at Aix-la-
Chapelle. Dr. Russell was followed by Dr. Ferrier, who
covered the whole ground of the treatment of tabes—prophy¬
laxis, measures calculated to arrest further degeneration, pallia¬
tive treatment, and Frenkel’s exercise methods.

Dr. Feibes and D. Lievin, both of Aix-la-Chapelle, outlined
the methods they employed. They were in agreement that in
all cases of tabes, and especially in early cases, mercurial
treatment did good, and that treatment by inunction surpassed
all other forms. Also both were adverse to intra-muscular
injection, on account of the danger of a sudden mercurialism
from the accumulation and sudden absorption of mercury in

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the gluteal region. Dr. Michell Clarke, on the other hand, and
Dr. Gordon Gullan, had both recently employed injections of
mercurial salts without any ill effects. Many others took part
in the discussion, and there appeared to be a general consensus
of opinion that the pessimism with which the mercurial treat¬
ment of tabes is generally regarded was unwarranted ; that the
unfavourable results so far obtained have been largely due to
the inadequacy of the methods employed, and that whilst an
anatomical cure might be an impossibility, a clinical cure
should be attempted in every case.

On the second day a discussion on “ Marriage and Insanity ”
was opened by Dr. Savage. Contrary, perhaps, to the opinion
of the lay public as a whole, and to that of most medical men.
Dr. Savage contended that insanity need not in every case be a
bar to marriage, and that persons who had suffered from mental
disorder classifiable as insanity had recovered and married
without risk to their partners or children. On the other hand
he was of the opinion that, speaking broadly, those with
periodic recurrences, epileptics with mental symptoms, those
with marked delirium or hallucinations, the sexually perverse or
impotent, and, of course, general paralytics, should be debarred
marriage. Dr. Shuttleworth, whose experience was drawn from
the products of ill-assorted marriages rather than from the con¬
tracting parties themselves, said that his own inquiries and
those of others had satisfied him that neuropathic inheritance
was a far more potent cause of mental defect or disorder that
the personal mental condition of the parent, and that in conse¬
quence the marriage of neuropaths, and particularly cousin-
marriages among neuropathic stocks, should be discouraged.
Therefore although, as he supposed, the time was not yet ripe
for laws regulating marriage and prohibiting that of the unfit,
it was incumbent on the medical profession to do their utmost
to educate public opinion on the subject.

Dr. Robert Jones, whilst agreeing that in the main the
marriage of people who had been insane was inadvisable, and
maintaining that delusional insanity and epilepsy should be
absolute bars against marriage, considered that the tendency of
nature to the average type should not be overlooked, and that,
therefore, the progeny of neuropaths might be normal. In a few
thoughtful remarks he referred to the law of Mendelism, and
showed how those who applied Mendelism to this problem of

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the transmission of abnormal mental characters did not take
cognisance of the fact that there was no such thing anywhere
in human nature as gametic purity. In consequence dogmatic
utterances as to the importance of heredity were not warranted.
Indeed, from a study of his own cases he had arrived at the
conclusion that heredity was not nearly so important a factor
as was generally believed, and that the really important deter¬
mining factors were environmental influences, alcoholism, and
tubercle.

It became evident, as others joined in the discussion, that
there existed certain divergences of opinion on this important
question, not so much, perhaps, with regard to the undesir¬
ability of marriages between insane persons, but, firstly, with
regard to the individuals who should be debarred marriage;
and secondly, the means of preventing such unions. Therefore,
when Dr. Greenlees brought forward a sweeping resolution in
favour of the prohibition of marriage not only to insane persons,
but also to neurasthenic individuals, seconded by Dr. A. R.
Douglas, the resolution was criticised, amended, then whittled
down, later referred to Committee, and finally was withdrawn.
There appeared to be a general agreement with Dr. Savage
that the time was not ripe for legislation, and also that the
biological evidences on which dogmatic statements as to the
place and importance of heredity in the causation of mental
disorder ought to be founded were still insufficient to warrant
the recommendation of State interference with marriage.
Probably, also, most members present were in agreement with
Dr. Savage when he said that the State regulation of marriage
might have the effect of reducing society to a dead level of
mediocrity, and that he could not help sympathising with the
little girl who said that when she got to Heaven she hoped she
would find there a little corner of Hell to play in.

The third and last day was made notable by the reading of
several capital papers, including a highly original communication
and demonstration by Dr. Bdrdny, of Vienna, upon certain new
methods of examination concerning the relationship between
the vestibular apparatus, the cerebellum, the cerebrum, and the
spinal cord. Dr. B&r&ny first of all described two methods of
examination in the diagnosis of cerebellar diseases, the first
investigating the equilibrium of the body, as by Romberg’s test,
and the second, the pointing movements of the extremities

lvi. 47

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during vestibular irritation, either when experimentally pro¬
duced in normal persons or as the result of disease.

Dr. B&r&ny’s paper was so valuable that it should be read in
full when published in due course in the British Medical Journal ,
but it may be said here that it consisted essentially of a descrip¬
tion of the equilibrative and co-ordinative movements observed
in normal persons under artificially produced nystagmus, i.e.,
by turning or by syringing one or other ear with cold water ;
an analysis of the neuro-muscular mechanism underlying the
production of these same experimentally produced disorders,
and a comparison of these with the disorders of equilibration
due to disease, whether of the vestibular apparatus, cerebellum,
cerebrum, or cord. Dr. Bardny showed that the behaviour of
normal persons under experimental nystagmus followed definite
rules, and that the departures from these in morbid conditions
afforded valuable aids to diagnosis, and in addition threw light
upon the function of the neural mechanisms subserving these
movements. A brief quotation from Dr. B&rany’s paper will
give an example of this : “ If we cause a normal individual with
closed eyes to stretch out his arm and touch with the forefinger
an object held in front of him and then drawback his hand and
point again at the object, we find that nearly everyone, even
the uneducated and children, can, with a small amount of
practice, point with accuracy at the object. If we turn a
normal individual ten times on a turning chair to the right and
arrest suddenly, we observe a strong vestibular nystagmus to
the left. If in this moment we repeat the ‘pointing experi¬
ment,’ the man will no more point correctly to the examiner's
finger, but point to the right side. This pointing to the side is
surely due to a vestibular innervation of the arm muscles. It
is only the question from where this innervation comes. Again,
I do not wish to tell you all the possibilities which I have dis¬
cussed in a paper read before the Neurological Association in
Baden Baden, 1910. I can only tell you the result of my
reasonings—that this innervation comes from the cortex of the
hemisphere of the cerebellum. The most important fact which
made me assume this hypothesis is, that in two cases of
operated healed cerebellar abscess of the right hemisphere, the
patient, who did not show any trouble from the standpoint of
the neurologist, after ten times turning to the left did not point
to the right side with the right hand (the hand of the diseased

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side), but pointed absolutely correctly, whereas the hand of the
healthy side showed the usual error. I supposed that by the
abscess the centre in the cerebral hemisphere was destroyed,
which in the normal delivers the desired innervation.”

Dr. Bardny’s demonstration, delivered in excellent English,
was followed with the greatest interest by all present.

Following the reading of Dr. Bdrdny’s paper, Dr. D. G.
Thomson again brought forward the necessity for post-graduate
curricula and diplomas in psychiatry at universities and other
qualifying bodies. After a discussion, in which many members
joined, the following resolution was put to the meeting and
carried unanimously:

“ That this meeting of the Section of Psychological
Medicine, assembled at the Annual Meeting of the
British Medical Association in London, 1910, believing
that it would tend to advance our knowledge of the
pathology and treatment of mental diseases, strongly
approves and recommends the institution of a post¬
graduate course or curriculum and a diploma in
psychiatry, and further, that this resolution be brought
before the Council of the British Medical Associa¬
tion.”

Dr. Alexander Bruce then demonstrated a series of lantern-
slides illustrative of a sclerosis of the adventitia of the vessels
of the spinal cord, associated with multiple (amputation)
neuromata in the substance of the cord. The condition had
apparently begun as a sclerosis of the membranes in the
neighbourhood of the points of emergence of the anterior and
posterior roots, from which points it had spread along the
membranes and had entered the substance of the cord by the
lymphatic system of the adventitia of the vessels, and had
extended along these irregularly as far as their ultimate
terminations, producing a great thickening of the outer wall,
with a connective tissue. The result was a series of areas on
the grey and white matter differing from disseminated sclerosis
in that the patches of sclerosis contained actual fibrous tissue
which had grown in, and were not mere overgrowths of the
neuroglia. In addition the lower portion of the cord showed
numerous microscopic tumours composed of spindle-shaped
cells and medullated nerve-fibres. These were in every instance
situated in the adventitia of the blood-vessels and were probably

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[Oct.,

secondary results of a deflection of some of the anterior root
fibres by the sclerotic tissue.

Dr. Edwin Ash having read a paper entitled “ The Psycho¬
logical Treatment of certain Functional Conditions,” Dr. W. A.
Jolly gave a deeply interesting account of an investigation
carried out at the Physiological Laboratory of Edinburgh Uni¬
versity, of the knee-jerk and simple reflexes. The object of
the research was to record the interval of time elapsing between
a tap on the patellar tendon and the beginning of the electrical
variation (recorded by Einthoven’s string galvanometer) indi¬
cating activity of the quadriceps muscle ; and to compare this
interval with the delay occurring in the case of reflex action of
the thigh muscles in response to mechanical stimulation of the
sole of the foot. The result showed that the delay in the latter
was about twice that of the knee-jerk, and the inference drawn
therefrom was that the knee-jerk mechanism involves one
spinal synapse or set of synapses, and that the other reflexes
mentioned involve two.

Unfortunately, Dr. Jolly’s paper was read at the end of a
busy meeting, and the time at the disposal of the Section did
not permit of the discussion which its value merited.

Part II.—Reviews and Notices.

Mesmerism and Christian Science : a Short History of Mental Healing.

By Frank Podmore. 8vo. London: Methuen & Co., 1909.

Pp. 306. Price ioj. 6 d. net.

Mr. Podmore has long been active in these investigations of psychic
phenomena, and out of the fulness of his knowledge he has produced
a book which gives an excellent account of this interesting and
important subject. Mesmer’s appearance in the latter part of the
eighteenth century, in a period of intellectual ferment, occasioned a new
sensation among the idle rich, and crowds of patients flocked to his
reception-rooms. These strange scenes formed the subject of medical
investigations, and Mr. Podmore gives a very full account of the results
and the cases upon which these reports were founded. He concludes
that animal magnetism appears to have been especially efficacious in
the treatment of gouty and rheumatic affections. An interesting chapter
describes the faith healers who had preceded Mesmer and their methods.
We find some account of Gassner, Kenelm Digby, Paracelsus, Fludd,
and Maxwell, men whose names are familiar to those who take an

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interest in the cure of wounds by the power of sympathy and similar
occult mysteries. Their influence on Mesmer is set forth, while show¬
ing that the spiritualist doctrines found no place in his expositions.
His magnetic system was purely a question of matter and motion,
skilfully presented to a public who were averse from the mystical
teaching already familiar to those seekers after strange gods. The first
French Commission of 1784 reported that there was no proof of the
existence of the animal magnetic fluid, and emphasised the moral
dangers incurred in Mesmer’s experiments. However, de Jussien
suggested that those operations were directed and intensified by the
will, and thus indicated the true scientific explanation. The account of
those elaborate and long-continued discussions recorded by Mr. Podmore
suffices to give an intelligible understanding of the case as represented
by the conflicting parties. It is a valuable resume of much contentious
writing conveyed to the reader in an intelligible form. It is impossible
to follow out in this brief notice the history of later French commissions
of 1825 and 1837, and we can only indicate that mesmerism in England
is treated in an impartial and interesting manner. The account given
of Elliotson’s investigations and opinions, of Esdaile’s wonderful series
of operations in India, of Braid’s clear and convincing expositions, forms
a memorable chapter, and awakens old memories. The later history of
the subject having been followed out in reference to the Continent and
America, the more immediately interesting part of Mr. Podmore’s book
begins with his consideration of Thomas Lake Harris, whose influence
on Laurence Oliphant was of such an extraordinary character, and led
him to write that strange book, Symptieumata. From Harris it is an
easy step to Mrs. Eddy and Science and Health. Mr. Podmore points
out that those who practised mesmerism were sooner or later absorbed
in the ranks of the spiritualists. Thereafter there were two camps—one
occupied with hypnotism or suggestion, the other professing mind¬
healing as sectaries more or less reputable. More than enough has
been said of Mrs. Eddy, but if there be anyone who desires to acquire
knowledge of this person and her claims he will find here recorded by
herself that it is not right to copy her book and read it publicly without
her consent, because that is injustice in a holy place. However,
Mr. Podmore has dealt faithfully with many cranks, and we do not
grudge Mrs. Eddy a niche in his chamber of horrors.

Since this review was written we regret to hear of Mr. Podmore’s
unexpected death. His long and judicial studies of these mental
phenomena made his name widely known, and his place in psychology
will not be easily filled.

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Part III.—Epitome of Current Literature.

i. Neurology.

On the Behaviour of the Pericellular Nerve-plexi in some Pathological
Processes in the Nervous Tissue [6W rnodo di comportarsi dei plassi
nervosi pericellulari in alcuni processi pathologici del tessuto nervoso).
(Riv. di Pat.Nerv. e Merit., vol. xv,fasc. 6 , June, 1910.) Besta, C.

If the histological findings described by the author in this communica¬
tion be confirmed by other investigators, they should go far towards
re-establishing the supremacy of the neuron doctrine, so strongly
assailed in recent years by the researches of Apathy, Held, and Bethe.
Employing a modification of the photographic methods of Cajal, Besta
claims to have succeeded in obtaining a clear view of the terminal
nervous arborisations around the nerve-cells in various parts of the
cerebro-spinal axis, and the relations of these to the nerve-cells. He
describes the normal cell surrounded by a thick feltwork of very fine
amyelinic fibres, many of which terminate in a small knob-like expan¬
sion which lies in contact with the cell body. Some of these seem to
penetrate beyond the margin of the cell. Corresponding with the
processes, but at a slightly higher level, an abundant interlacing of fine
fibres is sometimes seen. It is impossible to state definitely whether
these fibres form a network or a simple plexus, and whether they assume
intimate relations with the cell surface or not. In no case, however,
has the author been able to detect any anastomosis with the endo-
cellular reticulum. The difference in behaviour of the nerve-cell and the
peri-cellular arborisations under pathological conditions is particularly
striking and significant. Avulsion of the sciatic nerve was performed in
eighteen rabbits. These were subsequently sacrificed at periods varying
from 2 to 120 days and the associated nerve-centres in the cord
examined. The nerve-cells were found to be markedly affected, show¬
ing various degrees of atrophy and disintegration, whilst the pericellular
arborisations and amyelinic plexuses were perfectly normal. The terminal
expansions were clearly visible and normally disposed. They were,
however, quite detached from the surface of the cells, which were
shrunken and atrophied, leaving a space around them occupied by a
material of indefinite structure.

In a second series of experiments the author practised occlusion of
the abdominal aorta in a number of rabbits, for a time sufficient to give
rise to necrosis in the grey matter of the lumbar and sacral regions of
the cord. Only exceptionally was the necrosis of the nerve-cells found
to be complete. In the first few days after the operation, both cells
and pericellular arborisations showed marked alterations, but, even where
the nerve-cell changes were not severe, the destruction of the pericellular
fibres and terminal expansions was most marked. Ten dap after
operation, the nerve-cells showed signs of commencing restoration, but
the pericellular apparatus remained destroyed. Nerve-cells were seen
to present normal or almost normal morphological features notwith-

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standing that the terminal arborisations which normally rest on their
surface were completely destroyed, whilst the amyelinic plexuses which
surround them had in great part disappeared.

From the results of these investigations, it would seem that the nerve-
cell and the pericellular apparatus react independently of one another.
We can have destruction of the nerve-cell with complete integrity of the
terminal arborisations and amyelinic plexus, or, again, extreme reduction
of the plexus and total disappearance of the terminal arborisations with
persistence of the nerve-cell in almost normal condition. These results
are opposed to Held’s views regarding the concrescence and continuity
between terminal arborisations and nerve-cell and favour the contact
idea of Cajal. Besta suggests that certain clinical manifestations for
which a corresponding morphological cell-alteration has not been found
may find an explanation in special alterations of the terminal plexuses.

J. H. MacDonald.

2. Physiological Psychology.

A Study of Genius: Poincari \Enqucte Midico-psychologique sur la
Superiority intellectuelle ; M. Henri Poincarf\. (Sent. Mid., March
23rd, 1910.) Toulouse.

Toulouse, who has previously carried out minute medico-psycho¬
logical investigations on Zola, Berthelot, Dalou, etc., has now turned his
attention to Poincari, one of the greatest of mathematicians and still in
the maturity of his powers. Manouvrier, Bonnier, and other specialists
have aided in the investigation.

Poincare’s mathematical aptitude appeared spontaneously at the age
of eleven. His father, an uncle, and two cousins have, however,
attained intellectual distinction, and his maternal grandmother pos¬
sessed mathematical aptitude. It is noted that his head is large in
relation to his height.

Toulouse considers that Poincari is of neuropathic temperament.
He suffers from neuralgias and has subjective visual sensations when
fatigued. He is very liable to insomnia and experiences a stable form
of coloured hearing. The neuropathic trouble may be dated from
severe diphtheria at five; he has also, perhaps, worked excessively.

Unlike some mathematicians, Poincari has a good memory for
figures, and can remember eleven when only heard once. His mental
type is auditory, though most mathematicians are visuals. His senses
are weak rather than strong. In movements, he is awkward and
inferior.

An instructive point in Poincare’s genius is that he is directed by his
work rather than that he directs it. He believes in unconscious mental
work, and when work is not easy he abandons it. His powers of atten¬
tion are not great and the oscillations are marked. In his essential
mental mechanism he is unstable. His work is spontaneous and
automatic, but not easily stopped. He does not work at night in order
to avoid insomnia. He makes no plans in his work. Like some other

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great mathematicians, he is absent-minded; thus on one occasion he
unconsciously took a wicker cage from a shop-front and walked down
the street with it.

In setting forth these and other results of his investigation, Toulouse
makes many interesting comments. Havelock Ellis.

Hysterical Anesthesia. ( Journ . of Abnotm. Psychol ., April , 1910.)

Linenthal , M.

Hysterical anaesthesia is held by Janet to be due to a contraction of
the field of consciousness consequent upon an inherent mental
weakness, an inability to synthesise more than a limited number of
sense impressions at the same moment. Other observers, notably
Breuer and Freud, are diametrically opposed to this theory. They
state that in many of their cases they fail to find any inherent mental
weakness of the kind described, but that the patients frequently possess
strong characters, remarkable will power, and unusually clear and critical
minds.

Janet’s distinction between the “ stigmata ” and “ accidents ” of
hysteria cannot be upheld, and his whole conception involves many
difficulties. The author considers these various objections at some
length, and then proceeds to develop his own theory of the subject.

The hysterical condition has been shown to be due to a state of
dissociation—a certain group of experiences is dissociated and forms
an autonomous psychical system separated from the personal conscious¬
ness. This autonomous system is, however, still capable of functioning,
and the phenomena which thereby result constitute the symptoms of
hysteria. Every symptom, including the anaesthesia, must have its
explanation in the primary traumatic experience responsible for the
dissociation.

Anaesthesia will be found in all cases of hysteria where the sensory
dissociation existed during the initial trauma. The hysteric is anaesthetic
because at the time of the original accident he was unaware of certain
sensory impressions which, under normal conditions, would undoubtedly
have affected his consciousness. Thus, in a case where the original
traumatic experience consisted in a severe fright, there was a subsequent
amnesia for the experience in question and a complete left hemi-
anaesthesia. It was found that at the moment of the fright the patient
had fallen upon his left side. On account of his disturbed psychical
condition he had, however, perceived none of the resulting sensations.
Hence a left hemi-anaesthesia subsequently remained. The explanation
suggested is strongly supported by the fact that, although the original
fright episode could be resuscitated by hypnosis, the hemi-anaesthesia
persisted during the hypnotic state. The traumatic psychical system
therefore exhibits one dissociation within another, the tactual sensations
being dissociated from the other elements constituting that “ moment
consciousness.”

A similar explanation may be applied to the limitations of the visual
field. Bernard Hart.

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Hysteria and Psycho-analysis \Hysterie und moderne Psycho-analyse\

{Psychol, neurol. JVochenschr., Hr. 45-50, 1910.) Priedldnder, A.

This is a critical review of Freud’s psychological theories and
methods. In the main a hostile standpoint is adopted, but the author
is prepared to recognise much that is valuable and suggestive in the
work of Freud and his school. He considers that the original theories
propounded by Breuer and Freud in the Studien iiber Hysterie have
been most fruitful for the psychology of hysteria, and that the methods
of therapeutics founded upon them may be profitably employed in
certain traumatic cases. He is definitely opposed, however, to many
of Freud’s subsequent developments, and regards the latter’s sex-
theories with dislike and distrust. Bernard Hart.

3. /Etiology of Insanity.

Dementia Preecox caused by Dental Impaction. {Monthly Cyclop, and

Med. Bull., Nov., 1909.)

The lesion of dental impaction, that is, teeth so angled against their
neighbours as to be possible irritants, has been known as an occasional
cause of intense pain, but has never before been studied clinically in
its other relations.

The writer examined fifty-eight cases by skiagraph, and found this
condition to exist in about one-half of these cases. The patients in
whom impactions were found suffered from a great variety of nervous
disorders, ranging from headache, habit-spasm, restlessness, epilepsy,
through insomnia to melancholia and dementia praecox.

Dental treatment in these cases was carried out by removal not only
of the impactions, but of all irritation of teeth and jaws, as the irritation
caused by impaction differs only in degree, not in kind, from that of
other dental lesions. The best therapeutic results were obtained in
severe cases of manic-depressive insanity and dementia praecox, and
the author is of opinion that, at least a large proportion of these cases
are directly dependent on pure irritation, often situated in the teeth
and jaws, and are readily curable when dealt with early. Of eight
cases seen by him in consultation, in whom thorough dental treatment
was carried out, including the extraction of one or more impacted
teeth, six recovered their mental health, one at the time of writing was
convalescent, and one much improved. Of these patients, five were
cases of dementia praecox, of whom four recovered and one was con¬
valescent.

Impaction in these cases caused no local pain, and in few of them
pain of any kind. Pain was also absent in many cases due to caries
and alveolar abscess, and he believes that the lesions underlying the
severe psychoses are usually painless. Dementia praecox, he reiterates,
is a product of purely peripheral irritation. As dental irritation is
common at all ages, there must occur consequent mental disorders in
the young and the very old, varying from the dementia praecox type as

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the reaction-mode varies with age. The predominating type of lesion
also is determined, he says, by the age of the patient.

The psychoses of senility, when dental in origin, are usually caused
by caries, abscess, and exostosis. In children, on the other hand,
recent experiment has convinced him that imbecility, whose symptoms
run so close a parallel with dementia praecox that a few cases of acute
onset have lately been described as dementia pracocissima, has as its
underlying lesion in many instances impactions, usually multiple, and
capable of causing the terrible mental ravages found in this condition.

A. W. Wilcox.

4. Clinical Neurology and Psychiatry.

Difficulties of Diagnosis between Minor Epilepsy and Certain Hystericcd
Convulsive Spasms [Diffiailte du diagnostic entre les crises Apiltp-
tii/ues frustes et certains tics convulsifs hysteriques\ ( Gaz . des Hop.,
May , 1910.) Cruchet, R.

A case closely simulating minor epilepsy in a boy, aet. 8, is recorded,
which was only successfully diagnosed after a long period and watching
as an in-patient.

Four diagnoses are discussed : (1) Minor epilepsy, (2) simple tic or
spasm, (3) malingering, (4) hysteria.

The following is a description of the attacks : suddenly his eyelids
quiver, his eyes turn up, so that only the whites are visible; this lasts
for two or three seconds. There was a history of eighteen months.
The boy denied all knowledge of what occurred, but he flinched from a
threatened blow, never dropped anything that was in his hand, but
would upset it over him ; attention increased the attacks, which were
as many as forty a day. Only one injury was ever sustained. Coaxing,
bribery, slapping, bromides, cold and tepid baths were of no effect
Certain occupations, breathing exercises, reading, etc., would bring on
the attacks. There were no biting of tongue, incontinence of urine,
nor headaches or drowsiness.

Minor epilepsy was finally excluded when the boy admitted that he
knew what occurred, though for nearly two years he denied any
knowledge of the attacks; simple tics, by the lack of bashfulness about
the attacks, and that reading, breathing exercises, etc., did not stop them
or control them ; malingering by the fact that discovery did not diminish
the attacks, attempts to induce other types of attacks failed, and the
imitation was too perfect. Malingerers usually make preparations for
their attacks. In favour of hysteria was urged that many years ago he
had seen a friend in epileptic attacks. Many dolls close their eyes in
this fashion. His mother had slight quivering of the lids.

He is being treated by suggestion during normal (?) sleep, and stated
to be improving. M. A. Collins.

Epileptic Aura [Auras Epileptique\ (Rev. de Psyehiat ., March,
1910.) Vallet and Marinier.

Some interesting psycho-sensory and psychic aurae are recorded :

(1) A man, set. 37. He first hears a well-known musical air, which

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is at times all; at others the words of the song are heard, and then he
sings them; this is followed by a visual hallucination. He sees a herd
of goats ; an animal, larger than the others, separates from them, and
turns to the left. At this moment consciousness is lost.

(2) A soldier, who had been wounded in the head, saw everything
around jump about and get gigantic in size; he then saw two eyes
advance to him, and lost consciousness the moment they reached him.

(3) Balzac records that Napoleon saw a red man taking part in the
chief events of his life.

(4) A girl, set. 22, would say, “Look at those people; something is
going to happen to them.” She then fell in a fit.

(5) A man, set. 35, would say to his friends, “ How pale you look;
you are going to fall.” At this moment, he turns pale and falls.

(6) A woman, set. 30, would see herself out in the street trying to

get on an omnibus, and apparently jolted over. At this moment, she
would fall. M. A. Collins.

Paroxysmal Tachycardia as an Epileptic Equivalent [La tachicardia
accessionale come equivalente epilettico\ (II Manicomio , anno xxv.
No. 3, 1909.) Sacchini.

The case recorded in this paper is of interest from the clearly epileptic
origin of the cardiac symptoms. The patient had been subject from
the age of five years to attacks of grand mal of the usual type. Owing to
progressive mental deterioration he was sent to the asylum when twenty-
one years old, and there, some two years later, he was observed to have
occasional attacks of tachycardia of somewhat peculiar character. In
the attack, which was of sudden onset, the face became pallid and then
cyanotic; the patient appeared extremely distressed and shrieked out,
“ I am dying ”; he had intense dyspnoea, and his pulse was small,
irregular, and so frequent as not to be countable. When this phase
had lasted about three minutes, the circulatory disturbance would
gradually pass off, the pulse resuming its normal rhythm and the
dyspnoea abating. The patient would then smile, rub his head, and
ask, “What was the matter?” He passed water in the attack,and had
complete amnesia. In the intervals between the attacks, there were no
symptoms referable to the heart, and the most careful examination
failed to reveal anything abnormal in that organ. Under the influence
of bromide treatment, the paroxysms became rare and eventually ceased
altogether.

In a brief discussion of the pathogenesis of the symptoms the author
leans to the view advanced by Bellisari, that the tachycardia is due to an
arrest of the inhibitory function of the vagus resulting from an irritation
of the cortex. W. C. Sullivan.

Post-operative Insanity [Sulla pazzia post-operatoria\. (II Manicomio ,
anno xxv. No. 3, 1909.) Galdi.

In this paper, after a critical digest of the literature of the question,
the author gives a summary of thirteen cases from his own practice in
which insanity developed after surgical operations of greater or less
severity. A detailed discussion of the clinical evidence leads him to

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the following conclusions: (i) A post-operative psychosis does not
exist as a clinical entity, the mental disorders which may follow surgical
operations being, on the contrary, of very various character; (2) such
disorders when arising immediately after the operation are of toxic
origin (due to microbic infection, to anaesthetics, to antiseptics, etc.);
when appearing some time later they usually belong to the degenerative
psychopathies ; (3) hereditary or acquired predisposition to insanity is
the predominant factor in the production of these disorders, the influence
of the surgical operation being merely that of an occasional exciting
cause; (4) the seat or nature of the operation does not exercise any
decided influence on the genesis of post-operative insanity, and in
particular it is not proved that gynaecological operations are specially
liable to be followed by mental disturbances ; (5) the mental symptoms
that develop after the removal of important organs, being due only to
the auto-intoxication consequent on the suppression of the internal
secretion of the organs, cannot properly be regarded as coming under
the rubric of post operative insanities. W. C. Sullivan.

Mental Disturbances associated with Ovarian Syndromes [/ disturbi
psichici in rapporio colie Sindromi ovariche ]. (II Polyclin. Scz.
Pratica, 1909.) Fornaca , G.

This is a synthetical and critical review of the literature dealing with
the various forms of mental disturbance met with at the periods of
puberty, menstruation, pregnancy, lactation, the puerperium, and the
menopause (normal, pathological, and surgical). Many of the mental
syndromes occurring at these critical periods are not related imme¬
diately to deficiency or alteration of the ovarian secretion, but due to
the intervention of other factors which exercise a more harmful influence
on the nervous system, and this is particularly true with regard to
puerperal and lactational syndromes. Ovarian opotherapy has been
found by many observers to give excellent results in the true ovarian
syndromes. J. H. MacDonald.

Ptyalism in Mental and Nervous Affections \Dello Ptialismo wile
malattie meritali e nervose]. (Piv. Sper. di Fren., vol. xxxvi, fasc.
i, ii, 1910.) Benigni.

The author’s observations lead to the following conclusions : In
mental affections, ptyalism, even when real, has no diagnostic or pro¬
gnostic importance. It is to be regarded as a secondary symptom,
nearly always related to the toxic agent which produces the morbid
mental state. In nervous diseases, however, sialorrhoea is a not infre¬
quent symptom, and may have a certain diagnostic and prognostic
value.

In both classes of affections, ptyalism has various causes. It may be
produced by direct anatomical or toxic irritation of the salivary centre
or of the secretory paths in the hemispheres. It may also be due to
abolition of the cerebral inhibitive influence, or be brought about
reflexly by pathological conditions in some viscera, or, finally, by
mental, anatomical, or toxic excitations of the sensory nerves.

J. H. MacDonald.

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I 9 IO.] CLINICAL NEUROLOGY AND PSYCHIATRY.

729

Five Cases of Rumination in Insane Women [ Cinque casi di mericismo
in alienate\ (Ann. del Manicom. Prov. di Perugia , Ann. Hi,
fasc. iv, 1909.) Fornaca, G.

After repeated chemical examination of the stomach contents in five
cases of rumination, the author concludes that the principal causes of
the condition are hyper-secretion, and especially hyper-acidity and
hyper-chloridia. Rumination does not occur after every meal, but
irregularly, after eating too much and too greedily, when the gastric
secretion is highly acid, and the food composed mostly of solids.
Changes in the mental state of the patient do not influence the act, nor
has the latter any influence on the mental condition. Diminution of
the absorbing capacity of the stomach and the activity of the gastric
movements can be excluded. Administration of drugs designed to
lessen the excitability of the nervous system have no remedial effect.
Treatment with bicarbonate of soda or other alkalies which diminish
the acidity of the chyme brings about improvement, and, finally, cure.
Amongst the insane rumination is met with most frequently in subjects
who are mentally weakened and lead a vegetative existence.

J. H. MacDonald.

Suicide in Hysterical Individuals [// suicidio negli isterici ]. (Riv. Sper.
di Fren., vol. xxxvi,fasc. i, ii, 1910.) Fornaca , G.

The question whether the attempts at suicide made by hysterical
subjects are serious attempts, made with the definite desire to end their
days, or if they are the outcome of a desire for attention, publicity,
sensationalism, notoriety, etc., has given rise to a great variety and
confliction of opinions. The author has studied minutely the clinical,
personal, and family histories of 255 cases of suicide or attempted
suicide re-admitted to the casual wards of the hospitals at Rome. Of
these 62 occurred in hysterical subjects, and were made the object of
special inquiry described in this interesting communication. The
author arrives at the following five conclusions : (1) Hysterical subjects
may seriously attempt suicide with the definite object of ending their
existence. (2) The reasons which urge a hysterical subject to suicide
are, as a rule, the same as those which influence the ordinary suicide.

(3) Long premeditation of the act is uncommon in hysterical suicides.

(4) Degeneracy and homonymous morbid heredity are very frequent in

hysterical suicides. (5) The majority of hysterical subjects who make
a serious attempt at suicide or succeed in the act are hysterical
degenerates. J. H. MacDonald.

Antipathy of Unconscious Origin arising from a Dream \Antipathie de
cause otiirique et inconsciente'}. (Journ. de Psychol., May-June,
1910.) Kreist, M.

In this paper, the author recounts the case of a man who entertained
an increasing animosity towards his wife. He became so cantankerous
that she began to consider the question of divorce. The interesting
feature of this antipathy consisted in the fact that the patient himself
could not understand it, and stated that it co-existed with a feeling of
great affection for his wife. It seemed that his irritation was always

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more marked on waking in the morning, and towards the evening he
often became quite amiable.

Under hypnosis patient related a dream in which his wife told the
children that their father was a very uncouth man, and in the dream
the couple engaged in a strenuous dispute. Upon waking he forgot
the dream, but found everything the pretext for quarrels with his wife.
When the hidden cause was revealed to the patient in the waking state
his irrational antipathy disappeared.

Such a case throws considerable light upon sentiments and feelings
which often appear inexplicable, and indicates that conscious activity
may be controlled by unconscious processes of which the personality is
unaware. H. Devine.

The “Paranoia of Governesses ” \Le “Dilire de Gouvertiantes”\ (fount,
de Psychol., fan-Feb., 1910.) Blondel, C., and Camus, P.

Though the existence of a certain paranoic constitution can scarcely
be contested, there are not infrequently highly important contributing
causes which give the delusions their particular colour. Among such
conditions those of a social and professional character occupy an
important place.

Among teachers and governesses, systematised delusions display
certain special traits which some writers have described under the
name “ Delire de Gouvernantes ” (Gouvernantewahnsinn). Ziehen,
analysing the principal setiological factors of this form of paranoia,
mentions especially repeated slights and want of attention, contrasting
with a knowledge of actual intellectual superiority. The authors record
two cases illustrative of this type of paranoia.

In both cases the fundamental theme is erotic in character. Con¬
strained by their position to an enforced celibacy, but moving in a
social environment superior to their own, they are sometimes exposed
to the desires and homage of pupils or patrons of the highest rank.
The romances they weave, the dreams of love and marriage, are only
imaginative in origin, and of necessity frustrated. Hence the vexations,
disappointments, and repeated regrets. Their superior attainments
give them an exaggerated opinion of themselves, which forms the basis
for the development of expansive delusions.

Such individuals are frequently in a false position, neither mistress nor
domestic; they are liable to continual affronts. From an absence of
regard, and from vexations of all kinds to which they are subjected,
even in front of their pupils whom they should command and direct,
they feel an irritation which can only reinforce their feeling of hostility
and nourish ideas of persecution. H. Devine.

Examination of the Blood in Dementia Prcecox \Blutuntersuchungtn
bei Dementia Prcecox ]. (Allge. Zeilschr. f Psych., vol. Ixvii, No, j.)
Heilemann.

This examination was spread over two years, and was conducted in
150 cases of dementia prsecox. Dr. Heilemann deals with morphological
changes and serum examination of the blood.

The existing literature on the subject does not give an account of

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1910.] CLINICAL NEUROLOGY AND PSYCHIATRY. 73 1

any definite result; the findings are as yet, according to Kraepelin,
uncertain and many-sided.

The blood used by Dr. Heilemann was extracted from the ear lobe,
fixed in methyl-alcohol, and coloured with haematoxylin-eosin or with
Giemsa solution.

The absolute count of white blood-corpuscles was in many cases
somewhat, but not remarkably heightened, a circumstance which, taken
by itself, is of little importance. More interesting is the analysis of the
white corpuscles and the numerical comparison of their different forms.
They are thus described :

(1) Lymphocytes: small (about the size of erythrocytes) round cells
composed of large nuclei and only a thin covering of plasma. In some
of these the plasma mass is enlarged.

(2) Large mononuclear cells. They are three times as large as the
above-named, and have plump, rounded, or horseshoe-shaped nuclei
which colour faintly.

(3) Polynuclears or neutrophiles, with lobulated or broken-up nuclei
and rich protoplasm (leucocytes in a narrower sense); and

(4) Eosinophiles, which are similar to neutrophiles, but in which the
protoplasm is filled with coarse granules which greedily absorb the acid
colouring matter.

In comparing the percentages of these different forms with the normal
percentages, there was found to be in dementia prsecox a notable decrease
of polynuclears. In no case did they attain the normal quantities
(lymphocytes, 20-25 per cent .; polynuclears, 70 per cent, or over; other
cell-forms, 2-4 per cent.), but were in every instance much below normal,
in some cases only being found in half quantities. This decrease was
accompanied by an increase in all the other cell forms, the mono¬
nuclears and eosinophiles increasing with the lymphocytes, and some¬
times attaining double their normal quantity. In cases of other mental
diseases tested the findings were mixed. Age and sex had no influence
in the change of blood condition found. It is not certain, however,
whether this change was varied according to different forms of dementia
praecox. It is indicated that a high number of eosinophiles generally
accompanied catatonic symptoms.

From these discoveries definite blood changes in dementia praecox
are an established fact. That these changes indicate a chemical
evolution in the system is a near-reaching conclusion. On account of
their difference in character it would be useless to compare somatic
diseases, which in one direction or another influence the blood-picture
in a similar manner to that seen in dementia praecox. On the other
hand, the hypothesis of a toxin being present in the blood would
explain these changes. Naturally, nothing can be said in regard to
the value of the symptom and the role it plays in the complete
phenomena of the disease. But there is an interesting physiological
analogy to the blood-pictures described, to be found in the blood of
a young child. In this the lymphocytes are greatly increased, and
further, Benjamin has found that the blood of a healthy suckling baby
contains up to 14 per cent, mononuclears and 7 per cent, eosinophiles.
As to whether there is any underlying connection in the two cases is a
question open for discussion. Hamilton C. Marr.

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On the Clinical Value oj the Wassermann Reaction in Nervous Diseases
[ Ueber den klinischen Wert der Wassermannschen Reaktion bei den
Nervenkrankheiten\ (Neurol. Cbl., 1910, No. 11.) Springer, H.

After examination of 241 patients, 56 of whom suffered from mental
diseases, Dr. Springer arrives at the following conclusions:

In lues cerebri, the cerebro-spinal fluid reaction is nearly always
negative; on the other hand the serum reaction is nearly always positive
(in over 90 per cent.)

In tabes, the fluid showed positive reaction in 80 per cent., and the
serum in 66’6 per cent.

In 106 cases of syphilis, without nervous disorder, the blood-serum
showed, in the first stage, 727 per cent, positive results, in the second
stage 92 '2 per cent, (in latent condition of the same stage 60 per cent.),
and in the third stage 93*7 per cent. (40 percent, in the latent condition).

In three cases of syphilis, without disease of the nervous system, the
reaction was negative. In five out of six cases of hereditary’ lues the
serum test was positive. In non-syphilitic cases it was always negative.

Dr. Springer also emphasised the value of the Wassermann test in
organic nervous diseases of children. Hamilton C. Marr.

Chemical, Cytological, Hcematological, and Histological Studies of the
Cerebro-spinal Fluid in Mental Diseases [ Chemische , zytologiscke,
hccmatologische tend histologische Studien tuber den Liquor cerebro-
spinalis bei Geisteskrankheiten ]. (Jahrb. fiir Psychiat., vol. xxx.

Nos. 2 and 3.) Wada and Matsumoto.

The results of these studies are summed up thus :

(1) Paralysis (certain), nine cases. In thirteen out of fourteen
punctures “ phase 1 ” reaction of Nonne was distinctly positive, and
the whole albumen mass and cell-count much increased. In one case
the albumen and cell reactions were at first negative, but on further
examination gave positive results.

(2) In remission of paralysis the result was also positive.

(3) Fifteen cases of other mental diseases were examined. Out of
sixteen punctures only one (a case of epilepsy) showed a slight positive
albumen and cell reaction. On further examination of this case, “ phase
1 ” reaction and the cell reaction were negative, while the total albumen
mass was slightly increased. It is thus obvious that in some cases
repeated puncture is necessary in order to finally decide the diagnosis.

(4) In the above quoted sixteen punctures “ phase 1 ” reaction was
fifteen times negative, the total albumen mass nine times, and the cell test
thirteen times normal. “ Phase 1 ” reaction has, therefore, the greatest
differential diagnostic value for distinguishing paralysis from other
psychoses. If the reaction is negative paralysis can be denied, even if
the total albumen mass or cell-count is increased.

(5) In paralysis the relationship between the cell-count and albumen
mass was not proportional.

(6) Among the cells of the cerebro-spinal fluid of paralysis there was
87 per cent, of small lymphocytes and also a very small number of
large lymphocytes, polynuclear leucocytes, transitional forms, fewer
epithelioid cells, and ependymal cells.

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(7) In one case and in an acute exacerbation of paralysis there was
polynuclear leucocvtosis of the blood and relative increase of the same
leucocytes in the fluid. This may be a sign that the paralytic poison is
suddenly richly produced and develops its general working.

(8) Dementia praecox, six cases. In four cases the albumen and
cell reactions were negative. A case which had had an apoplectic
attack showed only a slight increase of cells, and in a case of chronic
alcoholism the total albumen mass was somewhat increased.

(9) In the case of apoplexy in dementia praecox there was a slight
increase of cells, no lymphocytes, and a remarkable increase of the
polynuclear leucocytes of the cerebro-spinal fluid. At the same time
there was no lymphocytosis and no change in the percentage of the
single leucocyte varieties of the blood.

(10) Chronic alcoholism, two cases (one dementia praecox and one
manic-depressive insanity). Both showed a slight increase of albumen,
normal cell-count, and negative “ phase 1 ” reaction.

(n) Post-apoplectic dementia, one case. Albumen and cell
reaction negative.

(12) Epilepsy, five cases, six punctures. In one case, there were
slightly positive results on the first testing of albumen and cells, as in
paralysis, but on testing again “ phase 1 ” reaction and cell-counts were
negative, while the albumen was slightly increased. Further, there was
a slight increase in the total albumen mass in two cases, a slight
increase of cell-count in one case, and quite negative albumen and cell
reactions in another. “ Phase 1 ” reaction was in five punctures negative.

(13) Idiocy, two cases. Negative albumen and cell reactions.

(14) If there was a leucocytosis of the blood the cell-count of the
fluid did not increase, excepting in the cases of paralysis.

(15) A proportional weakening of the percentage of similar kinds of
leucocytes in the blood and in the fluid did not take place, except in
one case and in an acute exacerbation of paralysis.

(16) The cell contents of the spinal fluid and of the meninges of
the lowest sections of the spinal cord were not proportional.

(17) In the histologically examined cases it could not be testified
that there were cases in which (as found by Merzbacher), without
irritation of the meninges, there was an increase in the cell-count of the
fluid.

(18) In three out of four cases in which there was a certain or

probable history of lues the albumen and cell reactions were quite
negative, so that it was quite easy to tell the difference between this
and paralysis. Only in one case was the cell-count alone somewhat
abnormal. The patient sometimes suffered from an apoplectic attack,
and on histological examination there was found a cell infiltration into
the pia mater. Hamilton C. Marr.

5. Treatment of Insanity.

The Treatment of Hysteria by Psycho-analysis. {New York Med. Rec.,
Aug. 6th, 1910.) Parker, G. M.

The author seeks to co-ordinate Janet’s method with Freud’s,
believing that each supplements the other. He associates himself more

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especially with Freud’s earlier work, and appears to be less acquainted
with the late developments of the Freudian method. He adopts light
hypnosis at the outset in many cases (though not regarding this as the
ideal method) on account of the great saving of time, and states that
without its aid 60 per cent, of the hysteric cases in his clinic at the
Roosevelt Hospital could not be analysed.

Four cases of hysteria are here recorded and the author considers that
they belong to three different groups : (r) Shock neurosis, or psycho-
neurosis, distinguished by the predominance of shock and resultant clear-
cut dissociation, the dissociated psychic contents becoming organised,
and producing a double process of absorption and intrusion. There is
no necessary sexual causation. These cases fit in with the mechanism
described by Janet. (2) This group has a wider territory and is
marked by the sexual nature of its psychogenic factors, by volitional
exclusion and gradual dislodgment rather than cleavage dissociation, by
the direction given to these dislodged associations issuing from unful¬
filled desires, and by the effect upon consciousness produced by conver¬
sion of these elements into intruding somatic systems. Hypnosis is
not used as the treatment takes much time, but Freud’s method alone
produces any results in these cases. (3) This is the largest group, and
is marked by the presence of both mechanisms in an incomplete form,
Freud’s being usually fundamental and the other superimposed.
Janet’s method must here be followed by Freud’s and by light
hypnosis.

Parker is a convinced though temperate advocate of the psycho¬
analytic method. Havelock Ellis.

6 . Pathology of Insanity.

The Role of Bacteria in the Pathology of the Central Nervous System
[Le role des bactlries dans la pathologie du systeme nerveux central].
{Arbeit, aus d. Pathol. Inst, der Univers. Helsingfors , Bd. Hi, H. i,
1910.) Homen , E. A.

The author’s views are based mainly on observations in the domains
of human pathology and experimental research carried out in the
pathological institute of the University of Helsingfors. The following
are some of the chief conclusions. Amongst other paths of entrance
of virus (formed elements and toxins) the intestinal tract ranks important
Transportation of virus from intestine to central nervous system may
take place not only through the blood-stream, but also by the lym¬
phatics, especially those contained in the branches of the sympathetic
nerve, and thence by the communicating branches into the spinal cord
(Wickman). Experimental pathology has shown the possibility of the
passage of the virus to the nerve-centres along the peripheral nerves
through their lymphatics, and especially the spaces occupying the
internal aspect of the perineurons. The spinal ganglia and roots act
to some extent as filters or stations. Their resistance once overcome,
the virus extends to the cord and its membranes, and this more readily
by the posterior than by the anterior roots. Within the nervous system

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extension takes place, not only along the meningeal spaces (in infants,
perhaps, also the central canal) and the blood-vessels, but also the
lymphatics, particularly the lymphatic spaces in the tunica adventitia
and the perivascular spaces of His.

Whilst the causes that predispose to the localisation of micro¬
organisms in the tissues generally apply also to the nervous tissue, the
latter reacts in a particular manner. It is unusual to find organisms in
the nerve-elements themselves or in immediate contact with them. If
placed there experimentally they disappear rapidly, owing possibly to
the soil being unfavourable or to the changes produced in the nerve-
elements exerting a deleterious action on them. In the mesodermal
tissues, on the contrary, they localise themselves and develop fairly
readily. Although the organisms may have disappeared, the patho¬
logical process may be continued by toxic bacterial products remaining
in the tissues in association with degenerated elements, and circulatory
disturbances resulting therefrom. If extensive tissue alteration happen
to follow bacterial invasion, then the organisms may develop, or at least
live, for a long time in that situation (eg, cerebral abscess).

The action of bacteria and their toxins on the central nervous
system may be local or remote, or both combined. In local actions,
the tissue changes are produced by the bacterial proteins, and in part
by their specific toxins. There is then superadded the irritating
influence of products of decomposition of tissue elements, and local
circulatory disturbance. The mode of reaction of the tissue (degenera¬
tions, necroses, exudations, infiltrations, proliferations, and combinations
of these) depends on the kind of organism, the number, degree of
virulence, and the general and local resistive capacity of the indi¬
vidual. Proliferations, when present, occur at the periphery or in the
neighbourhood of the primary foci. The mesodermal elements
especially react by proliferation, and the adventitial to a greater extent
than the endothelial cells. Proliferation of neuroglia, on the other
hand, occurs, as a rule, later, and progresses more slowly. It is of
comparatively slight importance, and rather secondary to the degenera¬
tion of the nerve-elements.

Mixed bacillary infection is generally more severe than single
infection.

In acute infective diseases, local foci may be found in the nervous
system, where no bacteria can be detected and there is no reason to
suppose their prior localisation there, or even the existence of a
mechanical cause, such as embolus. These seem to be toxaemic in
origin. The tissue-modifications are generally slight. Sometimes they
are severe and of a degenerative or destructive character. In the latter
case they can hardly be due to toxaemia alone, for it is difficult to
explain why the circulating toxins by themselves should produce a
severe lesion, sharply limited, yet without elective characters.

A certain importance must here be attributed to the thrombi and
other vascular alterations leading to narrowed lumen of the vessels that
are often present in these cases. Such vascular conditions may some¬
times act as initial causes inasmuch as they render possible or accentuate
a toxic action which is concentrated precisely on these particular areas.

Cases where an infective or toxic agent is combined with a mechanical

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agent, e.g., infective embolus of a terminal artery of the cerebrum, are
not uncommon. Sometimes it is difficult to decide whether an in¬
flammatory process is primary and due to an infective-toxic agent or
secondary and developed, e.g., in connection with an ischaemic softening.
Much discussion has taken place in connection with the thrombosis
of the sinuses and veins of the pia-mater and the associated encephalites
and softenings. The researches of the author’s colleague, Therman,
go to prove that in the majority of cases the thrombi are secondary, and
caused by the same toxic process which has determined the meningo¬
encephalitis. The author expresses his belief that the interpretation
of many lesions is aided by an exact differentiation of the various cells
found in the focus under the microscope. He is convinced that the
majority of the large cells, especially the so-called epithelioid cells of
Friedmann, and the granular bodies, are not, as many think, derived
from the neuroglia, nor from fixed mesodermal cells (adventitial and
endothelial), nor from typical plasmatic cells, but are polyblasts in the
sense of Maximow, or derived from these, that is to say, derived from
lymphocytes. We would not be justified in speaking of primary
inflammation in the case of processes, where at the initiation, and as
an essential factor, we find only degenerations, thromboses, or embolisms
and haemorrhages. The presence, however, of a certain number of
polyblasts in a primary focus would prove its inflammatory character.

J. H. MacDonald.

7. Sociology.

Automatism in crime \L'automatisme dans la crimina/itf\. {Rev.

Philosophy Feb., 1910.) Marro.

In the cerebral processes involved in the commission of a homicidal
crime Marro proposes to distinguish two main factors, viz., on the one
hand, the exaltation of irritability in the affective centres expressed in
the condition which he terms “ psychic hyperaesthesia,” and on the
other hand, the presence of the pre-formed excito-motor mechanisms
requisite for executing the homicidal act. It is the second of these
factors that is mainly considered in the present paper. These special
mechanisms have been organised in the evolution of the race in connec¬
tion with the primary functions of self-preservation and reproduction,
and though civilised man normally restrains them by the influence of
the later developed moral and social feelings, they are readily brought
into action under appropriate emotional conditions. In relation to the
sexual function these mechanisms have been developed predominantly
in the male in the struggle with other males for the possession of the
female, and this, in Marro’s view, is the reason of the greater prevalence
of homicidal crime among men. The motor images which constitute
this combative mechanism are most readily excited to activity when the
integration of the personality is imperfect, and when, to adopt Janet’s
conception, there is a loss or restriction of the power to form new and
complete syntheses adequate to the particular occasion, so that a con¬
dition of automatism ensues in which acts of a criminal character may¬
be committed. Marro refers to recorded instances of such acts in the

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state intermediate between sleep and waking, in somnambulism and in
the epileptic dream phase, and then discusses at greater length the
automatism of alcoholic intoxication In this connection he emphasises
the importance of emotional stimuli in initiating the activity of the
aggressive mechanism, which, when started in these conditions, often
works with an explosive violence ending in exhaustion. Military
training, designed as it is to cultivate the aptitude for attacking a
hypothetical enemy, renders this atavistic mechanism of aggression
particularly prone to activity, and for this reason homicidal crimes in
alcoholic automatism are specially frequent amongst soldiers. A
number of interesting observations are briefly cited to illustrate this
point. The tendency to automatism is more pronounced in individuals
of defective brain and also in the uneducated. Marro has found, for
instance, that the proportion of illiterates is nearly twice as large amongst
homicidal criminals as compared with other classes of offenders. In
general, the influences which place the mental organism in a state of
inferiority, the influences w’hich produce what Janet terms “ la mis£re
psychologique,” favour the development of criminal automatism.

W. C. Sullivan.

8. Asylum Reports, 1909.

Some English County and Borough Asylums.

Buckinghamshire. —Comparisons of asylum population at various
times in the last forty years show some curious results. During that
period the numbers in workhouses and with friends has increased by
193, and those in asylum by 253, the chief increase in both cases
being between 1895 and 1905. The population of the county between
1870 and 1880 increased by 1,000 and the increase in the insane was
37. But in the next decade the population went up by 9,000 while the
insane only increased by n. Such vagaries must increase the difficulty
of estimating requirements when new buildings are called for.

Cumberland and Westmoreland .—We note that post-mortem examina¬
tions were made in every one of the seventy-three deaths. The Com¬
missioners, in noting an excellent dinner, make the suggestion that the
patients’ dietary should be shifted every month, so that patients should
not always know what they are going to have for dinner from day to day.
Among the financial tables we find one that is interesting and probably
instructive to those who can follow the various factors which temporarily
influence maintenance expenditure. The average cost for each of the
items in the statutory expenditure returns is given for each year from
the commencement of the Asylum’s life in 1862. The prominent
factor is that the cost of provisions has progressively decreased until now
it stands at 2 s. 10 d. per week as against 5$. id. in the first complete
year. Salaries and wages cost about threepence, or 10 per cent, more
than they did. Necessaries rule a shade higher, while the dispensary
charge is half what it was, and wine, etc., which stood at over a penny
and three-quarters, and sometimes over two-, and even threepence, is

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now represented by one-sixteenth of a penny. On the other hand, the
charge for farm and gardens is a shilling or more than in the earlier
days, and this must be, we suppose, satisfactory evidence of greater
utilisation of the staple labour of a rural district. The net expenditure,
which, of course, is liable to disturbance by calls for extra furniture and
repairs and clothing, etc., works out now at 8r. 9 d., which is threepence
below the average of the forty-nine years under consideration.

Derby County. —Dr. Legge points out the divergence which exists in
the practice of those who have the disposition of the pauper insane in
contributing areas.

It has been suggested that less favourable cases come from industrial than
from agricultural districts. This is probably true, but it does not explain all the
differences that are met with. I would hazard the suggestion that an important
factor may be found in the persons who send patients to the asylums; that in
different districts there exist among relieving officers, workhouse officials, guardians
of the poor, and others concerned, different customs or views (which may become
traditional) as to the cases in which certification is necessary; that some are more
disposed to send the milder cases to the asylum ; that others let the patients
remain at home, or in the workhouse for a longer period, so that the chances
of recovery are lessened; that in various ways the patients selected for treatment
in the asylum are not selected on a uniform system. That differences of procedure
should exist between similar authorities is not surprising ; they are very common.
In some counties it seems to be the rule that an adjudication should precede an
order of transfer ; in others the adjudication is almost unknown. In two unions
in this country attempts have been made to admit all pauper patients under two
certificates as “not under proper care and control”; in the remainder of the
county pauper patients are almost invariably admitted in the ordinary way with
one certificate. Instances could be multiplied indefinitely.

One patient was discharged on account of one of the medical certifi¬
cates not showing any facts justifying certification—a rare occurrence
in these enlightened days one would think.

Derby Borough. —Dr. Macphail reports yet another relation of that
dreadful scourge, influenza.

In the months of January and February we had a severe outbreak of influenza.
During the six weeks the epidemic lasted, 115 patients out of a total of 350, and
19 officials out of a total of 58, were attacked. There were also a few doubtful
cases. In round numbers this corresponded to a third of our resident popula¬
tion. In many of the cases the disease was of a mild uncomplicated type,
particularly among the men, but in about 50 per cent, of the female patients and
staff the symptoms were of the gastro-intestinal type. A special feature of this
epidemic, the most severe in the history of the asylum, was the number of cases
that relapsed once or oftener. Towards the end of February, among some of
these relapsed cases, well-defined symptoms of dysentery appeared, and for the
first time in the history of the asylum we have to report an outbreak of colitis.
The total number affected was 23—8 males and 15 females; they were fairly
evenly distributed in all the wards, and did not affect any special class of patient.

I was unable to trace any communication of the disease from one patient to
another. The incidence was as follows : On two distinct occasions, at an interval
of a month, several patients were attacked simultaneously, had well-defined
symptoms, and when they recovered the disease did not spread further. The
only definite fact, which could scarcely have been a coincidence, was that practically
all the cases of colitis occurred in patients who had an attack of gastro-enteric
influenza a few weeks previously. There has been complete freedom from this
or any other epidemic disease since the month of April, and no member of the

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staff suffered from dysentery. These epidemics were directly or indirectly re¬
sponsible for seven deaths, three from influenza and four from colitis.

It is somewhat surprising that the admissions in the borough supplied
less than 3 per cent, of general paralysis, while the county admitted more
than 5 per cent. The steady increase of this disease in rural districts
compared with the somewhat stationary incidence in towns is a fact that
merits inquiry. Can the explanation be that the short service system
now in force for the army tends to return into rural homes an increasing
number of possible subjects. The percentage of former service in
general paralytics as given by Dr. Morrison above would seem to justify
such a suspicion.

Dr. Macphail gives his yearly average respite from second attacks in
those who have been discharged recovered and have relapsed. Last year
it was three years and seven months. It is much to be wished that all
would give this information. Given reasonable concurrence as to what
constitutes recovery, evidence of cardinal value would be obtained as
to the probability of relapse, a most important item in the natural
history of the disease. This value could well be increased by recording
the form of insanity on the prior attack.

Glamorgan .—General paralysis was found in 42 of the 382 admissions.
In these eleven showed positive signs of syphilis. In 34 paralytics this
disease was stated to be a contributory factor in twenty cases, while
in the other fourteen it was deemed to be the principle or chief
factor. Alcohol was found in 65 cases, and 155 had some form of
heredity. Colliers and miners formed more than one-third of the male
admissions. More than half the cases came in within three months of
inception.

Hereford County and City. —Thirty-two per cent, of the admissions
were found to be suffering from goitre. It would be very interesting if
Dr. Morrison could show what, if any, relation to the form of mental
trouble, course of the case, recovery-rate, etc., this disease may have.

The careful inquiry instituted into the cause or causes which have operated to
induce a mental breakdown in those admitted has elicited the fact that the neurotic
and insane heredity were the most potent as a primary factor, 23 per cent, males
and 40'8 per cent, females having a definite faulty heredity. Syphilis in males
gave 17’ 1 per cent .; nearly all were men who had served with the colours and had
seen foreign service. As a secondary cause alcohol was found to be operative in
35'3 P er cent, of adult males, but in 22 8 per cent, the excess had followed a prior
brain affection, and in the remainder, 11 "7 per cent., the habit had been acquired
by persons with a direct insane or neurotic heredity. In 6 5 per cent, adult females
the habit was also found to be associated with an insane or neurotic heredity.

Dr. Morrison, in adopting for the first time the new tables, adverts to
the extra work involved in keeping full and accurate registers. It
is one advantage of the new system that it does involve accuracy in
registering facts when found, as also industry in seeking for them. It is
to be hoped that in time all asylums will insure this accuracy by adopt¬
ing the tables, for though the precise value of the tables themselves may
not be evident, yet in time to come the enormous collection of accurate

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facts must, in the hands of experts, yield results of the highest import¬
ance. Anyhow, the thanks of the Association are due to all those who
undertake for the general good the undoubted increase in labour
involved.

Hertfordshire .—The tendency to increase in the number of patients
for whose care authorities are liable is illustrated by the fact that this
asylum, opened but a few years ago, has need to build for 234 additional
patients. At the same time the new wards, when opened, were called
upon to receive forty Middlesex patients from Napsbury, an asylum
opened still more recently. It must be consoling to the ratepayers to
find that the new accommodation has been provided for less than 100
per bed.

Dr. Boycott, though he has not gone the full length of adopting the
tables of the Association en bloc , gives a large amount of valuable
information on the principal lines laid down by the Statistical Com¬
mittee. In one respect we think that he has made an improvement
He gives the form of insanity on direct admission, dividing it into two
columns, one dealing with first attack cases, the other with not first
attack. Such information in large bulk would be very useful. We
note, too, that he gives a column or two to the relapses admitted
each year. We would suggest an improvement by showing, not the
relapses only, but the year from the recoveries of which relapses have
been admitted during the year under report. This would be analogous
to the information of each year’s working given in the old Table 4.
The results would tend to show the period of respite to which we have
alluded under Derby Borough. We note that in the table of religions
no less than twenty-two are detailed, while a considerable margin is left
for cases in which no form of religion is stated, this affording possi¬
bilities of yet further forms of belief.

Lancashire , Pres/wich .—On one point all who have to do with the
care of the insane must be agreed—the importance of freshly discharged
recoveries being afforded the best opportunity for maintaining regained
health in the early days of freedom. Various expedients are adopted,
but we think that that which is suggested by Dr. Perceval is wholly
commendable. A large area like Lancashire could well afford to try
the benefits of such a home as he suggests.

I have, on a previous occasion, called attention to the need, in my opinion, of a
convalescent home. I venture to do so again. As pointed out then, there are a
number of cases that reach a certain point in an asylum, and there they stop.
There is something wanted that we cannot give them. To these cases the value
of such a home can hardly be over-estimated. The sickly man who must imme¬
diately seek work, the delicate young mother who has to take up at once the full
household cares and duties of the hardworking poor, the anaemic domestic servant
compelled to get a place as quickly as possible, these, and many others, are
constantly coming under my notice. A suitable convalescent home on the coast
might convert them into permanent recoveries instead of swelling our list of
recurrences.

Most will agree with Dr. Perceval as to the evil influence exerted by
bad environment, but many will dissent actively from his assignment of

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the causa causans. Certainly many women of the new pugnacious type
will abuse him for daring to think that the female sex was created solely
for maternity and its duties. We are a little puzzled, too, in trying to
fit in his opinion that poverty is the great cause of alcoholism with
another very prevalent idea that alcoholism leads to poverty. Which
idea is right ?

There are few things that have not been named at one time or another as a
cause of insanity, from changes in the moon down to perverted ideas of religion.
The actual conditions, at present existing, conducive to the production of weak¬
lings subject to insanity are not far to seek. This country, and others, have
become dominated by a system of commercialism by which wealth and power are
so unevenly distributed that for thousands of persons permission to live, even on
the borders of starvation, is only granted on conditions of labour, compared to
which the lot of the old negro slave was princely. The greatness of a nation now is
judged by the amount of its exports and imports rather than the happiness and
welfare of its people. And so we have little children working in the factories, and
women, to get back to work, neglecting their duties of motherhood, for which
alone they were created. The inevitable result is the production of a large pro¬
portion of the candidates for the asylums. I should like to say with regard to
drink, of which we hear and see so much in this specialty, that I feel convinced,
and the conviction has been growing upon me for years, that poverty is the great
cause of alcoholic intemperance.

London City .—This institution continues to cater actively for the
less affluent private patients, of whom sixty-five, or nearly half of the
admissions, came into the asylum. They now constitute more than
a moiety of the total population, and, of course, find the greater pro¬
portion of the available income. We note that out of the total admissions
seven male and three female cases were of general paralysis. It would
be highly interesting to know, especially as to the female cases, whether
they were among the rate-paid or private cases. In fact we think, as
we have said before, that with all the material at his hand Dr. Steen
could give some comparative information of value. His population is
drawn from eleven countries other than England.

Dr. Steen has adopted the outdoor treatment for many cases, but
could not take the risk of letting them sleep out of doors after the
commencement of November.

As recorded above, twenty-six patients were sent out on leave of absence on
trial. In many cases this was done as a probationary measure to test the fitness of
the patient for complete discharge ; in a fair number of instances, however, this
procedure was made use of to give the patient a holiday away from the institution.
It is hoped that in the coming year the experiment thus commenced will be con¬
tinued to an even greater extent.

Salop and Montgomery .—The two counties have at last taken the
right step, by agreeing to dissolve union, to remedy the constant over¬
crowding and its attendant evils which have beset the management for
years past. Montgomery is to go out, and provide for its own lunacy,
claiming only that its contributions should be paid back to it. The
four boroughs still in the county are to pay, under a revised agreement,
about jQ 9 per annum per bed for accommodation—a very reasonable
charge ot 3 s. 6 d. per week.

The Visiting Committee appear to have been very early in the field

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[Oct.,

in attacking the pension classification, as they published a very fair
scheme on or before January 19th, 1910.

We note in this, as in other purely rural counties, that admissions
are supplied by the general labourers far in excess of the farm labourers.
The latter are probably in considerably greater numbers than the
former.

Staffordshire .—The Superannuation Act forms the subject of some
comments. As this county in quite recent years set a good example of
framing a very liberal pension scheme, the remarks on it shape rather
differently from those in other quarters where the scheme is a novelty.
Dr. Spence puts the matter very reasonably. We are glad to note that
the liberality of the authority has not been exhausted by its previous work,
and that it is to be exercised in bringing up as far as possible the future
to the past benefits, which formed part of the contract of service.

The year 1909 may be regarded as one marking an epoch in the history of those
who make the care of the insane their life occupation. The Asylum Officers'
Superannuation Act received the Royal assent in December last, and the first day
of April this year has been fixed as the date when the Act shall come into opera¬
tion. As far as the asylum officials of Staffordshire are concerned the new Act is
by no means an unmixed blessing, and it is feared that its effect will not tend to
minimise the work either in the selection of the staff, especially of the subordinate
members, or in the amount of clerical work, owing to the extra labour which the
office staff will be called upon to perform in order to carry out its enactments.
The Staffordshire officials of the first class already rejoiced in the benefits of a
pension scheme which permitted them to retire after twenty-seven years’ service
with a full two-thirds of their salary and emoluments. Under the new Act they
cannot receive such a pension until they have served thirty-four years, a very
important consideration, especially for the female members, who are really not able
to face the strain of so many years’ trying work, and at the same time do justice to
themselves and to the work entrusted to them. The Asylums’ Committee of the
Council have advised that, where possible, an addition of such a number of years
to the length of service as would place those who are already on the staff in as
good a position under the new Act as they were under the old county scheme,
should be recommended, as provided for in Section 1, Sub-section 3 of the Act,
but whether the Home Secretary will be equally generous in approving of this
course is quite another matter. The payment of the contributions of all those who
were on the staff of the three asylums at the date when the new Act commences its
operations is a proof of the kind and thoughtful treatment accorded by' the Council
to its officials, who fully appreciate and are grateful for the consideration. Not¬
withstanding these concessions, the fact remains that the position of the Stafford¬
shire Asylum employees of all grades is not improved by the new enactment, but
that, on the contrary, they are placed in a less advantageous position than they
were in at the time of the passing of the Act.

Dr. Christie reports that on account of the lessened pension and the
longer service the great majority of the staff at Stafford have elected to
contract out of the Act, believing that their rights under the former
scheme are assured.

Dr. Spence presses for more cottage accommodation for attendants,
showing that this is not only a morally justifiable demand, but one that
has a decided influence in promoting long service. His married
attendants have an average service of fifteen and a half years, while the
unmarried have only two and three-quarters. Besides, as he points out,
so much more room is set free for patients. Dr. Menzies adverts to the
same need. Some of his attendants receive £\o lodging money, which

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does not nearly meet the rates and rents of their houses. Some of
them have to walk home into Leek, as there is no cottage accommo¬
dation in Cheddleton itself. Apparently plans for some have been
submitted to the Local Government Board and Home Secretary, but
disallowed on the score of cost.

The statistics are carried out fully on the new system in each asylum.
The great differences between these in some matters, which we have
pointed out, still exist, but they cannot be valued rightly unless it is
certain that each asylum is fed, as far as direct admissions are concerned,
by its own defined portion of the county. At Burntwood the admissions
consist almost wholly of acute mania, acute melancholia, epileptic
insanity (of which there appears to be an undue proportion throughout
the county) and general paralysis, these accounting for about 200 out
of the 280 admissions, while stupor, confusional insanity, primary
dementia, the delusional, and volitional varieties are not represented. At
the other asylums it is different, Cheddleton especially supplying several
instances of the last-mentioned forms. Taking all asylums together the
mania cases exceed notably the depressed forms, only Cheddleton
showing a slight tendency the other way. A comparison of the setiology
found in the three asylums does not supply any suggestion of explana¬
tion, the usual predominant factors appearing in much the same
proportions where stated as “ principal.” Alcohol is a shade more
frequent at Burntwood, while syphilis was found more frequently at
Cheddleton, and was associated with a slightly larger proportion of
general paralysis. Occupation certainly shows some difference in the
various areas. Ironwork and its allies are well represented at Stafford
and Burntwood, while miners and pottery people appear in considerable
number at Cheddleton, no less than twenty-four out of 188 admissions
being from the latter calling and its many subdivisions. In all the farm
hand is infrequent, and the general labourer far outnumbers him.

The recovery-rates vary, but not to any great extent, centreing at
Stafford and Burntwood round 30 per cent. At Cheddleton the advantage
of separating direct admissions from others is well shown. The rate
on all admissions is 23 per cent., being undoubtedly degraded by the
fact that more than one-third of the admissions were dumped from the
other asylums. If these are taken away the rate rises to 36 per cent.
The death-rates in all are heavy, being considerably higher than the
average of the counties generally.

One feels, after an inspection of the great mass of carefully recorded
figures, that a skilled collation and analysis of the more interesting and
important points would well repay itself. The strenuous occupations,
more than one of which has its own trade health-risks, could well bear
working out. In this regard perhaps more interesting information could
be got than from an area like London, where the complexities of life
are so great, and where the varieties of work are less sharply cut and
defined.

Suffolk. —Dr. Whitwell makes some general remarks of value on the
subject of the spread of general paralysis. He supplies two excellent
maps, the first showing the distribution of reported cases of the disease
over the whole kingdom, the second showing its distribution over his

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own area. As might be expected, these centre principally round the
large towns, Ipswich and Lowestoft and their vicinity harbouring the
larger proportions. Bury is not so productive. The map rather bears
out notes made in these columns for years past—that the greatest
breeding grounds are large cities certainly, but large cities where
shipping is a principal industry. The exposure of ship men by their
reckless conduct to the incidence of syphilis no doubt has much to do
with this point. He was able to attribute two cases occurring in an
out-of-the-way rural parish to the accidental arrival of strangers.

He devotes some of his space to flouting the lethal chamber and
those who hanker after it. There is a theoretical or philosophic method
of meeting this very silly idea; there is also the practical one, adopted
with success by the writer. The proposer may be asked if he would be
prepared, supposing that the idea had been adopted, to consent to a
beginning being made with his own wife or daughter should the
affliction overtake them. The personal application of a principle
begets sober reflection, and there is no more chance of the insane or
the undesirable being put to death in this country than there was of
Mr. Lowe’s proposal to tax matches being adopted.

Sussex, East .—We adverted last year to the new form of farm
account adopted by the Committee. This year the report contains
both the old form in general use and the new form. It is interesting to
find that under the old form a credit balance of ^781 is proved, while
in the new there is a loss of fibo. Both are true in a sense, the chief
criterion being whether any value is to be assigned to the labour of
patients. We note that one general paralytic was discharged as
recovered, while one systematised and eight non-systematised delu¬
sional cases had the same good fortune.

West Hatn Borough. —Dr. Hunter is able to re-assure his committee
that there is a steady decrease in the occurring insanity of the area.
This fact he deduces from the declining proportion that first admissions
display to the population of the area. These numbered 1176 per
10,000 in 1902, but have progressively decreased to 4^54 per 10,000.
We note that i8'4 per cent, of the asylum population on December 31st
were epileptics.

Dr. Hunter gives a table showing the increase or decrease in weight
during the residence of each individual who recovered. Two females
appear to have lost 6 and 8 lb. respectively, but in all the other 74
males and females there was a gain ranging from 21 lb. to 2 st. 6. lb.
This speaks volumes for the general suitability of the diet chosen.

West Riding , Wakefield .—The result of Dr. Bevan-Lewis’s purgative
treatment of colitis is that in 1908 there was no case on record. In
1903 the first six months yielded forty-six cases with sixteen deaths.
The special treatment then commenced. The last six months of that
year yielded eleven cases and two deaths. Since then the disease has
waned and departed now entirely. The very simplicity and success of
this treatment leads to the hope that similar well-conceived plans may
yet help in the solution of problems, not more complex, which at
present defy treatment.

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The electro-therapeutic department continues to show encouraging
results. Of course the recoveries are chiefly derived from those forms
of insanity which tend to get well under ordinary treatment, and they
seem mostly to be of the confused, stuporose type. But two cases of
acute delirium appear among the cures, accompanying the use of the
sinusoidal bath. As we know, no form of illness, physical or mental,
demands the quicker application of treatment of the right kind ; and it
must be of the right kind, since there is little room for mistake in the
rapid downward progress. The idea is suggested that there must be
something directly active and specific in this form of electricity,
beyond the general idea of indirect benefit from alterative or tonic
action. We note that in the course of the year no less than six cases
of this terrible form were admitted. Turning to the death and recovery
tables we can trace the touch-and-go character of the attacks. We find
five recoveries and two deaths. In a report coming from such a strong
observer as Dr. Lewis one reads with much interest his classification of
the admissions. We observe that in the year under report he has had
to use all the forms given, with the exception of moral imbecility
impulse, and obsession (volitional). Moral insanity, which is so much
neglected by most, provides one male and five females, the insanity of
doubt one female, and alternating insanity one female. Confusional
insanity, stupor, and primary dementia show eight, eight, and twenty-
seven cases respectively, the female sex providing a disproportionate
share of each variety.

Turning to C. 3, showing the forms of insanity on admission of the
recoveries, we find that one female epileptic recovered; two had the
same good fortune with alternating insanity, while three males and ten
females recovered from systematised delusion, and three males and
one female ceased to be morally insane. These facts are worth
remembering by those who are apt to make a prognosis from the name
of the particular disease.

Wiltshire .—The adoption of an economiser for the boiler feed has
led to a saving of over ^60, or more than 16 per cent., in the cost of
coal used. As the capital expenditure involved amounted to ^650 the
investment appears to be lucrative.

Tnere is something to be said on each side of the question raised in
the following paragraph :

(13) There have been at one time or another during the year thirty-seven paying
patients in residence, the charge made varying from 15s. to 20s. per week. All
these patients are persons who, it is understood, if the Committee declined to
receive them as paying patients, would be sent to the asylum as paupers through
the guardians in the ordinary way, and the Committee have continued to adhere
rigorously to the regulation which they some time since laid down in this connec¬
tion not to admit as private patients any who have means sufficient to enable them
to be treated in a private asylum, every application of this kind being subjected to
careful investigation.

A visiting board of guardians left behind them a note :

We agree with a suggestion made by Dr. Bowes that it would be beneficial to
the institution if a separate building could be provided where the most hopeful
cases sent might be treated and kept apart from the worst patients.

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This should strengthen his hands in asking his committee to provide
that which would undoubtedly increase the curative functions of a good
asylum such as his.

We entirely endorse Dr. Bowes’ opinion about the treatment of
persons charged with attempted suicide.

As many as eighty-five had a tendency to suicide, the latter being a High pro¬
portion. In this connection it may be remarked that the administration of the law-
in dealing with cases of attempted suicide appears unsatisfactory and to vary in
different districts. In some instances the attempt at self-destruction is undoubtedly
deliberately made with full knowledge of the nature of the act, but it does not
appear sufficiently recognised that in the majority of cases those who make the
attempt are irresponsible by reason of their state of mind. In the absence of
expert advice great injustice may, and probably is, inadvertently done in com¬
mitting such persons to prison instead of to an asylum where they might receive
the treatment they require.

Some English Registered Hospitals.

Barnwood .—The hospital has had a very successful year both in its
duty to its patients and in finance. The recovery-rate was 50 per cent.,
both sexes having the same rate.: 30 per cent, of its patients were enter¬
tained and cared for at considerably less than the average cost. The
staff likewise benefit from the application of excess of income, for the
scale of remuneration has been increased, and no less a sum than
,£5,000 has been added to the Pension Fund, which now amounts to
.£67,000.

We think that Dr. Soutar takes a very correct position towards the
statistical tables, which are furnished in full. He deprecates their
being read as purporting to give accurate informating about particular
cases ; rather he looks forward to the proper study hereafter by experts
of a large bulk of records.

The study which the compilation of the tables necessitates has, however, its
immediate practical good in that it furnishes the physician, more or less fully,
with a knowledge which enables him to prescribe for the patient who has recovered,
the conditions upon which and the limitations within which he must live if he
would best avoid the risk of another collapse. This education of patients, during
convalescence and afterwards, in the mode of life which offers greatest promise of
security from another attack, is based on an intimate study of the individual and
his environment. But of even the imperfect knowledge thus acquired only
fragments can be presented in our annual statistics, and these, without caution,
may lead to false deductions. Thus, year by year, we record that an inherited
neurotic taint was ascertained in a large proportion of our cases—in 1909, in
45'7 Pe 1 " cent, of the total admissions. When stated in this way, it would seem
that heredity is far and away the most potent factor in the causation of insanity,
but on that conclusion doubt is cast by the reflection that insanity occurs in but a
trifling proportion of those who come from the same so-called “ neurotic” stock.
Gross instances there are in some families of wholesale mental failure, which tells
of the potency of the taint transmitted by physiologically faulty ancestors. But
such instances are relatively rare. Much more common is it to find in succeeding
generations only isolated cases of mental defectives amongst a host of healthy and
vigorous persons. It is clear that in these two classes very different values
appertain to the influence of heredity as a causal factor, and figures which show
the percentage of ascertained insane and neurotic heredity in the total admissions
should be accepted with the reservation which this consideration requires.

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Bethlem .—The task of converting the old iron window-sashes into
wooden, with an increase of light and cheerfulness, is progressing
fast. It strikes one when going round old asylums that the pioneers of
more enlightened treatment missed one great opportunity of differen¬
tiating between asylum and prison. Economy could hardly have
determined the retention of such depressing fittings.

The need to vacate wards for the alteration has somewhat restricted
the volume of insanity treated. The recovery-rate has been high, as
it was 47‘i6 for the certified patients, the females having a shade the
best return. It is somewhat striking that the same rate for the voluntary
patients was ten points lower, the females among them having a con¬
siderably lower rate than the males. It appears from these figures that
early treatment does not always lead to the best results, though probably
a better return would be shown if all the voluntary cases had stopped
for the time required to make a good recovery. The death-rate among
the latter class of patient happens to be slightly higher than that of the
certified, but this might be a mere accident independent of the mental
disease. Nine general paralytics were admitted, on seven of whom
definite syphilitic evidence was found. They were all males. We note
that no stupor cases came in, while confusion and primary dementia
were well represented, especially the first named. Hereditary influence
was found in a little over one-third of the entries. This proportion
was slightly exceeded by prolonged mental stress. Alcohol appeared
in only six of 164 admissions, while syphilis accounted for seven and
influenza for eight cases. We note a recovery from moral imbecility
and also one from general paralysis.

The Coppice , Nottingham .—The paucity of male patients is noted
here, as in many institutions admitting private patients only. For
some years past the Commissioners’ Report has shown over all England
a lessening admission-rate of males in relation to that of females of the
private class, while in respect of pauper admissions there is but little
variation. As the Commissioners say in their entry, it is a cause for
wonder that there should be any vacant accommodation, seeing the
substantial comforts given for so low a rate as an average of jQ2 2s. 6 d.
per week. Low as it is, not more than 10 per cent, of the patients can
meet the average cost. Interest from accumulated benefactions enable
this benevolence to be practised.

The Retreat , York. —Dr. Bedford Pierce complains, not without
reason, at the long duration of disease on admission.

With reference to the duration of the mental disorder before admission, it was
found that if the chronic cases be excluded, and all who had been ill more than
two years, and also those who had had previous attacks, the average length of time
that the patients had been ill previous to their reception was six months. It is
difficult to avoid the conclusion that a great deal of this time was wasted, and that
had the patients been placed under care earlier the results would have been more
satisfactory.

We note that among his seventeen recoveries fourteen had been ill
before admission. He was able to discharge as recovered one female
who had laboured under systematised delusional insanity and one male

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748 EPITOME. [Oct.,

with obsession. Heredity, either insane or epileptic, was found in half
the cases, the toxins being quite slightly represented. Recent melan¬
cholia was by far the most prevalent form of insanity admitted, primary-
dementia and confusion following. The more excited forms were but
few. There was no death among the males, this being a record.

The Commissioners repeat their just protest against the barbarous
practice of patients being taken for their interviews with the judicial
authority to the police-station. We repeat, too, that those who are
responsible for the practice fall away from that humanity to the insane
which was a marked attribute of York of old.

Some Scottish District Asylums.

Aberdeen , Kingseat .—We note that in this asylum the Plenum system
was tried and found wanting, and has been replaced by radiators and
natural ventilation. It is found that the change has been attended by
saving of cost as well as by sanitary improvement.

The last of the closed villas has now been opened, the change neces¬
sitating an addition of four nurses to the staff. Dr. Alexander presses
for new admission blocks in order to remove the maniacal and depressed
from other patients, for their treatment on hospital lines. As we have
pointed out before, this is a logical and necessary element in perfected
segregation, but it has its dangers. The aggregation of excited cases is
inconvenient and sacrifices to some extent the hospital principle,
whereas abundant experience shows the benefit of all curable cases being
taken into one building and treated on hospital lines. The dilution of
the excited cases tends to reduce excitement, while simple arrangements
can be made for any cases of inordinate or irreducible excitement being
dealt with where they can do little harm to others.

Ayr. —This, the first report issued by Dr. M’Crae, is a readable and
instructive document. Without going so far as he does in deprecating
the importance of ferreting out heredity, we must say that there is much
sense in what he writes about the factor.

As the result of inquiry into the previous history of each case, a hereditary pre¬
disposition to insanity and nervous diseases could be traced in sixty-four cases, or
41 per cent., which closely corresponds with last year's statement. It is commonly
held that, given adequate means for inquiry, all cases could be shown to have an
insane ancestry. But what individual among the general population would not
only too readily detect a peculiarity in some reputable forbear, if he believed it to
be to his advantage to do so ? It is to be feared that the popular awe and dread of
this as yet mysterious influence goes a long way to breed despondency and alarm,
and even despair, in the minds of many earnest and worthy persons, who may lose
heart in the battle of life. I desire to emphasise this point because it is to heredity
that the origin of disease is too apt solely to be ascribed, and too little attention is
paid to environment, which after all is an ever-increasing grand total of accidents,
to which all of us are continuously subjected. A fuller study of our surroundings,
which are tangible, is more likely to help us towards an elucidation of the causation
of mental diseases than a fatalistic belief in the mysteries of heredity. Questions
of heredity require so many generations to produce material sufficient to establish
evidence, that can only be profitably studied by special investigators in lower forms
of life, and applied by analogy to the case of man. The asylum physician is better
employed in using the material he has to hand in methods of clinical research
(which is essentially approaching the subject from the environmental aspect), than

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by attempting to unravel questions of heredity as concealed in the very unreliable
data mostly furnished by the relatives of insane patients.

Gartloch. —Dr. Parker gives, as usual, some interesting tabular
information bearing on his population. This must be, unfortunately,
somewhat discounted by the fact that many cases are treated at Duke
Street, and thus do not reach him. But, of those admitted by him, he
finds that the period of life from thirty to fifty supplies a greater pro¬
portion than the antecedent or subsequent groups of ages. He also
continues to find increasing support of former experience that heredity of
alcohol tends to early breakdown. Of the 112 cases in which he found
a complete history, 78 per cent, of those who became insane before and
at the time of adolescence (fixed at twenty-six years of age) had
alcoholic heredity, while this was associated with only 40 per cent.
of those of a greater age. Dr. Robert Jones found exactly the same
facts. Of course these figures, which have become reliable by their
long accumulation, cannot be taken to controvert Dr. Karl Pearson’s
findings as to the heredity of alcohol. They only go as far as establish¬
ing that among those who have an alcoholic heredity the predisposition
is to break down early. It would seem, at least, that if alcohol has no
direct deleterious effect on offspring, it must have some share in pro¬
ducing an inborn condition of non-resistance to other setiological factors.

Dr. Parker points out, again, the bad effects of boarding out on the
residue of asylum population, and suggests that these might be met by
boarding out some of the troublesome but not dangerous cases, under
a carefully prepared system of grouping, with medical supervision.
He thinks that the freer life under these conditions would tend to
reduce troublesomeness, and seeing that experience goes to show that
lunacy tends to adapt itself to environment, we should think that such
an idea is worth trying if a suitable locality can be found.

A Scottish Chartered Asylum.

Royal Edinburgh Asylum. —We turn with much interest to this
report, as no doubt will be the case with many others, lay and medical,
who have been accustomed to study it in a long series of years as the
exposition by skilled observers of interesting and important points
occurring in the practice of the year. We are glad to see that the
managers are able to report a continuance of the good and successful
fight against the common enemy. Dr. Robertson’s own report breathes
progress in every part; it is quite certain that he will take every
advantage of his present great opportunities to give full scope to those
original ideas which mark his attitude to the insane. One would have
wished to be able to lay down his report without any feeling but that
of complete satisfaction. This, however, cannot be the case, for in
pointing out aims which are undoubtedly right, and have been endorsed
by the practice of all his compeers, he has been indiscreet in classing
as undesirable some practices which have been shown to be incon-
trovertibly sound, on grounds of reason as well as of emotion, and
only to be inapplicable when wrongly applied. It is in no carping spirit
that we make this criticism ; we desire only to speak in the interests of
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all those who have, like himself, to face most anxious responsibility, those
who may well to some extent feel themselves condemned in the sight
of the public.

Asylum being hospitalised .—Under the supervision and direction of these new
officials, trained, as almost all of them have been, in hospitals, the work done by the
staff has naturally assumed features of a more hospital character. This is our
aim nowadays, and nothing has aided us more in attaining this object than the
introduction into asylums of hospital-trained nurses. My own policy for many
years has been openly to put under suspicion every practice that is in operation
which is peculiar to asylums. If I find I can do without it I abolish it, and if I
find it cannot be done without, but that it can be replaced by another method of a
hospital character, then I introduce that. Subjected to this stern criticism it is
surprising how many anachronisms and unmedical traditions have been exposed,
and with a policy of hospitalisation so definite and active, progress towards the
goal we strive for is a comparatively simple matter.

The disuse of padded rooms .—As an instance of characteristic asylum practices
which have been discarded, the disuse of padded rooms and of the practice of locking
up patients in single rooms by day may be mentioned. Strange as it may seem,
the padded room, of which we are now beginning to feel ashamed, was apparently
invented about sixty-six years ago by Conolly, the great apostle of the non-
restraint and the humane systems of treatment for the insane. It is quaintly
described by him in his sixth report as “a room of which the floor is a bed and
the four walls are padded.” In his day its employment was without doubt a step in
advance, as it was a substitute for the less humane methods of mechanical restraint
by strait jackets and straps which he had discarded, and was a sheer necessity.
Owing to the ill-treatment which his patients had previously received at the hands
of their attendants, many were revengeful and aggressive, and considerable risk
was run when restraints were removed for the first time. For ten years the system
of non-restraint was not officially recommended by the authorities because of this
danger. At that time the padded room was no doubt needed, and its use was to
be commended, but now that the art of tactful management is practised, and
patients from the first moment they enter the wards are treated with consideration
and kindness, it has become practically unnecessary. Cases of furious or raging
mania, such as were described in those days, are never seen now, because they
were goaded into being by the vile treatment they received, whereas skilful treat¬
ment has a tranquillising effect. We now employ a very much larger staff than
was done in those days—probably two or three times as great—and we have a
large night staff, while they had none. Our attendants and nurses are not only
more numerous, but they are carefully trained and highly skilled, and they are of
a more intelligent and respectable class. Conolly writes of the nursing staff of
that day that they "were worse dressed and wilder looking than the generality of
the patients.” With a staff such as we now have and good supervision, we rely on
constant personal care and attention by night and day to tranquillise the excited.
We are glad to see these symbols of the past disappear, not so much on acconnt
of any direct harm they actually did to the patients when not abused, but because
their influence on the morale of the nursing staff was not elevating.

Is it in accordance with medical science to say that cases of furious
or raging mania are never seen now? Let us take the admissions into
Morningside itself during the year (Table XI) : three cases of acute
delirious insanity in each sex are shown, and among the recoveries one
male, and among the deaths one female—the latter should read as two
females if “exhaustion from delirious insanity,” assigned in the death-
table (Table V), may be taken to refer to these cases. There is an
obvious inaccuracy in the figures of Table XI. It may be that these
cases are to be excluded by the saving clause of “ such as were described
in those days.” But even if this is so, can we exclude the cases of
furibund epilepsy and of alcoholic illusions which are liable at any time

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to come under our notice ? Then what is to be gained by preaching
that such cases can be manufactured by forms of treatment that are dead
and gone long ago? We all know that any case may be spoilt by
wrong treatment, but as such intra-asylum treatment is now impossible,
is it right to suggest that failure to tranquillise by skilful treatment
points this way ? We entirely object to the terms in which Dr.
Robertson has spoken of (a) the padded room and ( 6 ) seclusion. With
regard to the former, he seems to have completely forgotten that second
purpose for which the padded room is now generally used—the care of
the weak and feeble, whose tendency to fall about and injure them¬
selves has been so mercifully obviated. And as to the latter, surely the
occasional use is dictated by consideration of what is proper for the
patient, for the other patients, and for the staff itself. For the patient
we know that continued exposure to the operation of external stimuli in
a state of excitement is prejudicial, and that its bad influence can be
modified and often removed by withdrawal of the patient from them,
by his being placed by himself in an unlocked room, and that therefore
it is called for as a medical procedure. If, as often happens, the
patient cannot be got to see this for himself, and continues to expose
himself, common sense demands that the treatment adopted shall be
made efficient by turning the lock on him. We need say nothing about
the good of the other patients ; environment is too important an element
nowadays to be neglected. Why should a sick patient, sent to an
asylum for tranquillisation, be distracted and injured by preventable
noise and alarm ? As to the staff, there can be no more demoralising
agent than continued hopeless waiting for better things. Nurses are
but mortal, they themselves are liable to mental injury, they work in
bad environment, and should be saved that continued mental stress
which ranks highest among recognised aetiological factors, outside
heredity and alcohol. It is not the influence of such “ discarded
practices ” as padded room and seclusion that is bad for their Ttioralc ;
it is the wrong spirit in which they are used. It is the fatal ease of
their use that engenders a wrong frame of mind. The same arguments
apply precisely to the bed-treatment of acute insanity, which Dr.
Robertson uses with approved effect. At one time this was decried by
many, officials and others, as leading to a lazy, trouble-saving attitude,
but now it is freely adopted as the best of all treatments when used
remedially. So far from the morale of the nursing staff being injured by
these practices, we should imagine that it would be fortified by their use
when it is clearly seen that they are adopted by a strong man who is
known to be utterly opposed to their improper use. Nothing could
better demonstrate serious but determined consideration of the patient’s
needs on his part. The present writer had the advantage many years
ago of being told by a Commissioner, who had acquired his physicianly
frame of mind in a general hospital and not in an asylum, that it is
most unphysicianly to neglect the use of any form of treatment, such as
restraint if it was called for, however distasteful it might be. When
reading that one patient was secluded at Morningside “ on account of
maniacal and dangerous excitement,” we cannot help feeling that Dr.
Robertson himself has recognised the justice of this view.

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Part IV.—Notes and News.

THE MEDICO-PSYCHOLOGICAL ASSOCIATION OF GREAT
BRITAIN AND IRELAND.

The sixty-ninth annual meeting of the Association was held in Edinburgh, at
the Royal College of Physicians and Morningside Asylum, on Thursday and
Friday, July 21st and 22nd, 1910.

The retiring President, Professor W. Bevan Lewis, M.Sc., occupied the chair at
the commencement of the proceedings.

Present: Drs. T. S. Adair, H. Alexander, J. Bain, L. D. H. Baugh, D. Blair, C. H
Bond, D. Bower, A. H. Boyle, J. F. Briscoe, L. C. Bruce, R. B. Campbell,
J. Carswell, J. Chambers, S. Coupland, A. R. Douglas, T. Drapes, C. Easterbrook,
T. A. Elkins, J. J. Fitzgerald, J. W. Geddes, W. Gilmour, C. H. G. Gostwyck,
W. Graham, R. D. Hotchkis, J. C. Johnstone, Robert Jones, W. S. Kay, J. Keay,
N. T. Kerr, T. W. McDowall, T. C. Mackenzie, G. J. Macphail, H. C. Marr, C.
Mercier, J. Middlemass, H. M. Mills, H. Morton, G. E. Mould, W. Muirhead,
Hayes Newington, L. R. Oswald, W. A. Parker, Bedford Pierce, W. Reid, G. M.
Robertson, W. Ford Robertson, J. Rorie, G. H. Savage, C. J. Shaw, R. Percy
Smith, R. C. Stewart, A. Stoddart, J. C. Sturrock, A. L. Taylor, D. G. Thomson,
T. Seymour Tuke, A. R. Urquhart, and D. Yellowlees.

Visitors : Drs. Chas. Clarke and H. H. Drysdale (Cleveland, U.S.A.)

Council attendance : There had been present at the previous Council meeting:
Drs. Adair, Bevan-Lewis, Bond, R. B. Campbell, Chambers, J. J. Fitzgerald,
Graham, Hotchkis, Robert Jones, J. Macpherson, Mercier, Miller, Mills, Mould,
Hayes Newington, Oswald, Percy Smith, Stoddart and Urquhart.

The following gentlemen intimated regret at their inability to be present -. Drs.
Benedikt, Marriott Cooke, Kraepelin, Morel, Needham, Toulouse, Turnbull and
many others.

Minutes.

The President reminded members that the minutes of the last meeting had
been published, and it was usual to take them as read.

The minutes were taken as read, and were signed.

Next came the election of officers and nominated members of the Council.
Voting papers for this purpose had been distributed, and some had been received
by post. The latter would be added to the others. He appointed Dr. Stoddart,
Dr. Thompson, and Dr. Bedford Pierce as scrutineers. After the ballot had been
taken the President announced that the nominations had been accepted.

Dr. Needham's Illness.

The President said he would like to refer to the serious illness of one of the
Commissioners in Lunacy, Dr. Needham, who was lying at a nursing home at
Leeds. He said he was sure none of those present would wish to allow the
occasion to pass without voicing sympathy and condolence with him. Members
knew Dr. Needham’s genial personality so well, and his interest in all lunacy
administration, that it would be a graceful act to express to him, through the
General Secretary, a sympathetic message.

Agreed.

The President said the next item was the appointment of Examiners for the
ensuing year. They had been already nominated by the Educational Committee
and approved by the Council.

Agreed.

Appointment of Auditor.

The President pointed out that this year Dr. Craig retired as auditor.

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1910 .] NOTES AND NEWS. 75 3

Dr. Seymour Tuke proposed Dr. Robert Steen, of Stone Asylum, as second
auditor.

This was seconded and agreed to.

Parliamentary Committee.

The President said the list of nominations for this Committee was already
before the meeting, and it had been approved by the Council. It was in the pro¬
vince of members to note any absent name, or to add a name.

Dr. Bower said he felt some diffidence in adding a name to an already large
committee, but as the subject of the feeble-minded would be before the Association,
he would like to add the name of Dr. R. L. Langdon Down.

Dr. Seymour Tuke seconded the motion, and it was carried.

Educational Committee.

The President said the Educational Committee was a numerous body, but that
was fully explained. All the examiners were included, and rightly so.

Dr. Bond said he had received a letter from Dr. James Rorie intimating that he
would like to rejoin the Educational Committee. He (Dr. Bond) had pleasure in
proposing it.

It was duly seconded, and approved.

Dr. Yellowlees expressed the desire to withdraw his name, as his sight would
not now serve him well. He would like it withdrawn from both committees.

The President said he did not think that request would be at all readily
acceded to. Members would like to see Dr. Yellowlees’ name on the committee,
even though he might not be present at its meetings.

Dr. Yellowlees said it was very good of the President to say that, but he did
not feel he was of any use on either of the committees.

The President said the Association wanted Dr. Yellowlees’ name on the
committee, and he thought the meeting would be unanimous in leaving that name
on the list.

Library Committee.

The President said the list of the Library Committee nominations was before
the members, and he thought it was a highly representative committee in every
way.

Agreed to.

Report ok the Council.

The General Secretary read the report of the Council to the annual meeting,
and moved its adoption as follows :

The number of members—ordinary, honorary, and corresponding—on December
31st, 1909, was 707, to which were added in the list printed for January 1st, 1910,
the names of fifteen ordinary members elected during the year 1909, making a
total membership of 722. This is an increase of twenty-six as compared with the
membership of the previous year, and as contrasted with eleven, which is the
average yearly increase during the last ten years.

The following table shows the membership during the past decade :

Members.

1900.

1901.

1902.

1903.

1904.

1905 .

1906.

1907.

190S.

1909.

Ordinary

568

580

586

597

620

641

638

645

652

673

Honorary

3 <>

Corresponding

I I

T otal

616

628

6 35

645

670

688

685

690

696

722

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From this it will be seen that in the ordinary membership there has been a net
increase of twenty-one (which has not been exceeded since 1903), while the
honorary and corresponding memberships have increased respectively by three
and two.

The number of new ordinary members elected and registered has again been
exceedingly satisfactory, namely, fifty. In addition to these, three were added to
the register with date 1908, and the name of one former member was replaced.
This is quite a notable influx, speaking well for the position which the Association
has attained for itself, and justifying its many spheres of influence.

The resignations of eighteen ordinary members were received and the names of
seven others were removed.

The Council regrets to have to chronicle the deaths of eight ordinary members.
Their names have already appeared in the obituary column of the January number
of the Journal. Among them are the late Dr. Henry Stilwell, who had been a
member forty-seven years, and the late Dr. William Ireland, a member of nearly
forty years’ standing.

The usual quarterly meetings were held in February, May, and November.
That in February was, by the courtesy of Dr. Rothsay Stewart and the Committee
of Visitors, held at the Narborough new asylum for the counties of Leicestershire
and Rutland. The thanks of the Association are due to Dr. Rothsay Stewart for
his genial hospitality.

Similar thanks are due to Prof. Bevan-Lewis in connection with a most success¬
ful annual meeting, which was held in Leeds and at the West Riding Asylum.

The attendance at all the meetings has been phenomenally good, and the
standard of papers has been such as to excite interest and valuable discussion.

Eleven Divisional meetings have been held, at which the attendance has been
satisfactory. The membership of the Divisions, as reported to the May Council

meeting this year, was :

South-Eastern.249

Northern and Midland ....... 150

South-Western.103

Scottish.SS

Irish.59

The Council has had under consideration a proposal for giving Divisional
prizes for best papers read by assistant medical officers, with a view to encouraging
original work among them.

The Criminal Procedure Committee has not found it necessary to meet.

The British Committee of the proposed International Institute for the Study of
the Causes of Insanity has continued to meet, and presents a report. A summary
of its history and the present position of matters in connection with it is communi¬
cated in the current number of the Journal.

A Preliminary Committee upon the Medical Inspection of School Children was
formed in May. It has held two meetings, and presents a report.

The Educational Committee, under the chairmanship of Dr. Mercier, has had
an unusually busy year—mainly in the relation to the new regulations for the
nursing certificate. In addition, it has been actively urging forward, through its
Sub-committee, the scheme for the granting of the proposed degrees and diplomas
in psychological medicine by the universities and other qualifying bodies.

The Parliamentary Committee, under the chairmanship of Dr. Bower, has also
overtaken much important work, largely in connection with the Asylum Officers'
Superannuation Act of 1909, which came into force on April 1st this year. A
“ Commemoration Banquet ” was held in London on December 20th last to cele¬
brate the passing of this Act, at which the special guests were the Right Hon.
Lord Monk Bretton, C.B., Sir William Collins, M.D., M.P., and Dr. Shuitleworth.

A Joint Advisory Committee was formed, partly of members of this Association
and partly of members of the Asylum Workers’ Association, to consider questions
in reference to the working of the Act as they might arise from time to time.
The Committee has met on many occasions, and it presented a report at the
February meeting. It has also since then had several meetings for the transaction
of important business. Mr. H. F. Keene, Clerk of the London Asylums Com¬
mittee, has been good enough to attend its meetings and to assist it materially. It
is now taking active steps in certain matters brought before it.

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1910.] NOTES AND NEWS. 755

The Journal, under the same ex perienced editorship, continues to be much appre¬
ciated, and its circulation is satisfactory.

The Library Committee presents a report indicative of much activity on the
part of its members during the year, and embodying suggestions which are likely
to be followed by increased use of the Library.

The proceedings of the Association have on each occasion been presided over
by Prof. Bevan-Lewis, who has worthily occupied the Presidential chair with
dignity and courtesy.

The finances of the Association, in the same watchful guardianship as hereto¬
fore, continue in an eminently sound condition, and the members are indebted to
the Treasurer for a valuable report upon the matter presented at Wakefield.

The entries for the nursing certificate during the past year have numbered
nearly 1,000, being about the same number as in the preceding year. The
Registrar’s duties—always heavy—are likely to be considerably augmented by the
coming into operation of the new nursing regulations. To him, to the Divisional
Secretaries, and other officers, who so ungrudgingly bestow so much of their time
to the duties of their offices, the hearty thanks of the Association are due.

In concluding this report, the Council wishes to place on record its high
appreciation of the valuable services rendered to the Association by its Hon.
General Secretary, Dr. C. Hubert Bond, during the past year. The Council is
well aware of the increasing burdens placed upon the shoulders of the General
Secretary, and expresses its heartiest thanks to Dr. Bond for the way in which he
has carried out these arduous duties.

Dr. Percy Smith seconded, and the report was adopted.

Educational Committee.

Dr. Stoddart read the report of the Educational Committee, and moved its
adoption as follows :

During the past year seven meetings of the Educational Committee have been
held, three extra meetings having been necessary in order to get through the
new nursing regulations.

The Registrar reports that 183 and 786 candidates presented themselves at the
November and May examinations respectively; m passed in November and 461 in
May.

The work of the Sub-committee appointed to revise the regulations for the
training and examination of nurses is now complete, and the new regulations and
syllabus have been passed by this committee and by the Association. The new
rules for the conduct of the examination in nursing have been duly considered and
have received the sanction of the Council.

A sub-committee has prepared a scheme for the teaching of psychiatry and
allied subjects, which has passed the Educational Committee and been presented
to the Universities and other teaching and examining bodies, with a petition that
they may adopt the scheme and grant diplomas in mental disease. The scheme
is now under consideration by the Universities and other teaching and examining
bodies.

C. Mercier (Chairman).

W. H. B. Stoddart (Hon. Secretary).

A member asked whether it would be in order for the meeting to hear the
report by Dr. Bedford Pierce on behalf of the examiners. After some discussion
it was decided not to read this report. In accordance with a recommendation by
the Council, it will be printed and sent to all asylum medical superintendents in
the United Kingdom.

Dr. Bedford Pierce said the rules of the conduct of the examination were
settled, yet the report said that those rules were under consideration. He did not
know whether the report included what took place on the preceding day.

Dr. Stoddart said the report was prepared for circulation prior to yesterday’s
meeting, and he did not know whether he ought to include in it the previous day’s
proceedings.

The General Secretary said it was usual in reading it to incorporate any
important work overtaken in the previous day's committee meeting.

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756 NOTES AND NEWS. [Oct,

Dr. Stoddart said he would alter his report accordingly.

Dr. MaCPHAIL said he rose to make a point about the rules concerning the
conduct of the examination. There was considerable ambiguity as to which
members of the staff were eligible for certain examinations. He raised the point
at the meeting of the Educational Committee, but it was not thought sufficiently
important. But he would like now, in general meeting, to move, that in order to
avoid ambiguity in the matter an instruction be that the old regulations be opera¬
tive for nurses and attendants who entered asylum service prior to November 1st,
1909, provided they enter without delay.

Dr. Miller seconded.

Dr. Stoddart said he thought the resolution was out of order. He regretted
that what he had with him was only a draft copy, and the rules were passed at the
adjourned meeting last year.

Dr. Urquhart said the record showed that Dr. Mercier's version was passed
that after May, 1911, no candidates should be able to present themselves under
the old rule.

Dr. Macphail said that was the whole point of his motion, that the rules were
passed into law on November 1st, 1909, and one had no right to make it retro¬
spective, and that persons who commenced their studies before then were eligible
under the old rules. He wanted a distinct ruling by the Association on the point
as to whether persons who had commenced their studies before November, 1909,
were not eligible under the old regulations.

The President said he thought that was accepted at the meeting. But pro¬
bably Dr. Stoddart would be in possession of the particulars.

Dr. Mercier said there was no doubt it was passed in the sense in which Dr.
Stoddart understood it. The object of Dr. Macphail’s motion was to rescind that
resolution of the Association and substitute another. It had been thought on
further consideration that it would produce some injustice upon attendants who
had entered the service of the asylums under the old regulations, and in the belief
that they would be examined under the old regulations if they were now compelled
to submit to the new regulations. Whether that was a matter which the Associa¬
tion ought to take into consideration, whether attendants who had entered the
service and had had opportunities and time to pass under the old regulations,
should not be compelled, now that they had neglected that opportunity, to take
the diploma under the new regulations alone, was a matter for the consideration
of the Association. But it did not appear that the regulation as it now existed
would be retrospective to that extent, but that attendants who entered in the belief
and on the understanding that they would be examined under the regulations as
they then existed, would have a new set of regulations imposed upon them ; and it
was to provide that all those entered under those conditions would be examined
as if the new regulations had not taken place, that Dr. Macphail’s resolution was
proposed. He would not wish the Association to rescind such a deliberate opinion
which it arrived at, were it not that the amendment was supported by the Registrar,
who was more experienced in those matters, and whose opinion on them was more
entitled to weight than that of any other member of the Association. As the
Registrar had seconded the resolution he would withdraw any opposition which
he otherwise might feel.

Dr. Urquhart asked for the decisive date, and if it was in the report by Dr.
Stoddart.

Dr. Stoddart said that after May, 1911, no candidates will be able to present
themselves under the old rule. In the rules themselves were the words, “The
first preliminary examination will be held on the first Monday in November, and
the first final examination under the new regulations will be held on the second
Monday of November, 1911.” Therefore there would be no single examination in
November, 1911.

Dr. Mercier said there was another matter of very great importance which arose,
and to which, as soon as the present matter was disposed of, he would like to draw
attention.

The President said it was advisable to point out, as Dr. Mercier alluded to it,
that rescinding any resolution like this would be out of order unless due notice
were given. He read the rule covering such matters. He then put the resolution
as follows : “ That all nurses and attendants who entered the asylum services prior

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PRINCETON UNIVERSITY

NOTES AND NEWS.

I9IO.]

757

to November 1st, 1909, be eligible to enter for the nursing examination under the
old regulations.”

Dr. Mills said that left it open for the attendant who entered before 1909 to
present himself or herself at any time for the next thirty years, and they could
demand to be examined under the old regulations. He was with Dr. Macphail in
trying to get a slight extension, but was opposed to extending the time indefinitely,
as the resolution did.

Dr. Macphail said he was prepared to alter it to a limit of two years. He did
not want to make it indefinite. He would be agreeable to putting in “Up till
1912,” or any words which would have that effect.

Dr. Percy Smith said he thought Dr. Macphail meant that after two years
candidates who had not availed themselves of the privilege should no longer be
able to do so.

The President said he understood that was what was meant.

The resolution was read as follows :

“ That all nurses and attendants who entered the Asylum Service prior to
November 1st, 1909, be eligible to enter for the Nursing Examination under the
old regulations, provided they present themselves for examination on or before
November, 1912.”

The resolution thus amended was carried.

Dr. Merciek said there was another matter in connection with the regulations
which the meeting might consider—a very important one indeed. In the report of
the meeting at which those regulations were adopted, Clauses 4 to 14 inclusive
were passed without comment. Among those was Clause it, which provided that a
nurse should not present herself or himself for the preliminary examination who had
not attained the age of twenty-one. What was in the original draft was that it was
the final examination at which the nurse must have attained the age of twenty-one
and not at the preliminary. If a nurse must have attained twenty-one years of age
at the preliminary examination, that would certainly reduce the number of candi¬
dates at the preliminary examination very largely indeed, and it would postpone
the attaining of the diploma until the age, in many cases, of twenty-three or twenty-
four. How and when the alteration took place he did not know, but it appeared in
the printed draft in one form, and in the resolutions which were passed by the
Association in another form, and yet it did not appear by the report that any
alteration was made by the Association. It might be a printers’ mistake, but it
was desirable that the Annual Meeting should regularise it. Therefore he proposed
that the age of the candidates should be not less than twenty-one years when he
presented himself for the final examination, instead of that being the age when he
sat for the preliminary examination, as it now appeared in the regulations.

Dr. Stoddart seconded.

The President said he thought the resolution would be supported by the feeling
of the meeting.

Carried.

The Treasurer’s Report.

The Treasurer (Dr. Hayes Newington) said his report was in the hands of
the members, and there was very little he need say in addition. The auditors
visited him the other day and found everything correct, as they would tell the
meeting. There was a large amount under the heading of “ miscellaneous,” but it
was chiefly made up of .£78 in regard to pensions, i.e., the half share of legal
expenses, shared with the Asylum Workers’ Asssociation, and expended in the
Commemoration Dinner, at which the Association entertained the people to whom
they were so grateful for aid in Parliament and outside. There was a payment of
^58 for the index, entertainment of guests at the Annual Dinner and the provincial
dinner, and a considerable amount of committee printing. As he said last year at
Wakefield, the Association could not grudge any amount of money spent on com¬
mittees doing the work of the Association. There had been a great advance of late
years in accurately reporting the work of the meetings for future use. He moved
the adoption of the report as follows :

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RINCETON UN

II. IIAVICH NP.WINOTON, T«»*iin«o.

1910.] NOTES AND NEWS. 759

GASKELL MEMORIAL FUND.

1909.

£■

July 22nd, Dr. Devine

July 1st, Balance

... 44

(prize) ...

Dividends

Dr. Grills

Oct. 2nd „

(additional

1910.

prize)

»5

Jan. 2nd „

Aug. 10th, Medal

April 2nd ,,

Examiners’

Fees

Expenses

1910.

June 30th, Balance

£<£_

£ 99 _

H. HAYES NEWINGTON, Treasurer.

Dr. Clouston seconded. In doing so he said he had often been a critic, even
of the Treasurer; but he had no criticism to offer this year in regard to the
accounts.

The President said he was sure all present would agree with what Dr. Clouston
had said.

The report was adopted.

The Editors’ Report.

Dr. Urquhart read the editors’ report, and proposed its adoption as follows:

The past year has brought no special change in the affairs of the Journal. The
volume and quality of the original communications have been well maintained, and
there has been some increase in those of a clinical character from the junior members
of the Association. It is very desirable that these should be still further extended.
We are indebted to Dr. Clouston for having initiated the publication of 11 Clinical
Notes.”

The cost of the Journal was considerably below the average of past years,
the net cost, after deducting sales and receipts from advertisements, being about
,£243. The cost, however, fluctuates from year to year, but the average remains
much the same as ten or fifteen years since, when the number of copies printed
was considerably less. The advertisements still yield a comparatively small sum,
and it is very desirable that further efforts should be made to remedy this.

The difficulty in connection with the surplus or reserve copies of the Journal
alluded to in last year’s report has been met. The Librarian has found additional
storage whereby the Library has been relieved, and Dr. Bower has consented to
continue the storage of those which are already in his care. The thanks of the
editors and of the Association are due to Dr. Bower for the care and trouble that
he has taken in this matter for many years past, and specially in selecting and
forwarding such copies as are purchased" from time to time.

The thanks of the editors are also due to Dr. Lord for his able assistance
during the past year, as well as to the numerous collaborators who assist him in
the production of the Epitome.

(Signed) H. Rayner.

A. R. Urquhart.

James Chambers.

Dr. Stoddart seconded, and it was adopted.

Parliamentary Committee.

Dr. Bower moved the adoption of the Parliamentary Committee’s report,
which all the members, he said, had seen. It had been learned from the report of the
Council that an Advisory Committee to help to elucidate the difficult points in the

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760 NOTES AND NEWS. [Oct,

Act had been appointed, of which Dr. Hayes Newington had been appointed
Chairman. Perhaps Dr. Newington would like to say a few words as to what had
been done, and what was likely to be done in the matter. He moved that the
report be adopted as follows :

Report for the Year 1909-1910.

The Committee has met six times and has been chiefly occupied with forwarding
the passage of the Asylum Officers’ Superannuation Bill, and they are glad now to
be able to state that the hope, expressed in their last annual report, that it would
become law, has been realised.

Although the Committee are aware that the Act as it stands does not embody
all that they desire, they felt it their duty on November 23rd to recommend the
Council of the Association to accept the Bill as it then stood, as they felt further
attempts at amendments might imperil the whole Bill.

The Registration of Nurses Bill has made but little progress, and it is being
carefully watched so as to safeguard the interests of mental nurses, and secure
proper representation on any Nursing Council for the Association.

{Signed) David Bower, Chairman.

June 10 th, 1910. H. Wolseley-Lewis, Secretary.

Dr. Stoddakt seconded.

Dr. Hayes Newington said the Advisory Committee had met several times,
and was still holding meetings. In attempting to facilitate a right interpretation
of the Act as far as could be done at first, it was evident that a considerable
amount of opposition had to be encountered, which chiefly arose from a meeting
called by the Commissioners in Lunacy of England, who asked the County
Councils’ Association and a representative of the Home Office and of the Local
Government Board, besides the Association and the Asylum Workers' Association.
There was a long discussion, which lasted a good part of the morning and into the
afternoon, but they did not get very far. They asked for a definition of some
views uttered by the Lunacy Commissioners on the question of classification, but
they were not prepared to put them into writing at the time. But since then they
had been published by the County Councils Association, and it had to be
recognised that in the matter of liberal dealing with the discretion given by the
Act under the heading of “ classification,” the Association had to contend with that
body as a very powerful enemy. Directly they saw the terms of the circular they
did the best they could by issuing another, and found that some good had
thereby been done where doubt existed, though in some places the County
Council’s circular had done some harm, and in some cases, even after the Visiting
Committee had framed a fairly liberal scale, the County Council’s letter had
arrived and had had a considerable effect on the Committee, so that they revised
the matter to the disadvantage of the Staff. It was believed by the Joint Advisory
Committee that the Commissioners in Lunacy, in expressing the opinions which were
attributed to them—it could not be definitely said they had uttered them—were not
giving the right interpretation of the Act. Counsel’s opinion had been taken,
from that eminent counsel, Mr. Macmorran, on the question of classification, and
that opinion supported the views of the Committee. It was certain that the
circulars sent out by the Committee had done some good. There was still much
possibility of harm, and therefore Dr. Shuttleworth was working practically night
and day, helped by the kindness of Sir W. J. Collins, with whom he had had several
interviews. It had been hoped to send a deputation to the Home Secretary, but as
he had refused to receive one from the County Councils Association, it was
concluded he would not receive one from this Association. But they had every
hope of being able to get his sympathy in the matter. He had seen that last night
Sir William Collins was going to ask a question of the Home Secretary in the
House, and that would raise the whole point. He, Dr. Newington, had not yet
been able to see whether that had been done. At any rate, the matter was still in
the active stage, and no effort would be spared to induce the Home Secretary to
exercise any influence he had in restraining what was considered to be an incorrect
spirit of rendering the terms of the Act. He did not think he could say more
than that, except that they were deeply indebted to Dr. Shuttleworth for his most

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persistent work. He and Dr. Bower had worked hard on the matter for months
past. It was a curious thing, but he believed it had been said there was a large
amount of self-interest in the Association’s pressing on the scheme for pensions.
But the fact was that the three people who had had for many years past to bear
the brunt of the work were entirely free from any interest whatever. He suggested
that that fact was extremely good evidence that the work was done simply for the
good of the insane.

Dr. Carlyle Johnstone asked, arising out of what Dr. Newington had just
said, whether it would not be possible for the Parliamentary Committee, or the Joint
Advisory Committee, to circulate copies of Mr. Macmorran’s report to all superin¬
tendents in Scotland. Very few of them at present appeared to have seen it. It
was a most valuable document, and it supported what a few of the superintendents
in Scotland had been fighting for. It was matter for regret that it was not
earlier in the hands of superintendents and of district boards in Scotland. He
supposed it would be possible to send each of them a copy.

Dr. Newington rejoined that the difficulty was that counsel's opinion was
sometimes double-edged, therefore it was necessary to be careful. But he was in
correspondence with Dr. Shuttleworth, and they were going to see Mr. Macmorran
on Monday. Any decision would affect Scotland as well as England. What was
good law in the one country was good law in the other, and if the Home Secretary
could be got to put his foot down and say the Act should be carried out as they
conceived it should be there was nothing to fear.

Dr. Carlyle Johnstone said that if the counsel’s opinion supported the
opinion held in Scotland it was regrettable that the Scottish members were not
in possession of it. He had it himself, and it had been of great use to him.
But nobody else seemed to have had it in Scotland, and he feared it was too
late now to protect their interests in Scotland, because the General Board did
not see eye to eye with them, and their views were likely to have an adverse
influence with regard to the interests of the subordinate officials. If the
document was not confidential, the opinion of Mr. Macmorran could be sent to all
the superintendents in Scotland, who should have copies to show to members of
their Board. The effect of that would be good. But if that was not done imme¬
diately it would be too late.

Dr. Hayes Newington said the points mentioned were well within the
cognisance of the Committee, and there was a desire not to do mischief. There
were many asylums comfortably settled, and there were a few who could be helped.
But one must not help a few at the expense of the many, and they had to be
careful how the material was handled. He must ask the members to leave the
matter in the hands of those who had studied it, and who knew what they were
doing. He could give the meeting reasons why it was necessary to be careful, and
they were fortified in that position by very superior advice.

Dr. Carlyle Johnstone complained that when there was material which it
would be wise and well to forward immediately to Scottish superintendents they
did not get it until they asked for it. Scotland had been rather left out in the
cold in that matter.

Dr. Newington said that was not so. The Association had asked Scotland to
come and help them, but there had not been much help forthcoming. He promised
that directly after the conference with Mr. Macmorran on Monday, which would
take him home before he had hoped to go, the information available would be
sent.

Dr. Carlyle Johnstone said he did not wish to make any reflection on what
Dr. Newington or any other member of the Committee did; the point was that
Scotland was being circularised by the English County Councils Association, and
was not being circularised by the Medico-Psychological Association, and so they
remained in the dark in regard to the latter. If it were not for a few men trying
to disseminate light in Scotland, they would be absolutely in the dark there. He
therefore asked Dr. Newington to give some consideration to what he had said.

Dr. Bower thought, as a member of the Advisory Committee, that they should
very carefully consider the advisability of sending the circulars which were drawn
up to all asylum committees, or only to those committees where it might be
helpful. It was decided to send it only to the committees where it would do good,
and where a decision had not already been come to.

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Dr. Thomson said Dr. Carlyle Johnstone might be under the impression that
English superintendents had been supplied with the information to the exclusion
of the Scottish superintendents. He, Dr. Thomson, had not heard any more about
it than Dr. Johnstone had.

The report of the Parliamentary Committee was adopted.

Report of Library Committee.

The General Secretary, in the absence of the Chairman of the Library Com¬
mittee, moved the adoption of the report, as follows:

During the past year a considerable number of books have been added to the
Library. They consist of the more recent works, both English and foreigm,
relating to the various aspects of psychiatry, and a complete list has already been
published in the Journal. In addition to this the annual subscription to Lewis’s
lending library has been doubled, as it has been found very convenient for
obtaining books which do not happen to be in the Library of the Association.

It is satisfactory to note a marked increase in the number of books borrowed for
reference by the members of the Association. This is no doubt attributable to the
notice which has been inserted in each number of the Journal.

While the recent additions to the Library have largely brought it up to date, there
are still a number of books which should be included in a library of this character.
It is therefore proposed to request a further grant of ^40 from the Council.
Should this be forthcoming a portion of the sum will be utilised in the purchase
of new books, and the rest will be devoted to the binding of some 140 volumes
which are already in the Library. Many of these unbound books are of consider¬
able value and interest, and in their present state tend to become tom and
destroyed.

It was found that there were a large number of unbound volumes of old journals
in the Library. Unfortunately the majority of these are incomplete and therefore
quite valueless for purposes of reference. All such have been discarded, as they
only served to absorb much-needed accommodation. Complete volumes were
retained, and possibly the missing years might be purchased at some future date
in order to complete the sets. In most cases, however, so many volumes are
lacking that the expense would be very considerable, and it is scarcely advisable
to attempt to replace them at present while money is required for more immediately
pressing needs.

The removal of a quantity of useless material has been the means of affording
a considerable amount of space for new books. The question of increased accom¬
modation is, therefore, not one of immediate urgency, though it will ultimately
have to be considered as the Library increases in size.

Suggestions as to the purchase of new books will be welcomed by the Committee,
and it is hoped that the Library will be found increasingly useful to the members of
the Association.

( Signed ) Henry Rayner, Chairman.

H. Devine, "I Hon.

B. Hart, j Secretaries.

This was seconded and carried.

Report of Auditors.

In the absence of both the auditors Dr. Bond read the following report, and
moved its adoption, which was carried:

The Auditors beg to report that they have examined all the accounts and seen
the vouchers, and in all cases they have found them correct. The auditors note
that at the beginning of the year there was a considerable balance due on account
for advertisements, and this has now been cleared off and a new system has been
started whereby the moneys due will be paid quarterly instead of as received bv
the advertising agent. The income from the Handbook was ^50 9s. 6d., as against
£46 19s. in 1908. The income from the advertisements in the Journal was
£23 13s. 10 d. The balance owing from members’ subscriptions is less than last
year. The auditors note with satisfaction that the increase for the year is a record

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one, vie., £211, and this in spite of the additional expense which the Association
undertook in connection with the new Pension Act, vie., £78, and the expenditure
of ^58 12s. on the index of the Journal. During the year, £400 was invested out
of the savings of the Association. The total investments (irrespective of the
Gaskell Fund) now stand at £1702 6s. id., this sum being the price of stock on
December 31st, 1909. There was a slight net increase in the value of the stocks
as compared with the previous year.

The Treasurer is to be congratulated on the finances and the various accounts
of the Association.

(Signed) Maurice Craig.

John R. Lord.

Report of Criminal Procedure Committeb.

Dr. Urquhart said that, so far as he was aware, nothing had been done in the
matter during the past year. It was generally felt that with so many Parliamentary
reports, and the likelihood of the Government taking action, it would be well to see
what action would be taken by the Government before going further.

Report of the Preliminary Committee re the Medical Inspection of

School Children.

Report to the Council by the Committee appointed by it on May 24 th, 1910.

The Committee consists of Drs. C. Hubert Bond, A. G. Foulerton, H. Hayes
Newington, H. Rotherham, James Scott, G. E. Shuttleworth, and F. R. P. Taylor.
Each of the meetings held has been attended by the whole Committee.

The following is a reference to the Committee:

"To inquire into the propriety of the Association framing and tendering to
authorities advice on the search for and the definition of mental deficiency
which is incompatible with retention in elementary schools, with sugges¬
tions for the appropriate treatment of such deficiency, and to consider
any other cognate matters. The committee to have power to make
inquiries in any direction it may consider to be desirable, and to report
to the Council, and, if the Council approves, to the annual meeting in
July, and to co-opt, if it please, other members.”

The Committee has unanimously arrived at the following conclusions :

(1) It is of the opinion, after careful consideration, that the Association cannot
help school medical officers by laying down definite criteria, whereby to differentiate
between merely dull or backward children and mentally deficient children ; and it
further considers that it is most desirable that authorities should arrange for
facilities being provided for consultation in doubtful cases between school medical
officers and the medical superintendents of county and borough asylums, or
other recognised experts.

(2) It thinks that in all cases of mental deficiency provision should be made
for a continuous history of the case being kept as long as the case is under
official supervision.

(3) When a mental defective passes from under the care of the Education
Committee, having been maintained at a special institution, a report by a mental
expert should be made to the local authority.

(4) It is desirable that medical superintendents of county or borough asylums
should be empowered to communicate with school medical officers about any cases
under their care, whose children are attending elementary schools under the
supervision of those officers.

(5) It is desirable that in cases of mental deficiency the age at which the
supervision of the Education Committee ceases should be extended to twenty-one
years.

(6) The Committee is firmly of the opinion that there should be provision for
supervision of mental defectives after they cease to be under that of the educa¬
tional authority.

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(7) The following questions, among others, need further inquiry and con¬
sideration :

(a) Is the expense attending the education of mental defectives, as at present
conducted, justified by the results ?

( b) If the recommendation contained in paragraph 6 is adopted, what sugges¬

tions can be made for the best practical methods of carrying it out?

Finally, the Committee is of opinion that its preliminary inquiries justify its
recommending to the Council and the Association that a further and larger
committee should be appointed to which this report should be referred, with the
same duties and powers as were conferred on itself. The new committee to report
to the Association at its next annual meeting and to the Council in the interim as
may be found necessary.

Signed on behalf of the Committee,

H. Hayes Newington, Chairman.

July, 1910. C. Hubert Bond, Secretary.

Dr. Hayes Newington, speaking of the work of this Preliminary Committee,
said the history was that two years ago, when the Children’s Act was passed, he
brought before the Council of the Association the possibility that when the import¬
ance of the mental side of medical inspection of children became evident great
attention would be paid to the matter, and that the Association might be of use in
helping the authorities to formulate their schemes. But times moved very fast,
and authorities framed their scheme before anybody could say much about it, and
so the matter dropped. A little time ago he was talking with the Medical Officer
of Health in Sussex, a member of the Association, who took a skilled interest in the
matter, and eventually he, Dr. Newington, said he would bring the matter before
the Council. That gentleman wanted to know if there was any possibility of the
Association being able to help the school medical officers in arriving at a conclusion
as to where the difference lay (and how to find it) between the defective and the ordi¬
nary backward child, because important questions had to be settled by those officers
with no very perfect knowledge. He had, therefore, brought the subject before
the Council at the last meeting, and suggested that a preliminary committee should
be appointed to consider the matter, and, if necessary, bring it forward again. The
committee was small, but it represented various interests—medical, county councils,
and criminal. The matter had been thoroughly thrashed out once or twice from
all points of view, and the unanimous conclusion come to that they ought to
report to the Council in the first instance, and to the annual meeting further if the
Council concluded, as it had concluded, that it would be advisable to do so. The
idea was to appoint a larger and more permanent committee to go into the subject.
He did not think there could be any doubt as to the advisability of that, because
there was no other body in the United Kingdom which could tackle the question.
The Commission on the Feeble Minded, whose work would be very much in
evidence in all the inquiries, was really dead, and there was no further inquiring
power on its part. The Committee thought it could be of use in considering the
forms of institutions and treatment which could be advised for all the backward
children, and he would point out the excellent work which had been done by Dr.
Rotherham at Darenth. Dr. Rotherham had shown what could be done in the
beneficial education of defectives, and the Association might be able to help others,
with Dr. Rotherham’s aid, and suggest beneficial and productive forms of training
for children who were not too advanced in mental defectiveness or morally back¬
ward. He might say that one result of the preliminary inquiry was that he had
observed that many of his colleagues were very ready to look at the subject from the
mental point of view ; but it was desirable that one or two others on the committee
who were not mental experts should inquire into the matter from the other side.
Members of the Association were inclined to look at defectives as products of the
disease which was their special study. A different view was possible if one looked
upon defectives as normal children gone wrong. At all events it was found very
useful to have an interchange of opinion between themselves and those who were
not mental experts. Among the gentlemen it was proposed to elect was Dr. Auden,
the Medical Superintendent of the Educational Committee, Edmund Street, Bir¬
mingham. He would be an extremely valuable man to have on the Committee,
and he had written to him on the subject. It was important that such an inquiry

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should be a joint one. If the Association thought fit to appoint that committee he
would propose to move another resolution after the present one, that the committee
be selected by the President, Past President, and the President-elect, Dr. Drapes,
Dr. Bond, and himself. Thus every portion of the United Kingdom would be
represented. Although the Acts which would have to be taken into consideration
at first referred only to England, yet the trend of public opinion, and especially
the report of the Commission on the Feeble Minded, showed that the interest in
the matter was extending into Ireland and Scotland. And no doubt what would
be found to be of service in England would be equally serviceable in the other
divisions of the United Kingdom. He moved the adoption of the report of the
Provisional Committee, and at the same time moved that the Association appoint
a more permanent committee to conduct inquiries.

Dr. Clouston seconded.

The President said that carried with it the appointment of the Selecting
Committee to report.

Agreed.

Dr. Thompson asked whether the Committee had powers to co-opt others from
outside the Association.

The President replied that that was provided for in the report as it now stood.

National Committee re the Causation of Insanity.

Dr. Percy Smith said he regretted that the Secretary of the Committee, Dr.
J. H. MacDonald, of Govan Asylum, had not been able to attend, as he was just
recovering from a severe attack of influenza. He could state, however, that
matters were much in the same position as when last reported. They had been
waiting initial action by the Italian government, and it was now possible that some
action might be taken following the forthcoming Berlin Congress.

Berlin International Congress.

The President mentioned that a Congress was to be held at Berlin on October
7th, and it was thought desirable that the interests of the Association should be
represented at it. Dr. J. H. MacDonald, Dr. Percy Smith, and Dr. Macpherson
were going, and it was for the meeting to say whether it wished them to be
delegates for the Association.

Dr. Percy Smith said it was usual on such occasions to give to the President
and General Secretary power to send as delegates of the Association any member
who might be going.

The President said if there were any other members going he would be glad
to invite their co-operation.

Agreed.

Housing Committee.

Dr. Bedford Pierce said that some years ago a special Committee was
appointed to inquire as to the possibility of acquiring new quarters for the Asso¬
ciation in London. He had not heard whether that Committee had reported.
The little room set apart for the Association was a disgraceful place for the
purpose, and he thought that in such a large city a better room should be found
for the Association, which was continually growing in importance and wealth.

Dr. Briscoe desired to support the remark of Dr. Bedford Pierce. He had
often attended meetings there when the room was very crowded, and the atmos¬
phere had not been free from impurities.

Dr. Percy Smith said there was a Committee, to which Dr. Newington also
belonged, and trouble was taken to find out what could be done. At that time
the Medical Society of London had a scheme for adding another storey to their
building, but that scheme was based on a supposition that this Association would
pay about ^150 a year. That, however, was beyond the finances of the Associa¬
tion. It would be very difficult to find another place where committee rooms of
that kind could be obtained. It was true that the Library was in a small room,

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which was scarcely suitable for the enlarged Educational Committees. The
Council met in a good-sized room, and so did the general meeting. The rooms of
the Royal Society of Medicine were fully occupied, and that Society was in tem¬
porary quarters, and so they could not do anything in the matter.

The President said he could inform the meeting that the Housing Committee
was still alive, and Dr. Newington would be pleased to revive it still more by
bringing that question before it.

Dr. Newington said the negotiations were not yet dead. The landlords found
some difficulty in the matter, independent of whether the Association became
tenants, and it was possible they might have modified the scheme. But the rent
proposed at the time was more than the Association could afford.

Quarterly Meetings.

Tuesday, November 15th, 1910; Thursday, February 23rd, 1911; Tuesday,
May 23rd, 1911 ; and for the Annual Meeting, Thursday, July 20th, 1911.

Divisional Meetings.

South-Eastern Division. —Wednesday, October 5th, 1910; Tuesday, April 25th,

South-Western Division. —Friday, October 28th, 1910; Friday, April 28th, 1911.

Northern and Midland Division. —Thursday, October 20th, 1910; Thursday,
April 27th, 1911.

Scottish Division. —Friday, November 18th, 1910; Friday, March 17th, 1911.

Irish Division. —Saturday, November 5th, 1910; Thursday, April 27th, 1911.

Dr. Thomson desired again to point out that the Annual Meeting of the
Medico-Psychological Association clashed with the representative meeting of the
British Medical Association. Last time he brought the matter forward he was told
it would receive the attention which it deserved. Evidently it was inconvenient to
the powers that be, because here again he and other representatives of the British
Medical Association were prevented from enjoying the meeting to the full. He
presumed the matter had been given attention.

The President said the subject had received attention, but considerable incon¬
venience had been found in adopting the alternative. He could only refer Dr.
Thomson to the incoming president, who alone could settle the matter for the
coming year.

Dr. Bedford Pierce confirmed the difficulty mentioned by Dr. Thomson, and
said that it would be desirable to hold the annual meeting in May.

Dr. Mills desired to associate himself with what Dr. Thomson had drawn
attention to—the clashing of the meetings of the British Medical Association
with those of this body. He also had found it exceedingly difficult to attend the
meetings he wished to, and he would be glad if arrangements could be made to
avoid a similar clash in the future.

Dr. Urquhart said he was glad to know that the question was still alive. He
had been hammering at it for thirty years off and on, and he thought it high time
that the Association should again consider whether they would go on spoiling the
British Medical Association meetings to the best of their ability, and suffering the
abstentions which occurred in this Association every year. He had repeatedly
suggested the month of May for their Annual Meeting. A total revision of the
matter was required.

Dr. Newington said it was scarcely this Association which was causing the
trouble ; it was a case of the wolf and the lamb. At one time the British Medical
Association confined itself to one week and the Medico-Pyschological took another
week. It was a new departure for the British Medical Association to take days in
the preceding week. The question had been debated many times. There used to
be some idea that those in asylums made arrangements for someone to be in charge
during their absence, and could better arrange to go from one series of meetings
to the other.

Dr. Percy Smith said to those who were engaged in teaching in the medical
schools May would be a very inconvenient month. At the end of July, however,

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the summer session was over and they could get away. But they could not get
to a provincial meeting in May.

The President said he wondered whether it would be sufficient if one got the
incoming president to promise to give careful attention to the matter, or whether
it was desired that a committee should be appointed to consider the whole subject.
Dr. Urquhart’s recommendation that the date of the meeting should be changed
from July to May was a very radical one, and there were various difficulties in
the way.

Dr. Thomson said that Dr. Urquhart suggested too much. All that he asked
for himself was an alteration of twenty-four hours.

The President said he was sure the matter would receive due consideration. If
members felt satisfied with his assurance on the point the subject might drop.

Dr. Urquhart said the incoming President must be consulted, because his
arrangements were paramount, and the Association would naturally come as near
as possible to what he desired. In the year of Dr. Conolly Norman’s presidency
the Association met early in June, and that meeting was a great success.

Dr. Mercier said Dr. Thomson always brought the motion up before the
Association, and he was always told he must apply to the President-elect. He
did not know that Dr. Thomson ever did that; he had not heard that he did so,
but he always ventilated the subject again at the annual meeting.

Dr. Thomson rejoined that he did not think it was for any single humble
member to make an appeal for an alteration simply to suit his own convenience.
That would be asking too much, but it was for the Executive of the Association to
bring the notice forward.

The President said he would have pleasure in trying to influence Dr. Drapes
on the point.

Dr. Percy Smith asked how many members of this Association were on the
Representative Board of the British Medical Association, and whether their con¬
nection was a permanent one.

Dr. Hayes Newington asked what the President would commend to Dr. Drapes
—a Wednesday meeting, or a Thursday?

The President said he would not recommend that the meeting be held in May.

Dr. Drapes said he was sure the Irish Division would be only too happy to
try and accommodate their plans for the meeting to the views of most of the
members, and it would be a cause of regret that any should be debarred from
coming by other engagements. He did not know, however, that it was left to the
President to decide on his own judgment. He thought it was the result of con¬
ferring with the Council, finding from them the date which would best suit the
members generally.

Dr. Bower asked whether the date, July 20th, 1911, was fixed with the new
President for that time.

Dr. Bond replied in the affirmative, but added that it was only put forward as a
suggested date and subject to the convenience of the President-elect.

Dr. Urquhart suggested that it was not absolutely essential to agree to July
20th, 1911, and asked whether the day of the month could not be left out. Would
Dr. Drapes consider the whole subject ?

Dr. Drapes replied that Thursday, July 20th, was not originated by him,
though he agreed it was convenient.

The President said it was subject to modification afterwards.

Election of Ordinary and Honorary Members.

The President nominated Dr. Bedford Pierce and Dr. Stoddart to act as
scrutineers, and suggested that it would be well to take at the same time the
election of honorary members.

Dr. Percy Smith said the first candidate for the honorary membership
was Dr. John Macpherson, whose proposal form was signed bv Dr. Clouston,
Dr. Urquhart, Dr. Yellowlees, Dr. Bevan-Lewis, Dr. Hayes Newington, and
himself (Dr. Smith). He said Dr. Macpherson was Commissioner in Lunacy
for Scotland, formerly Assistant Medical Officer, Royal Edinburgh Asylum,
Lecturer in Mental Diseases, Royal School of Medicine, Edinburgh; Morison
Lecturer before the Royal College of Physicians, Edinburgh ; author of Mtntal

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Affections, 1899, and numerous medical articles of importance. It would seem
hardly necessary in Edinburgh to recommend Dr. John Macpherson for the
honorary membership, but perhaps it was appropriate that someone from the south
should be allowed to perform that office, and it was an honour to him to have that
duty entrusted to him. He thought he might say that Dr. John Macpherson was
known in London and the south generally almost as well as he was known in
Edinburgh. His text-book on mental affections was, of course, extremely well
known ; and it might be said that of the text-books in the English language it
bore more impress than many of familiarity with continental work on the subject.
Dr. Macpherson was a member of the Classification Committee, which met a great
deal two or three years ago, and drew up the classification for the purposes of the
Association, and his knowledge and wise counsel were of the greatest possible
assistance, and all members working with him became familiar with his genial
personality. It had also been his good fortune to be associated with Dr.
John Macpherson as a Delegate to the Congress and the International Committee
held in Vienna in 1908. The report of that Congress, published in the Journal for

i uly, bore very largely the impress of the judicial mind. By the retirement of
)r. Fraser from the office of Commissioner in Lunacy for Scotland Dr. John
Macpherson now became the senior Commisssioner, and he might be allowed to
say that Scotland was fortunate in possessing such a senior Commissioner. The
Association would be as fortunate if his name were added to the list of honorary
members as it would be in having him as President at the meeting that afternoon.

Dr. Savage said it might seem unnecessary for anyone to support what Dr.
Percy Smith said, but he did so with the greatest pleasure. He felt the Association
was conferring an honour upon itself by honouring Dr. Macpherson.

The motion was carried.

The President said he had now the pleasure, after Dr. Percy Smith’s speech
nominating a medical commissioner, of nominating a legal commissioner for
England, namely, Mr. Arthur Hill Trevor, as honorary member of the Association.
Mr. Trevor was a Graduate in Arts at Oxford University, having been educated at
Winchester and Corpus Christi, Oxford. For three years he had acted as Secretary
of the English Lunacy Board, and had been a Commissioner for England and
Wales. Most of those present had been brought into association with him officially,
and all who knew Mr. Trevor would agree as to his independent judgment, his
breadth of view, and his force of character. His criticisms were always kindly and
generous, and free from untoward bias, and was coupled with a keen recognition
of administrative duties. He approached a case with the greatest sympathy, and
the same sympathy was extended to all that was progressive in lunacy administra¬
tion. It would be a very graceful act on the part of the Association to enrol Mr.
Trevor’s name on the list of honorary members, and therefore he hoped the
meeting would support him.

After the ballot it was announced from the chair that the honorary members had
been elected, namely, Dr. John Macpherson and Mr. A. Hill Trevor.

The following were elected as ordinary members :

Auden, George Augustus, M.A., M.D., B.C. D.P.H.Cantab., M.R.C.P.Lond.,
F.S.A., Medical Superintendent, Educational Committee, Edmund Street, Birming¬
ham (proposed by Bedford Pierce, Geoffrey Clarke, and C. Hubert Bond).

McKenzie, Ivy, M.B., Ch.B.Glas., Director, Western Asylums Research Institute,
Glasgow (proposed by L. B. Oswald, R. M. Marshall, and H. Morton).

Oldershaw, George Francis, M.B., Ch.B.Liverp., Assistant Medical Officer,
Royal Asylum, Perth (proposed by A. R. Urquhart, John H. Lyell, and B. J. Alcock).

Reid, William, M.A.St.And., M.B., Ch.B.Edin., Senior Assistant Medical Officer,
Burntwood Asylum, Lichfield (proposed by J. B. Spence, H. Hayes Newington,
and C. Hubert Bond).

Watson, William Scott, M.B., Ch.B.Edin., Assistant Medical Officer, Royal
Asylum, Morningside, Edinburgh (proposed by George M. Robertson, Alex. W.
Neil, and R. Dods Brown).

Notices of Motion.

The President announced that Dr. Bond desired to withdraw the motion (h) in
his name for the present. The motion had reference to the number of examiners.

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1910 .] NOTES AND NEWS. 769

Motion by Dr. Bower.

Dr. Bower proposed the following, of which he had given notice : “ That the
member holding the office of Secretary to the Parliamentary Committee be an
Official Member of the Council, and that Bye-law 31 be varied accordingly.” He
said it had often been an inconvenience to the Chairman or Secretary of the
Parliamentary Committee, who had not been able to follow up the business of the
Parliamentary Committee of the Council. He had intended to suggest the addition
of the Secretary to the Educational Committee.

Dr. Bond said that gentleman was already, ex officio, a member of the Council.

Dr. Bower said he also used to be under that impression, but failed to see his
name in the list of officers that had just been elected.

Dr. Bond explained that his name could not yet appear as that officer had to be
elected at the first meeting of the Educational Committee, namely, next November,
and that he then, by Bye-law 31, became, ex officio, a member of the Council.

Dr. Bower said he simply wanted to put the Parliamentary Committee on all
fours with the Educational Committee.

Dr. Bedford Pierce seconded the motion and it was carried.

Motion by the Treasurer.

Dr. Hayes Newington proposed the following motion: "That new members
elected in the last half of any year shall have the option of joining the Association
as soon as their election is complete, or of deferring joining to January 1st of the
succeeding year, and that Bye-law 19 be varied accordingly.” He said the present
arrangement was very inconvenient. Sometimes new members were elected at a
November meeting and they were due to pay half a guinea. They might consider
it hardly worth their while to join, and they sometimes did not come on until the
following year. Dr. Bond had found a difficulty with regard to them, and they
sometimes upset the accounts. He moved the resolution in order that what new
candidates did now illegally they should be able to do legally.

Dr. Briscoe seconded, and it was carried.

Thanks to the President and Retiring Officers.

Dr. Clouston said he had been asked only two minutes ago to propose a vote
of thanks to the President. Though it was difficult to do justice to such a vote at
two minutes’ notice, he realised fully that the work of the President and other
officers was so well known that no eulogium was really necessary. He knew the
President to be a modest man, and probably what he was about to say would
bring a blush to Dr. Bevan-Lewis's cheek, but he said in the face of all men and
all women that Professor Bevan-Lewis was the most outstanding and most
distinguished man in the profession on the pathological aspect of insanity, and in
that statement he did not include Great Britain only. The work which Professor
Bevan-Lewis did from the time he first went to Wakefield, his devising of a new
method of microscopical examination of the human brain, his continuous and
never-ceasing work from that time to the present, had produced fruits which were
reflected in the progress of psychiatric science, and the Professor had writ his name
large in the history of that department of medical work for all time. There were
not many men of whom he could say that, but he said it now with the conviction
that every man in the room agreed with him. Dr. Bevan-Lewis, having done such
a great work, conferred an honour on the Association by accepting its presidency.
He was not sure that it was altogether with Dr. Bevan-Lewis’s will. Several
members of the Council had to exert considerable pressure on Dr. Bevan-Lewis to
induce him to accept the post, but as President he had done all that any man
could do as head of the Association. The address delivered from the chair last
year was of the most scientific character, implying thought and work. It had
Bevan-Lewis written all over it, from beginning to end. With regard to the
officers of the Association, he could not mention them all; they were all good men.
But he could not omit mention of his old friend and a former assistant, Dr.
Hayes Newington, the Association’s Treasurer. To everybody to whom he intro¬
duced Dr. Newington he had to say that he was the real man holding the rod of

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the Association : he ruled everybody and without a single complaint. He also held
the purse-strings, and had a masterful presence, and whenever anybody thought of
the Medico-Psychological Association, Dr. Newington sprang into his mind’s eye.
He represented the spirit in which all the officers of the Association worked. Dr.
Bond also should be specially named. Every member appreciated his services,
and he took the opportunity of telling those who were included in the vote that
the thanks were not merely formal: members were very grateful to them. They
gave time, labour and thought and conscientiousness to the Association’s work, and
to those who took a minor part it was a great thing to have officers who carried out
the work of the Association so ably, for its progress had gone on year by year,
and this year there were no less than fifty new members. It was a great gratifica¬
tion to him to propose that vote to Professor Bevan-Lewis and the officers who
had conducted the affairs of the Association during the past year. He wished also
to include the Editors of the Journal.

Dr. Nicolson said it was a great pleasure to second the resolution which Dr.
Clouston had so admirably proposed. It would be a work of supererogation to
add anything to what Dr. Clouston had said; all agreed with him as to the great
position occupied by Prof. Bevan-Lewis, not only in the Association, but in Great
Britain and Ireland and in the scientific circles of the world. Concerning Dr.
Hayes Newington, the backbone of the Association, it was needless to add a
word. Dr. Bond had earned his spurs as General Secretary as well as any man
ever did.

Carried by acclamation.

The President (Prof. Bevan-Lewis), in reply, said he supposed it was in
accordance with the eternal fitness of things that one’s obituary notice should be
clothed in laudatory comment, and made fragrant with the sweetness of delicate
sentiment and all too-ffattering praise bestowed by one’s colleagues, an incinera¬
tion upon the altar of thanks, in other words that his apotheosis should be signalised
by a great cloud of incense into which one’s weary spirit disappeared for indefinite
rest. However that might be, it was imperative to draw a distinct line of demarcation
between the office of president, the highest which it was in the power of the Associa¬
tion to bestow, and the offices occupied by the permanent officials, who, as had
already been well said, were the motive power, the heart, and arterial system, even
also the nervous system, of the organisation. Those latter gentlemen had what
was denied to the President—annual reincarnation. Their’s was the perennial joy,
blossoming continually afresh into official life, their’s the constant labour of love,
yet a labour which was not by any means insignificant, for the affairs of the
Association needed the most careful watchfulness and discrimination. There was
also needed the output of considerable energy and much self-denial and consum¬
mate tact. He could say that because in the arena of the committee meetings
there was a shock of war between Caledonian, Saxon, and Celt, and if tact was
not required there, he did not know what was required. But for the President it
was ordained that his head be chopped off at short notice. Those perpetual
executions had been going on in the history of the Association to its remote past,
often involving very distinguished members of the specialty. But still they came,
complacent, pleased, and apparently highly gratified at their annual rite of
decapitation. He could only explain it on the grounds of the Association’s kindly
and considerate treatment of them during their year of office. No doubt it was a
very healthy condition of things, and a salutary warning on the part of the
Association that there would be no permanent official in the highest position
which the Association could confer ; that meant there should be no one who could
degenerate into the spirit of the dictator. If there were any such spirit resident in
the breasts of the ambitious younger members of the Association, he hoped they
would take warning from his fate that day and from that of his numerous pre¬
decessors. Or, better still, let such an one be relegated to one of the hardest-worked
committees, and then such an ambitious spirit would soon be torn into shreds by
the united energies of the constituent mass. He hoped he might not be considered
egotistic, but—and he said it largely on account of Dr. Clouston’s remark—
members and men generally differed very much from each other in their desire
for office. He confessed that he had always felt an almost ineradicable,
and, his friends told him, an almost insane shrinking from official positions.
A very kind friend, who held an exalted position in the Association, approached

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him with the words: “ We have determined to raise the bushel from off

your light.” When that bushel was removed according to his desire, he, the
speaker, feared that only a veritable rushlight was revealed. Yet each should be
proud of his little rushlight for even the faintest scintillations emanating if they
penetrated the gloom around claimed kinship with that eternal source of light,
whose energies it was their most sacred privilege to conserve and to utilise.
His short experience as President had taught him one lesson—a very important
one—the enormous debt which he, as President, owed, and which every member
of the Association owed, to the permanent officials of the organisation. Could
one find a more ideal Chancellor of the Exchequer than the revered Treasurer,
Dr. Hayes Newington? He was sure such could not be found, not even the
speaker's fellow-countryman, Mr. Lloyd George. Eminent for his personal
characteristics, charming in every way socially, possessed of a fund of humour,
of a full acquaintance with men and manners, he had a most paternal solici¬
tude for diffident presidents who were struggling into official life, and who looked
upon their duties in despair. He had also placed the finances of the Associa¬
tion upon a most substantial basis, and he was sure Dr. Newington’s with¬
drawal would be an irreparable loss to the whole body of members. Then, with
regard to the General Secretary, all knew how multifarious were his duties, how
manfully and bravely he carried them out, and how ready he was to meet every
emergency of the kind. He dare not use, concerning Dr. Bond, the words
which came first to his lips for fear of being regarded as prejudiced. They had
worked shoulder to shoulder together in the West Riding Asylum years ago, and
he had had joy at the continuous successes of his life, and at the way in which he
had won his spurs in the highest spheres. His personal obligations as President
were due to Dr. Bond for much assistance during his term of office. It was
known, also, how the work of the Registrar had increased by leaps and bounds,
yet he met it uncomplainingly and cheerfully, and he deserved all that had been
said about him, the position being one of difficulty, and of even greater importance.
Lastly, one came to that trinity in unity, the Editorial Staff of the Association,
who had brought the Journal into such a masterly position, whose quality was
recognised not only in England, but also everywhere abroad. Looking at the
length of the agenda for the present meetings, he did not know whether to
sympathise with or to congratulate the Editors upon the amount of grist which had
come into their mill. The Association should be congratulated on such veterans
remaining on the Editorial Staff. It only remained for him to thank those present
for himself and on behalf of his fellow officers for the very kindly sentiments
expressed that day about them. He had now a very pleasing function to perform,
namely, to vacate the Presidential Chair in favour of his successor. In that
" Modern Athens ” it would be idle on his part to speak of the qualities of heart
and intellect of Dr. John Macpherson, whose laurels had been won in that centre
and neighbourhood, and who was so well known to all, professionally and socially.
And he must add, as his own personal tribute, that it was a source of intense
gratification to him that during his official year he had been sandwiched between
such an eminent predecessor as the well-known neurologist Dr. Charles Mercier,
and such an ornament of the profession as Dr. John Macpherson. In placing the
Presidential insignia around the neck of Dr. Macpherson he said he felt assured
that no one would wear it with greater dignity or distinction. He wished the
new President a prosperous year of office and God speed.

Dr. Macpherson then took the Chair.

The President (Dr. John Macpherson) said that if anything could add to the
satisfaction and gratification of taking the Chair, it was that he had been inducted
into it by Professor Bevan-Lewis. Before commencing his address, he desired to
mention that he had a few letters from honorary members abroad : Professor
Benedikt, of Vienna, Dr. Toulouse, of Paris, Dr. Morel, of Belgium, Professor
Kraepelin, of Munich, and also one from Dr. Needham, Commissioner in Lunacy
in England. An extract from Dr. Needham’s letter to the President ran: “ It
seems to me an excellent thing that there should from time to time be such evidence
that the work, both of commissioners and superintendents of asylums, is in the
same lines and is benefited by, and indeed demands, free co-operation by all. I
write this, however, in bed at Leeds, where 1 have fallen ill. If I am able to attend
you may rely upon my making every effort to do so.” Of Professor Kraepelin’s

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letter a free translation ran : “ My dear colleague, I thank you for your very kind
invitation to your annual meetings. I regret extremely that, as I am in the middle
of my session, it is impossible for me to leave here. Please convey to my English
colleagues my personal greetings, and my hope that their assembly may be pleasant
and successful.”

President’s Address.

Dr. Macpherson then delivered an address entitled, " Conceptions of Insanity
and their Practical Results.”

Vote of Thanks to the President.

Dr. Charles Mercier said he felt he was singularly incompetent for the task
which had fallen to him of voicing the thanks of the Association to the President
for the address which members had received with so much gratitude and admira¬
tion. One reason why he was incompetent for the duty was that the President's
address was not to be criticised; one must not differ from him. He found it very
difficult to adopt that attitude—not an unusual circumstance in the Association.
Secondly, if he had wished to differ from what the President had said, he would
have found it difficult to do so. The address was founded upon the influence of
altruism in the concept and the treatment of insanity. There was nothing more
striking in modern civilisation than the amazing increase in the altruistic spirit in
the minds of the western world in the last fifty or a hundred years. When one
looked back to the ancient civilisation of Egypt and Rome, and to the less known
civilisations of Mesopotamia, one found that in actual material wealth and in the
amenities of life for those who were at the top of things they were but little inferior
to the conditions obtaining to-day under western civilisation. One found there
not only enormous wealth, with all the delights which wealth could bring to the
rich, but evidences of the highest civilisation in a code of law of the most elaborate
description, a code on which even western nations to-day founded their corpora
juris. Yet it was well known that those civilisations were the foundation of
slavery, that the amenities of life were only for the very few, while for the great
multitude there was nothing but grinding poverty, grinding servitude, and
unrewarded toil. When that state of civilisation was compared with ours it was
seen that the difference was one between selfishness and altruism. When one
looked upon all the advances which had been made in science and in progress—
the invention of the application of steam to industry, of electricity and its various
uses, of Listerism, of wireless telegraphy, and Darwinism—and compared them
with the amazing alteration which had taken place in the attitude of the mind
towards human suffering and towards death, one would find that the latter would
weigh down all the former put together. Improvements in the arts and sciences
had been going on for thousands of years, but the advances in altruism had been
practically almost limited to the last fifty years. It was in the memory of men
now living that ordeal by battle had lost its power; it was during the reign of
Victoria that children at school were treated by methods of barbarism. It was
well known in their own specialty with what barbarity the insane were treated.
The same could be said of every department of life. Soldiers and sailors were
treated with merciless severity ; sometimes they died under the lash for mere trifling
breaches of discipline. But such things could not happen now. He invited his
hearers to think of the condition of the gaols in Howard’s time, when men were
cast into prison for the most trifling offences, when a man could be sentenced to
death and hanged for stealing to the value of five shillings; and when he had to
await his trial in a gaol in which the chances were ten to one that he caught
typhoid fever, and when even the judges on the bench contracted gaol fever or
typhoid fever from the felons who were tried before them. There was, only last
night, a debate in the House of Commons on the conditions of prisoners, and one
thing which everybody insisted upon was that prisoners should not be punished: that
they should be treated not only with mercy, but with indulgence; that things should
be made pleasant for them, and there should be no severity in their treatment. It
was most instructive to compare that attitude with what obtained fifty or a

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hundred years ago. The most marvellous change had been that which had come
over humanity in its tenderness towards human suffering. Thus he was fully
able to endorse what the President had said. When he saw that the address was
to be on the concepts of insanity he thought it might be an instance such as that
which was toasted at the Royal Society, when the President offered the following
toast to his guests: “ Here’s to the last scientific discovery, and may it never be
of any use to anybody.” To clarify our concept of insanity was a task to which
he (Dr. Mercier) had contributed his humble inite not long ago. And he could
assure the President that if he set out to say what the concept of insanity ought
to be,he was undertaking a Sisyphean task, and he was not likely to obtain general
concurrence. But in one thing he was happy to agree with the President—as
happy as he was likely to be in agreeing with anybody—namely, the preponderating
importance which he assigned to the clinical side of the science of psychiatry.
The pathologists and microscopists came round to the meetings with a haughty
air, placed their preparations before the members, and demanded that they should
be accepted. But the pathological laboratory was the downstairs—it was the area
and the pathologist was the servant of the clinician. The clinician was the person
most to be considered. The object of the specialty, as of all medicine, was to
treat disease. Suffering patients came to the physician to be relieved of their
sufferings. Their duty was to relieve them, and that relief could only be given by
the clinical physician acting in his clinical capacity. The pathologist, with his
amazing terms and theories, was merely the man to cook up the materials which
the clinician supplied to him, and to supply the data from which the conclusions
could be drawn. Therefore, let not the pathologist be too arrogant in contem¬
plating the ignorance of the clinician. He much admired the President when he
spoke of the immense advance which had been made from the entity of disease to a
conception of the syndrome. As he understood the President, mania and melancholia
were formerly considered to be diseases, but now they were known to be syndromes
only. He was reminded in that connection of the discovery of the authorship of the
Iliad and Odyssey, that they were not written by Homer, but by another gentleman
of the same name who lived at about the same time. Once more he expressed his
agreement with the President when he deprecated the use of mixed physical and
psychical phrases. That he held to be the very abomination of desolation. Such
were " psycho-motor,” or “ idio-motor,” or some of the words given by the
President, such as “ stored impressions,” “ mental pictures," “ centres for the
association of ideas.” They were neither physiology nor psychology; they were
horrible hybrids; they neither deserved to be in heaven nor in the other place.
Their place being a limbo, they should float between the two. They were not
scientific, but were the negation of science. It was as bad as speaking of conduct
as a branch of psychology. In his concepts of the nervous system as sensori¬
motor, he, Dr. Mercier, recognised the influence of his dear and revered master, Dr.
Hughlings Jackson. It was only by keeping in mind the concept of the nervous
system as a sensori-motor system, that it was an apparatus for the reception and
storage and expenditure of force or motion, that one could avoid that terrible con¬
fusion of thought which would regard mental states as being stored up in the brain,
as one eminent physiologist said, as bile was stored in the cells of the liver. He
gathered the concensus of the meeting’s thanks and laid them at the feet of the
President for his most thoughtful and philosophical address.

Dr. Robert Jones said it had fallen to him to second the vote of thanks to the
President. It had been a very great pleasure to him—and he knew he was voicing
the feeling of others also—to hear that most suggestive address. That question of
the relationship of mind to body had always been a most fascinating one to him,
and the President had gone over all those views and brought their historic sequence
to bear upon the progress of psychiatry. The address was as well delivered as it
was charmingly phrased, and he was sure all would enjoy reading it in their arm¬
chairs. All that could be said of the address had been well said by Dr. Mercier,
whose sentiments he cordially re-echoed.

Dr. Ford Robertson then read a paper on " Infective Foci in General Paralysis
and Tabes Dorsalis.” It was discussed by Dr. Mackenzie, Dr. Dods Brown,
Dr. Percy Smith, and Dr. Winifred Muirhead.

Dr. Carswell gave a contribution on “The Treatment of Acute Mental Dis¬
eases of a Curable Type in Observation Wards.” It was debated by Dr. Sydney

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Coupland, Dr. Seymour Tuke, Dr. Briscoe, Dr. Clouston, Dr. Oswald, Dr.
Helen Boyle, Dr. Robert Jones, Dr. Yellowlees, Dr. MacDowell, Dr.
Hayes Newington, and the President. In replying, Dr. Carswell offered to
show anybody over his hospital.

Dr. J. P. Sturrock read a contribution entitled, “On Certain I nsane Conditions
in the Criminal Class.” Dr. Dunlop expressed his agreement with the paper.
Dr. Percy Smith, Dr. Robert Jones, and Dr. Briscoe also discussed it.

SECOND DAY.

The proceedings on Friday were resumed at the Royal College of Physicians,
and were opened by a very interesting address by Dr. Urquhart on “ Lunacy
Administration in Scotland, with Special Reference to the Royal Asylums.”

Dr. Lewis C. Bruce then read a paper on “The Deviation Complement in
Connection with the Diseases known as Mania.” Dr. Mackenzie and Dr. Fraser
discussed the paper, and Dr. Yellowlees expressed the meeting’s appreciation of
the painstaking work which Dr. Bruce had done.

Dr. Ivy McKenzie read a paper on "The Arsenical Treatment of Protozoal
Diseases." Dr. Briscoe, Dr. Clouston, Dr. Lewis Bruce, and Dr. Mercier
discussed the paper.

Dr. Hugh Morton read a paper on “The Chemistry of the Cerebro-spinal
Fluid.”

The President announced that Dr. Morton had been awarded the Association’s
bronze medal and money prize for his essay on “ Bio-chemical Examination of the
Cerebro-spinal Fluid in Cases of Mental Disease ” ; and he took this opportunity of
presenting him with the medal and cheque.

Dr. Winifred MuiRHEADread a paper on “The Wassermann Reaction in the
Blood and Cerebro-spinal Fluid, and the Examination of the Cerebro-spinal Fluid in
General Paralysis and Other Forms of Insanity."

Dr. Gilmour gave a contribution on “The Wassermann Reaction: a More
Reliable Technique."

Dr. Yellowlees and Dr. Percy Smith spoke in terms of high eulogy of the
work as evidenced by the papers.

Friday Afternoon.

In the early afternoon the party drove, by invitation of the Board of Managers
of Morningside Royal Asylum and Dr. G. M. Robertson, to Craig House, where
luncheon was served and presided over by Mr. James Adam, advocate, the Chairman
of the Hospital. Speeches complimentary to the Association and to Dr. Robertson,
the Medical Superintendent, and Dr. Clouston were delivered.

After luncheon Dr. G. M. Robertson opened a discussion on “The Treatment
of Mental Excitement in Asylums.” It was participated in by the President, Dr.
Briscoe, Dr. Clouston, Dr. Drapes, Dr. Stoddart, Dr. Bedford Pierce, Dr.
Oswald, Dr. Hayes Newington, Dr. Bond, Dr. Mackenzie (Inverness), and
Dr. Seymour Tuke.

Dr. Leonard Baugh read a paper on "Clinical Study of Anaesthesia, Mental
Confusion, and Moods in Epilepsy, Confusional Insanity, and Hysteria.”

Thanks.

Dr. Urquhart, in the name of the meeting, tendered to Dr. Macpherson its
hearty thanks for the manner in which he had controlled the debates and the
meetings generally. At the same time, he proposed that the sincere gratitude of
the Association should be expressed to the Managers of Morningside Asylum and
to Dr. Robertson, the Superintendent, for their splendid hospitality. In Scotland,
in the old days, there was a bad precedent that the meetings should not be held in
asylums, but that was now, happily, dead, thanks largely to the initiative of Dr.
Robertson. The Association had been going from asylum to asylum, and finding
the practice of the utmost value.

The President expressed his cordial thanks for the vote. He had found his

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duties very agreeable, and he had been kindly supported. He had had several
communications from Dr. Turnbull, and it would be a pleasure to members to
know that he was getting better, and hoped to be able to resume his duties.

Dr. G. H. Savage proposed that a hearty vote of thanks be tendered to the
authorities of the Royal College of Physicians in that city for their hospitality,
and to the University and Conservative Clubs for their kindness in throwing their
houses open to the members of the Association during their stay.

Dr. Drapes seconded the resolution. He said if anything could add to the
pleasure and dignity of that conference, it was meeting in such a city as Edinburgh,
with its classic beauty, its scientific elegance, and its stately halls. The University
and Conservative Clubs had also acted most generously, and it was, indeed,
gratifying to come as strangers to a far city and find oneself among friends.

The resolutions were carried by acclamation.

A garden party and reception had been organised for the afternoon at Craig
House, but as the weather was unpropitious the outdoor portion had to be aban¬
doned, and some six hundred guests were accommodated in the large Hall.

SATURDAY.

On Saturday a considerable number of members and their friends, at the invita¬
tion of the District Board of Lunacy and Dr. Keay, journeyed to Bangour
Village Asylum, in the large Recreation Hall of which a highly interesting account
of the inception, opening, and development of the Institution was given by Dr.
Keay.

The Treasurer said that, with the President's permission, he wished to add to
what he had said on Thursday about Sir William Collins’s question in the House
to the Home Office. The question, he found from The Times, was asked, and
elicited the information that the Home Secretary repudiated having any authority
whatever in the matter of classification for pensions. This answer entirely
disposed of any idea which might be conveyed by the County Councils Associa¬
tion’s circular, that the interpretation of “care or charge” therein given had the
approval of the representative of the Home Office at the conference with the
English Commissioners. He again wished to say that the Association was most
thankful to Sir William Collins for this and other services. In moving a hearty
vote of thanks to Dr. Keay for his very clear description of the asylum, he said
that he, personally, had looked forward keenly to coming to Bangour. Some
years ago, when the plans for the Hellingly Asylum were being thought out, he had
brought his colleagues as far as Edinburgh to hear from Sir John Sibbald and his
colleagues a description of the advantages of this highest form of segregation,
which was then much before the public in consequence of the reports that arrived
of the Alt Scherbitz Asylum. They were much impressed, but on consideration
felt that they could not go the whole way in adopting the scheme, but they had
made some advance in splitting up accommodation, especially in regard to a
hospital near the gates for recoverable cases. It was hinted to him at the time
that one bad effect of segregation was the enhanced maintenance rate produced
by the necessity for a larger staff. He rather doubted the truth of this, and now
he was most interested, on analysing the figures supplied to them by Dr. Keay, to
find that his rate was ios. 3d. per week as against ios. for the whole of the
district asylums of Scotland. He felt bound to say that if, after inspection, he
found that the patients were made more comfortable and otherwise benefited by
segregation, the extra threepence per week was indeed well spent. (Applause.)

The visitors were entertained to lunch by the Board, and afterwards were con¬
ducted over the various villas and other buildings. An enjoyable and instructive
day termined with tea at Dr. and Mrs. Keay’s house.

The Annual Dinner.

The members and guests dined together on Thursday evening at the Caledonian
Station Hotel, under the presidency of Dr. John Macpherson, President of the
Association. There were about one hundred present, and among the guests were

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the Lord Provost of Edinburgh, the Hon. Lord Salvesen, Sir Thomas Fraser,
Lord Guthrie, Rev. Dr. Fisher, Sir Halliday Croom, etc. During the evening the
Edinburgh Quartette rendered, in admirable style, some capital pieces. The after-
dinner speeches were of a very high order.

IRISH DIVISION.

The Summer Meeting of the Irish Division took place at the District Asylum,
Belfast, by the kind invitation of Dr. W. Graham, on Thursday, July 7th, 1910, at
11.30 a.m., the members having previously visited the old institution, which will
shortly be abandoned.

Dr. T. Drapes was voted to the chair, and there were also present Drs. W.
Graham, P. O'Doherty, J. Patrick, S. Graham, G. R. Lawless, J. Mills, J. O’C.
Donelan, and W. R. Dawson (Hon. Sec.).

Apologies were received from Drs. F. E. Rainsford, M. J. Nolan, E. O’Neill,
J. J. Fitzgerald, C. E. Hetherington, and others.

The Minutes of the last Ordinary Meeting of the Division, and those of the
Special Meeting, were read and signed.

The Hon. Secretary reported on various matters arising out of the Minutes,
especially with reference to the resolutions passed at the Special Meeting relative
to the appointment of Inspectors of Lunatics. To that sent to the Irish Members
of Parliament four replies had been received, all favourable; and Mr. Arthur Lynch
had asked a question on the subject in the House.

A letter from Mr. Winston Churchill was read, conveying the thanks of His
Majesty the King and of Queen Alexandra for the resolution passed by the
Division at its last meeting.

A letter from Dr. Hetherington was received, renewing the kind invitation to
meet at Londonderry on some future occasion.

The following were balloted for, and declared unanimously elected ordinary
members of the Association :

Ada English, M.B., B.Ch., B.A.O., R.U.I., Assistant Medical Officer, District
Asylum, Ballinasloe; proposed by Drs. J. Mills, J. O’C. Donelan, and W. R.
Dawson.

Edward Patrick Harnett Murphy, B.A., L.A.H. (Dublin), Assistant Medical
Officer, Stewart Institution, Palmerston ; proposed by Drs. F. E. Rainsford, J. O’C.
Donelan, and W. R. Dawson.

It was decided to hold the Autumn Meeting of the Division, fixed for Saturday,
November 5th, 1910, at the Royal College of Physicians, Dublin.

The question of how best to mark appreciation of the work of Sir George P.
O'Farrell in the interests of the insane in Ireland during his tenure of the office of
Inspector of Lunatics was then discussed, and ultimately it was decided to appoint
a committee, consisting of Drs. Drapes, Hetherington, W. Graham, Dawson, Nolan,
Ellison, James J. Fitzgerald, O’Neill, O’Doherty, Mills, and Lawless, with power
to add to their number, to co-operate with other representatives of the staff of the
Irish Asylums in arranging for a suitable presentation, it being felt that the move¬
ment ought not to be restricted to the medical officers. In the meantime it was
decided to send to Sir George O’Farrell an expression of regret at his retirement
and appreciation of his services.

Dr. Drapes then read a paper entitled “ A Case—and A Confession.” A male
patient had been sent in from the “ idiot ward ” of the workhouse with the history
of a suicidal attempt, and also that he complained of pain which, owing to the
absence of signs to account for it, was judged to be hallucinatory. The pain
was in the epigastrium, had been complained of off and on for about two years,
and in the asylum was judged for certain reasons to be at least partly mental.
Morphia was, however, almost the only thing that gave relief. Other symptoms
supervened later, and the case eventually turned out to be one of locomotor ataxy
with gastric crises.

Dr. Donelan quoted two cases in his experience in which pain, supposed to be
hallucinatory, proved to be due to tabes.

Dr. Graham thought that the abdominal pains of tabes might be explained by

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hyperaesthesia of the abdomen, accompanying diminished sensation in the extremi¬
ties.

Drs. Mills and Dawson also spoke, and Dr. Drapes having replied, the meeting
terminated.

A brake then conveyed the members to the new asylum at Purdysburn House,
where they were entertained at lunch by Dr. Graham, who afterwards conducted
them over the villas of the new institution already occupied, and also the buildings
in course of erection, finishing with the farm-steading.

After tea at Purdysburn House a pleasant and instructive day was concluded
with a hearty vote of thanks to Dr. Graham.

RETIREMENT OF SIR GEORGE O'FARRELL.

Tribute from old Colleagues and Fellow-workers.

The retirement of Sir George O’Farrell from the position of His Majesty’s
Inspector of Lunatic Asylums, and his impending departure from Ireland, brought
together a distinguished assemblage of his friends and admirers in the Council
Chamber of Dublin Castle on Tuesday, 12th July, 1910, to make him a presenta¬
tion as a token of the esteem in which he was held during his official career.

The meeting was presided over by the Right Hon. The Lord Chancellor of
Ireland, Lord Justice General.

The following were present or were represented :

The Right Hon. Lord Ashbourne, The Right Hon. The Attorney General, Percy
Bernard, D.L., Ralph H. Byrne, Sir C. B. Ball, M.D., E. Burke, Commissioner,
Local Government Board, Sir J. G. Barton, C.B., Chief Commissioner of Valua¬
tion, The Hon. Mr. Justice Barton, E. M. Courtenay, M.B.,The Right Hon. Sir
Patrick Coll, K.C.B., Sir F. J. Cullinan, C.B., Sir H. F. Considine, C.B., C.V.O.,
J. M. Colies, Colonel Courtenay, C.B., D.L., W. P. Connolly, Thomas Considine,
F.R.C.S., Sir Francis Cruise, M.D., D.L., The Right Hon. J. H. Campbell, K.C.,
M.P., The Right Hon. Sir J. B. Dougherty, K.C.B., K.C.V.O., Blacker Douglas,
D.L., Henry Doran, Commissioner, Congested Districts Board, Hon. J. French,
R.M., Sir John Fagan, F.R.C.S., Sir John Franks, C.B., Gerald Fitz-Gibbon, K.C.,
Wilfred Fitz-Gerald, J. S. Gibbon, C.B., Chairman, General ; Prisons Board, L. J.
Hewby, Treasury Remembrancer, Sir George Holmes, K.C.V.O., Philip Hanson,

C. V.O.; William Hone, Lady Holmes, The Right Hon. Sir David Harrel, K.C.B.,
W. V. Harrel, M.V.O., Lord Killanin, Malachy Kelly, Chief Crown Solicitor,
James Little, M.D., Physician to H.M.The King in Ireland, Christopher Latouche,

D. L., Mr. Commissioner Lynch, Sir John Lentaigne, F.R.C.S., J. P. Lynch, The
Right Hon. Mr. Justice Madden, Vice-Chancellor, University of Dublin, J. Mulhall,
Vice-Chairman, General Prisons Board, The Right Hon. Sir F. Matheson, Sir
F. X. F. McCabe, The MacDermott, D.L., Sir George Morris, K.C.B., W. L.
Micks, Commissioner, Congested Districts Board, The Master of the Rolls, Sir
C. J. Nixon, Bart., M.D., David Nicolson, C.B., M.D., Robert F. Olphert, R.M.,

E. O'Farrell, Assistant Under Secretary, J. R. O’Brien, Secretary, Congested
Districts Board, The Solicitor General, F. C. Pilkington, D.L., The Right Hon.
Sir H. A. Robinson, K.C.B., Sir Andrew Reed, K.C.B.,The Right Hon. The Lord
Rathmore, James Smith, Ernest G. Swifte, Metropolitan Police Magistrate, T. S.
Stafford, C.B., D.L., J. J. Taylor, C.B., Sir Henry Thynne, C.B., His Honor Judge
Wakely, Robert Woods, M.D., President, Royal College of Surgeons, Sir Stewart
Woodhouse, Lawrence Waldron, Benjamin Williamson, Vice-Provost, T.C.D.

The presentation consisted of a handsome 18th century half-oval Sheraton satin-
wood table, a silver inkstand, candlesticks, etc.

At the opening of the proceedings, the Secretary (Sir Stewart Woodhouse)
intimated that no less than seventy letters had been received by the Committee
from supporters of the testimonial. Of these, the letters of Sir F. Cruise, Sir A.
Reed, and Mr. Commissioner Lynch were read.

The Lord Chancellor, in making the presentation, said :—Friends, I am very
glad personally to be the medium of conveying to our old and true friend, Sir
George O’Farrell, this small tribute of regard which we present to him to-day. It

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77 8

[Oct.,

is but a small tribute, but I feel that Sir George will value it most from the good
wishes and goodwill which accompany it. (Applause.)

Sir George O’Farrell has been for many years one of the heads of the Asylum
Department which he administered, and I think anyone who can go back as far as
I can will be struck by the differences that exist now as regards the treatment and
care of lunatics from what obtained then. I think everyone will see these great
differences, and it is not too much to say that this improvement in the care and
treatment of lunatics is largely due to the efforts of Sir George O’Farrell.
(Applause.) We see it in the way they are housed, in the efforts that are made for
the amelioration of their unhappy condition mentally, and the efforts towards their
cure, and we see it in the provision that is made for their outdoor employment and
health, which contributes so much to their happiness (if we may apply such a word
to these poor people). All these have largely contributed, in my opinion, to an
improvement in their mental and physical health ; and now, I think, the condition
of our lunatic poor contrasts favourably with that in any other country. For all
this, we and the public owe much to Sir George O’Farrell, and I must not omit,
when I speak of him, the able colleague who was associated with him during that
time. (Applause). But we are speaking of him not only as an able administrator,
and an able fellow-worker, but also as an old friend. We know him as a genial
companion and as an esteemed and valued friend, and we all now wish him long
life, and health, and happiness in the retirement which he has so well earned, and
into which our good wishes will follow him.

I have great pleasure in handing over to him now these mementoes of our great
regard, with the good wishes from myself, and the good wishes from you, which
you have given me the privilege of expressing. (Applause.)

Sir Georgf. O’Farrell, in reply, said :—My Lord Chancellor and Gentlemen,
we read, on authority that cannot be questioned, that “ out of the fulness of the
heart the mouth speaketh.” I can only say, in contravention of that text, that the
fulness of my gratitude, which comes from my heart, has rendered me quite
incapable of adequately expressing my obligation for your gracious presence here
to-day, and for your beautiful gifts to me. If this presentation were made solely
on the grounds of personal merit, I should be at a loss to understand why I should
receive such a compliment from you, but I infer from the inscription, and from
your lordship’s kind remarks, that you are met to honour me as much in an
official as in my private capacity, and to acknowledge the efforts which my col¬
league and myself have made during the past twenty years to raise the standard of
the care and treatment of the insane.

I may say at once that the credit for the advances which have been made are due
rather to Dr. Courtenay than to me. He is one of the most unselfish of men, and
it would be no exaggeration to say that he has spent himself in the public service.
(Applause.) It will be always a very gratifying reflection to me, and to my
colleague, on our retirement, that we are leaving the lunatic poor in a better con¬
dition than we found them. They are better housed, fed, and clothed, and the
shackles of mechanical restraint have been entirely removed, and in nearly every
public asylum in Ireland, sufficient land has been acquired for their recreation and
employment. The State Asylum at Dundrum, which is intended for the reception
of criminal lunatics, and which twenty years ago was in a state of disorganisation
which threatened a public scandal, is now—under the management of Dr. George
Revington—highly efficient for its purpose. Lastly, we found that the private and
charitable institutions for the insane, with some exceptions, were so bad that we
were obliged to take steps to have them closed by order of your lordship's prede¬
cessor. In dealing with these, it was our good fortune to be associated with’the
gentleman who exercises, under your authority and direction, the great jurisdiction
committed to you, under the Sovereign’s sign manual, over the property and
persons of lunatics and minors, and we know from our own personal observation
that Dr. Colles’ administration of his office has brought untold comforts and
blessings to the large class of mentally afflicted who are under the control of your
lordship’s Court.

Gentlemen, it is hard to say farewell, and especially hard to be separated from
old friends such as you have been to me—from such a man as Sir George Morris,
with whom I have maintained, for over twenty years, a friendship and an intimacy
that has known neither interruption nor alloy.

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IQ 10.] NOTES AND NEWS.

779

I am indeed reluctant to leave Ireland. I am like the prisoner in Prior’s poem,
who

" Often took leave, but was loth to depart.”

I need say little more. Everything must come to an end. Practically my official
career ends to-day in this room, with the seal and sanction of your lordship's
approval. But never, until my last breath leaves me, shall I forget your kindness or
fail to recall the kindly faces which I now see around me. (Applause.)

Sir George Morris proposed a vote of thanks to the Lord Chancellor for pre¬
siding. He said the Lord Chancellor had presided on this, as on other occasions,
in the kindliest spirit, and had succeeded in conveying to Sir George O’Farrell the
unanimous feeling they all had of his departure from amongst them.

The Lord Chancellor, in reply, said he did not think he deserved any thanks
for coming to see Sir George O’Farrell, and to say a last word to him as an old
friend. It was rather a melancholy task, and he hoped he would not have to under¬
take a similar one.

THE LIBRARY OF THE MEDICO-PSYCHOLOGICAL ASSOCIATION.

The Library is open daily for reading, and for the purpose of borrowing books.
Books may also be borrowed by post, provided that at the time of application
threepence in stamps is forwarded to defray the cost of postage. Arrangements
have been made with Messrs. Lewis to enable the Association to obtain books from
the lending library belonging to that firm, should any desired book not be in the
Association’s Library.

A special gTant has recently been obtained from the Association for the purpose
of binding the large number of paper volumes now in the Library. Many of these
have considerable historical and scientific interest.

At the commencement of 1911 the Library Committee propose to put the
following scheme into operation. It is designed to meet the requirements of
those members who wish to have an opportunity of regularly perusing the current
Journals :

(1) The Library will subscribe to the following five Journals :

The Journal of Abnormal Psychology.

The Journal of Nervous and Mental Diseases.

The American Journal of Insanity.

Journal de Psychologie Normale et Pathelogique.

Zeitschrift fur die gesamte Neurologic und Psychiatrie.

(2) Any member of the Association who so desires may put down his name

for one or more Journals.

(3) When the current number of a Journal arrives at the Library it’will be

immediately posted to the member whose name is first on the list. He
will be at liberty to keep the Journal for a period not exceeding a
fortnight. He will then post it to the member whose name is second
on the list. And so on, until the Journal reaches the member whose
name is last on the list. At the conclusion of his fortnight the latter
will post the Journal back to the Library, where it will be preserved and
subsequently bound.

(4) Members’ names will be entered on the list for each Journal in the order

in which they shall have applied to the Secretaries.

(5) Members wishing to avail themselves of this scheme are requested to send

their names to the undersigned at Long-Grove Asylum, Epsom—not
later than November 30th, 1910. They should at the same time state
which Journals they desire to receive.

H. Devine, 1 Hon. Secretaries,

B. Hart, j Library Committee.

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NOTES AND NEWS.

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NOTICES BY THE REGISTRAR.

The next examination for the Nursing Certificate will be held on November 7th,
1910.

The new regulations do not come into force until 1911.

In May, 1911, there will be both a Preliminary and a Final Examination.

NOTICES OF MEETINGS.

Quarterly Meeting. —The next meeting will be held at II. Chandos Street,
Cavendish Square, London, W., on Tuesday, November 15th, 1910.

South- Western Division. —The Autumn Meeting will be held on Friday, October
28th, 1910.

Northern and Midland Division. —The Autumn Meeting will be held, by the
courtesy of Dr. Hopkins, at the York City Asylum, Fulford, on Thursday, October
20th, 1910.

Scottish Division. —The Autumn Meeting will be held on Friday, November
18th, 1910.

Irish Division. —The Autumn Meeting will be held on Saturday, November 5th,
1910.

APPOINTMENTS.

Lowry, James Arthur, M.D., R.U.I., Medical Superintendent, Surrey County
Lunatic Asylum, Brookwood, vice Dr. J. E. Barton, resigned.

Carre, Henry, L.R.C.P.&S.Irel., Medical Superintendent to the Glasgow District
Asylum, Woodilee, Lenzie, Glasgow.

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INDEX TO VOL. LVI.

Part I.—GENERAL INDEX.

Acute mania, relapsing into unconsciousness, a case of, 316
Admission rates, 115, 117, 124
/Etiology, 138,349, 725
After-effects of lumbar puncture, 496
Altruism, 592
Alcoholic epilepsy, 143
„ insanity, 25
„ ,, definition of, 25

,, ,, diagnostic signs of, 30

., ,, morbid anatomy of, 47

„ „ pathology of, 58

„ ,, symptoms of, 30,32

Alcohol, its relation to feeble-mindedness, 159
American Medico-Psychological Association, 385
Amnesia, hysterical, 724

Anaesthesia, mental confusion and moods, 693
„ peripheral, 419
Analysis of dreams, the, 346
Annual dinner, the, 775
Antipathy arising from a dream, 729
Aorta, abdominal, thrombosis of, 531
Appointments, 188, 387, 587, 780
Arterio-sclerotic psychoses, 532
Asylum dysentery, causes and treatment of, 296
„ ,, preventive measures, 201

,, officers’superannuation, 368
„ reports, 161, 544, 737
,, service of Cape Colony, 269
„ Workers’ Association, 513
Auditor, appointment of, 752
Automatism in crime, 736
Auto-suggestion and delusional insanity, 311
Auras, epileptic, 726

Bacilli, milk-curdling, 423

Bacteria in the pathology of the nervous system, 734
Bacteriological investigation into general paralysis, 647
Balance sheet, 758

Berlin International Congress, 385, 765
Birth-rate and social position, 676
Blood-count in alcoholic insanity, 38
Blood of the insane, a reaction in, 524
Blood-pressure in alcoholic insanity, 37
„ in mental disorders, 96

Blood, the, in epilepsy, 686

„ „ organisms in, in mental disease, 98

LVI.

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732

INDEX.

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Bordet-Gengou reaction, 525

British Medical Association, annual meeting of (1910), 715

Cape Colony, asylum service of, 269

1, ,, lunacy administration in, 261

>. ,, registration of mental nurses in, 271

Care and training of feeble-minded, 253
,, of poor insane, 322
Causes of death in insane, 363

,, of insanity, with especial reference to the correlation of assigned factors, 1
Cell-counts in diagnosis, 487
Censure, 438
Census, the next, 371
Cerebral cortex of lemur, 132
Cerebral hemispheres, average weights of, 231

>, ,, convolutional pattern of, 235

Cerebral paralysis, transient, causes of, 138
Cerebral tumours, 146

Cerebro-spinal fluid an aid to diagnosis, 485

t. „ „ in alcoholic insanity, 496

>■ 1. ,, in dementia praecox, 495

- >. „ in epilepsy, 495

„ cadaveric, 497

,, examination of, 732

Cholesterin in cerebro-spinal fluid, 361
Chorea, Huntingdon’s, cases of, 506
Christianity, effects of introduction of, 592
Classification, Tanzzi’s, 516

Clinical neurology and psychiatry, 138, 354, 524, 726
Clinical note, a, 499
Clouston, Dr., presentation to, 375
Coagulation rate in alcoholic insanity, 38
Cobra venom reaction, 525
Communicated insanity, 480
Committee, educational, 753, 755
„ library, 753
„ parliamentary, 753

>1 „ report for year 1909-10, 759

Complement, deviation of the, 630
Complex, a, elements of, 434
Concept of insanity, the scientific, 605
,1 ,, the empirical, 597

1, ,, the volitional, 590

Conceptions of insanity, 589
Conduct, insanity as disorder of, 405
Confabulation in alcoholic insanity, 41
Congress, Berlin international, 385
„ of French alienists, 336

„ of psychology, international, 187

Control of the insane with criminal tendencies, 542
Cornu ammonis, changes in, in epilepsy, 147
Correlation of causes of insanity, 6
Creatinine, excretion of, 201

,, method of estimations of, 204
Criminal anthropology, the beginnings ot, ibi

„ classes, insane conditions amongst, 653

„ lunatics, control of, 542

,, responsibility of lunatics, 326

Cysticercus, cerebral, plasma cells in, 542

Death-rates, 115, 119, 124

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INDEX.

783

Delirium tremens, relationship to alcoholic poisoning, 29
Degeneracy and eugenics, 670
Delusional insanity, auto-suggestion and, 311
Dementia praecox and dental impaction, 725
M .. blood in, 730

„ „ pathology of, 148

„ „ psychology of, 327

„ ,, syphilis as a cause of, 138

Dementia praecocissima, 726

Deviation of the complement in mental diseases, 630

Dinner, annual, the, 775

Diploma in psychological medicine, 373

Dissociation of a personality, 518

Divisional meetings, 183, 573, 776

Dolsa, Dr. 344

Dreams, analysis of, 346

„ Freud’s theory of, 443
Drugs and the drug habit, 128
Drunkenness and alcoholic insanity, 30
Dysentery, asylum, causes and treatment of, 296
,, ,, preventive measures, 301

Election of members, 174, 368, 556, 767
Electric bath treatment, 189
Encephalitis, traumatic, cases of, 363
Ependymal alterations in general paralysis, 89
Epilepsy, alcoholic, 143

„ anaesthesia in, 693

„ changes in cornu ammonis in, 147

„ in senile dementia, 151

„ treatment by bromoglidine, 533

„ „ by salt-free diet, 533

„ viscosity of blood in, 686, 688

Epileptic auras, 726

„ equivalent, 727

Epileptics, observations on, 470
Epithelioma in general paralysis, 531
Equilibrium, investigation of, 717
Essential excitement, 700

Estimation of leucocytosis in cases of insanity, 63
Eugenics and degeneracy, 670
Excitement, treatment of, in asylums, 700

Feeble-minded, the, bodily signs in, 462

„ ,, care and training of, 253

„ „ diagnosis and treatment of, 459

„ „ marriage of, 261

Feeble-mindedness and juvenile delinquency, 159
Fissures and convolutions of the insane brain, the, 150
Forcible feeding, 114
Freud, a psychology of, 431

Freud’s psycho-analytic method, a criticism of, 536
Fugues, 336

Gaskell memorial fund, 759

General paralysis, bacteriological investigation of, 647
,, brain surface in, 129

,, epithelioma in, 531

„ juvenile, 144

,, infective foci in, 640

„ lymphocytosis in, 652

LVI.

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784

INDEX.

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General paralysis, pathological anatomy of, 541
„ „ plasma cells in, 539, 541

„ „ persistence of neuro-fibrillae in, 151

„ „ symmetrical gangrene of the extremities and, 146

„ „ syphilis, its relation to, 339

„ „ serum treatment of, 574

,, ,, three unusual cases of, 509

„ „ Wassermann reaction in, 649

Genius, a study of, 723
Governesses, paranoia of, 730

Hallucinations, visual, in the sane state, 523
Hanwell Asylum, historical survey of, 558
Headaches, neurasthenic, 142
Heredity of diathesis of phthisis and insanity, 349
,, and neuro-insane constitution, 273
Homosexuality, inborn, 145
Housing Committee, 765
Huntington’s chorea, notes on cases of, 506
Hyslop, Dr. J„ 377

Hysteria and other psycho-neuroses, 327
,, notes on a case of, 502

,, psycho-analysis and, 725

„ suicide and, 729

„ treatment of, by psycho-analysis, 733

Hysterical amnesia, 724
Hysteroid movements, case of, 317

Ideation, co-conscious, 348
Income-tax and families, 683
Infective foci in general paralysis, 640
Insane brain, fissures and convolutions of, 150
„ conditions amongst the criminal classes, 653
„ poor, care of, 322
Insanity, alcoholic, 25

„ as disorder of conduct, 405

,, causes of, with especial reference to the correlation of assigned factors, 1
„ post-operative, 727

Insomnia, treatment of, 154
Inspectors in lunacy (Ireland), 557

International committee for the study and prophylaxis of mental disease, 390, 512
„ „ articles of, 393

,, „ constitution of, 396

„ „ history of, 390

„ „ Vienna meetings of, 397

„ work of, 397

,, congress for the care of the insane, 583

» » of psychology, 187

Intra-cerebral haemorrhage in the insane, 152
Isolation in the cure of psycho-neurosis, 157

Juvenile general paralysis, 144

„ „ and spasmodic paraplegia, 357

King Edward VII, death of, 556
Korsakow’s polyneuritic psychoses, 25, 138

Laboratories in Scotland, 629

Lactic acid bacillus, treatment of melancholia by, 422
Leucocytosis in insanity, 66
Library, the, 112, 188, 386, 584, 779

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INDEX.

735

Lombroso (Prof.), 343, 383
Lumbar puncture, after-effects of, 496
Lunacy administration in Cape Colony, 261
,, „ in Scotland, 612

,, Commission, 321
Lymphocytosis in general paralysis, 652

Manual of psychiatry, 325
Marriage and insanity, 716
„ of feeble-minded, 261

Medico-Psychological Association, adjourned annual meeting, 167
„ ,, balance-sheet, 758

.. meetings of, 172, 368, 555, 752
Melancholia, treatment of, by lactic acid bacillus, 422
Mental excitement, treatment of, 700
Mesmerism and Christian science, 720
Millingen, Dr. J. G. van, 581
Mitchell, Sir A., 378
Moody, Sir J., 111, 173
Moral insanity, so-called, 145
Morbid anatomy of mental disease, 227
Munich, clinic for psychiatry at, 568
Myxoedema in manic-depressive insanity, 140, 533

National Committee re causation of insanity, 765
Needham, Dr., illness of, 752

Nerve plexi, pericellular, in pathological processes, 722
Neurasthenic headaches, 142
Neuritis in alcoholic insanity, 30
Neuroglia in the brains of the insane, 150
Neuro-fibrils in the living, existence of, 131
Neuro-insane constitution, heredity and, 273
Neurological institute, New York, 330
Neurology, 131, 722
Nightmares, 523

Notices by the Registrar, 188, 387, 780
„ of meetings, 188, 387, 585, 780
Nursing in Cape Colony, 270

Obesity and tumour of pituitary body, 357
O’Farrell, Sir G., retirement of, 777
Obituary.—Lombroso, Prof., 383

Manning, Dr. J. H., 583
Mitchell, Sir A., 378
Rutherford, Dr. J., 381
Smith, Dr. R., 582

Observations on the morbid anatomy of mental diseases, 227
Obsession, a case of, 354
Onomatomania, 530

Optic thalami and corpora striata, functions of, 452
Ovarian syndromes and mental disturbances, 728

Padded rooms, disuse of, 750
Paranoia of governesses, 730
Parapsychism, 137

Pathology of insanity, 147, 363, 539, 734
Pellagra, cases of, 512
Penal responsibility, 158

Peripheral anesthesia in exhaustion psychosis, 419
Philosophy, the relation of medicine to, 129
Physiological psychology, 132, 345, 522, 723
Pituitary body, obesity with tumour of, 357
„ „ tumour of, 358

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INDEX.

786

Plasma cells, 86

,, ,, in cerebral cysticercus, 542

in general paralysis, 539
Progress of psychiatry:

America, 329
Belgium, 332
Brazil, 519
France, 33 6
Germany, 339
Italy, 341
Spain, 343
Porges' reaction, 141
Possession by animals, a case of, 356
Post-graduate course in psychiatry, 719

Post-mortem examinations in Tyrone and Fermanagh Asylum, 323

Post-operative insanity, 727

Presentation portraits to Dr. Clouston, 375

Presidential address, 589

Prophylaxis of insanity, 390, 577

Proteid reaction, 650

Protein reactions, 486

Pseudo-infantile characters, 136

Pseudo-reminiscences, 41

Psychiatry, meeting of German Association for, 339
„ in Russia, 514

„ progress of, 329, 519

Psycho-analysis and hysteria, 725, 733
Psycho-analytic method of Freud, 536

Psychological medicine, section of, at British Medical Association, 110
Psychologie pathologique, 130
Psychology of adolescence, 137

,, of dementia praecox, 327

„ of Freud and his school, 431

„ of puberty, 132

,, social, an introduction to, 324

Psycho-therapeutics, 152, 154, 538
Psychoses, toxic and exhaustion, 418
Ptyalism, diagnostic value of, 728
Purin diet in epileptics, 470

Rashes in pellagra, 512
Recovery rates, 115, 118, 124
Reflexes, investigation of, 720
Registration of nurses in Cape Colony, 271
Retarded recovery in acute mental disorders, 144

Report of Auditor, 762, of Council, 753, of Editors, 759, of Treasurer, 757
„ of Committees, Criminal Procedure, 763
„ „ Library, 762

,, ,, Parliamentary, 760

„ ,, Inspection of School-children, 763

„ ,, Superannuation Act, 368

Report (63rd) of the Commissioners in Lunacy, 1909, 114

» (51st) of the General Board of Commissioners in Lunacy for Scotland

116

„ (58th) of the inspector of lunatics in Ireland, 1908, 123

Reports, asylum, 1909, 161
Repression, 438

Responsibility, criminal, of lunatics, 326

„ diminished, and sexual offences, 543

„ penal, 158

Ross-Jones, protein reaction, 486
Royal Asylums of Scotland, 612

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INDEX.

787

Rubio, Dr. B., 344
Rumination in the insane, 729
Russia, psychiatiy in, 514
Rutherford, Dr. J., 381

Sabromin, 364
Salt-free diet in epilepsy, 533
School-children, medical inspection of, 763
Seclusion, 705, 751
Secondary excitement, 700
Sensibility, painful, examination of, 143
Serum treatment of general paralysis, 574
Sexual education and nakedness, 365

,, organs, influence of brain on development of, 350
„ offences and diminished responsibility, 543
Sociology, 158, 364, 542, 736
Social psychology, an introduction to, 324
Sputum, albumen in, 532
State supervision of the insane (1845), 594
Sterilisation of the unfit, 682
Subconscious, conception of the, 347
Suggestion in mental pathology, 357
Suggestibility in the normal state, 134
Suicide in hysteria, 729
Superannuation Act, 109, 368
Syndrome, definition of, 607
Syphilis, serum diagnosis of, 359, 362

Tabes dorsalis, treatment of, 715
Testicle, influence of certain drugs on, 352
Text-book of mental diseases, 514

,, of nervous diseases and psychiatry, 517
Thrombosis of the abdominal aorta, 531
Tobacco in relation to insanity, 353
Toxaemia and insanity, 63
Toxic and exhaustive psychoses, 418
Toxins, path by which they reach the cord, 86
Treasurer’s report, 757
Treatment of insanity, 152, 364, 533, 733

,, of mental excitement in asylums, 700
Tuberculosis among the insane in Ireland, 125
» the London County asylums, 366

Tumours, cerebral, 146

Tyrone and Fermanagh asylum, post-mortem examinations in, 323

Vinci, Leonardo da, 522

Viscosity of blood in epilepsy, 686, 688

... „ r . some morbid physical conditions, 687

Visual hallucinations in the sane state, 523

Wassermann’s reaction, clinical value of, 732
» 11 in insanity, 649

Part II.—ORIGINAL ARTICLES.

Baird, H ependymal alterations in general paralysis, 89

Ballard, E.F., a case of aggravated hysteroid movements, 317

Baugh, L. U. H., a clinical study of anaesthesia, mental confusion and moods, 693

Rlarhfnrrt i” v - obs f. rvatlo " s of epileptics : their reaction to the purin in diet, 470
Blachford, J V functions of the optic thalamus and the corpus striatum, 452
Brown, R. D„ viscosity of the blood in epilepsy, 686

BrU< 630 C ’’ deV ' ation of the com P le ment in the mental diseases known as mania,

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788

INDEX.

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Clarke, S., blood-pressure in mental disorders, 96

Coupland,-S., the causes of insanity : a study of the returns for 1907, 1

Dawson, W. R., some points concerning the diagnosis and general treatment of
the feeble-minded, 459

Douglas, A. R., the care and training of the feeble-minded, 253

Eager, R., four cases of Huntington’s chorea, 506
East, G. R., three unusual cases of general paralysis, 509
Ewart, C. T., eugenics and degeneracy, 670

Grcenless, T. D., lunacy administration in Cape Colony, 261

Hart, B., the psychology of Freud and his school, 431

Howard, S. C., systematic estimation of the leucocytosis in certain cases of
insanity, 63

Jeffrey, G. R., significance of heredity and the neuro-insane constitution in the
production of mental disease, 273

Lavers, N., a clinical note, 499

Lind, H., a bacteriological investigation into general paralysis of the insane, 647

Macpherson, J., presidential address, 589
Mercier, C., insanity as disorder of conduct, 405
Middlemiss, J. E., notes on a case of hysteria, 502

Muirhead, Winifred, occurrence of organisms in the blood and cerebro-spinal
fluid, 98

„ „ the Wassermann reaction in the blood and cerebro-spinal

fluid, 649

Orr, D., and Rows, R. G., histological evidence that toxins reach the spinal cord
vid the spinal roots, 86

Phillips, J. G. P., treatment of melancholia by the lactic acid bacillus, 422

Raw, N., a case of acute mania relapsing into unconsciousness, 316
Robertson, G. M., treatment of mental excitement in asylums, 700
Robertson, W. F., the infective foci in general paralysis and tabes dorsalis, 640

Smith, R. P., international committee for the study of the causes and prophylaxis
of mental disease, 389

Steward, S. J., causes and treatment of asylum dysentery, 296
Stoddart, W. H. B-, a theory of the toxic and exhaustion psychoses, 418
Sturrock, J. P., insane conditions amongst the criminal classes, 653

Thomson, D., auto-suggestion and delusional insanity, 311
Turner, J., alcoholic insanity (Korsakow’s polyneuritic psychosis), 25

„ „ examination of the cerebro-spinal fluid as an aid to diagnosis, and the

protein reaction described by Ross and Jones, 485

Urquhart, A. R., lunacy administration in Scotland, 612

Wallis, R. L. M., and Goodall, E., electric bath treatment in mental disorder and
the excretion of creatinine, 189
Warnock, J., cases of pellagra, 512

Watson, G., observations on the morbid anatomy of mental disease, 227
Wilcox, A. W., communicated insanity, 480

Part III.—REVIEWS.

Dana, Dr. C. L., Text-book of nervous diseases and psychiatry, 517

Freud, Prof. S., Selected papers on hysteria and other psycho-neuroses, 327
de Fursac, Dr. J. R., Manual of psychiatry, 325

Jung, Dr. C. G., The psychology of dementia praecox, 327

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PRINCETON UNIVERSITY

INDEX.

789

McDougall, Dr. W., An introduction to social psychology, 324

Marie, Dr. A., and others, Traits internationale de psychologie pathologique, 130

Moon, Dr. R. O., The relation of medicine to philosophy, 129

Nicke, Prof., Die Gehirnoberflache von Paralytischen, 129

Oppenheimer, Dr. H., The criminal responsibility of lunatics, 326

Podmore, F., Mesmerism and Christian science, 720
Prince, Dr. M., The dissociation of a personality, 518

Report (63rd), Commissoners in Lunacy (1909), 114

i> (51 st). General Board of Commissioners in Lunacy for 1909 (Scotland),

116

„ (58th), Inspector of lunatics in Ireland (1908), 123

Sainsbury, Dr. H., Drugs and the drug habit, 128
Tanzi, Prof. E., A text-book of mental diseases, 514

Part IV.—AUTHORS REFERRED TO IN EPITOME.

Baufle, Paul, 154
Behr, H., 539
Benigni, 728

Benon and Froissart, 142
Besta, C., 722
Bianco and Gandolfi, 364
Blondel, C., and Camus,

P-. 730

Bonfiglio, F., 524
Borel, P., 345

Catola, G., 541
Ceni, C., 350, 352
Choroschko, 138
Cl^ramranet, M., 143
Cornu, Ed., 532
Costobadie, H. P., 535
Cruchet, R., 726

Dagonet, J., 151
Deroubaix, A., 528
Dorner, J., 533

von Elimger, 150
Ellis, H„ 365
Evans, E., and Dewson,
M., 159

Fornaca, G., 728, 729
Francotte, 158
Freud, S., 354, 522
Friedlander, 145, 725

Galdi, 727
Ganter, R., 363
Giuffrida-Ruggeri, 136
Goring, C., 349

Halberstadt, 529
Hart, B., 347

Haymann, 364
Heilemann, 730
Hermann, Dr., 147
Homen, E. A., 734

Isserlin, Max, 536

Jones, E., 154, 523
Jung, E., 135
ung, C. J., 346
uquelier and Dalmas, 530

Kreist, M., 729
Kurt, Halbey, 535

Lannois, P. E., and Claret,
M., 357

Legrain, M., 144
Lemaitre, A., 137
Linenthal, 724
Lowenfeld, L., 538
Lugaro, E., 131

Maere, 528

Marie, A., 146

Marie and Davidienkow,

363

Marchand, L., and Petit,
G., 151

Marro, 132, 736
Meeus, 161
Mignard, M., 529
Mingazzini, G., 150
Mott, F. W., 152, 366
„ and Kelley, A. M.,
132

Nacke, P., 145, 353, 543
Naudascher, G., 146
Naville, E., 523

Nitsche, P., 542

Olah, Gustav v., 532

Pactet, M., 357
Papadia, G., 542
Parker, G., 138
Parker, G. M., 733
Potts, W. A., 159
Prince, Morton, 152, 348
Pighini, G., 148, 361

Ramella, 143
Rebizzi, R., 531
Remond and Chevalier-
Lavaure, 144
Riche, A., 142
Roubinovitch, J., and
Levaditi, 138

Sacchini, 727
Sandri, O., 358
Schwartz, 356
Serieux, P., 529
Springer, H., 732

Tomaschny, 140, 533
Tommasi, C., 141, 362
Toulouse, 723
Turchi, G., 359

Valentine, Paul, 157
Vallet, A., and Fassou,
A., 35*5

Vallet and Marinier, 726
Vdrger, H., 525
Vigouroux, M. A., 531

Wada and Matsumoto, 732

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ILLUSTRATIONS.

Giart to illustrate Dr. Baugh’s article on “ Anxsthesia, Mental Confusion and

Moods,” 697

Charts ,. ,, “ Observations on epileptics,” 472,

477 . 478

,, Dr. Bruce’s article on “ Deviation of Complement,” 632-635
, ,, Dr. Coupland’s article on “ The Causes of Insanity,” 2, 3

,, ,, Dr. Howard’s article on “ Leucocytosis in certain Cases of

Insanity,” 70, 71, 73, 74. 76-79

,. ,. Dr. Turner’s article on “Alcoholic Insanity,” 39, 44

Chart ,, ,, „ “ Examination of Cerebro-spinal Fluid,"

491

Photograph to illustrate Dr. Mackenzie-Wallis’s and Dr. Goodall’s article on “ Elec¬
tric-bath Treatment,” 190, 191

Photographs ,, Dr. Wamock’s contribution on “ Pellagra,” 512, 513.

Photo micrographs to illustrate Dr. Baird’s article on “ Ependymal Alterations in

General Paralysis,” 94, 95

„ ,, Dr. Muirhead’s article on “ The Occurrence of Micro¬

organisms in the Blood,” 108, 109

,, ,, Dr. Phillips’article on "Treatment of Melancholia,”

430 , 43 1

,, ,, Dr. Turner’s article on “ Alcoholic Insanity,” 48, 49

Letter from the Medico-Psychological Association to King George V, 589 ; reply of
the Home Secretary, 612

ADLAKD AND SON, IMPR., LONDON AND DORKING.

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