The fact that considerable attention has been drawn of late years, both in the medical and lay press, to the subject of operations undertaken for the relief of idiocy and other mental deficiencies of child-life, must be my excuse for taking up the time of this section with observations resting, not alone upon my own limited experience, but largely on that of others. The operation of craniectomy, or as some prefer to call it linear craniotomy (that is the cutting out of strips of bone from the skull), has, indeed, almost passed from the domain of science to the region of romance, and articles have appeared in several of our popular magazines under such sensational titles as “Creating a Mind,” which have led parents of mentally-deficient children to form extravagant conceptions of the powers of surgery in this direction. It may not, therefore, be inappropriate for medical men to weigh and measure the evidence which has accumulated during the last five years as to the possibilities and impossibilities of operative interference in these cases.

My object in this paper is to give a brief note of a trial which has recently been made in the Fife Asylum, in the way of introducing female nursing in the male sick-room. Nursing is peculiarly woman's province; and it has, I believe, often been felt that it would be a great advantage if female care could be more freely utilised in the management of male insane patients, or at least of those of them who are suffering from special bodily disease in addition to the mental symptoms. The main objections to the step have hitherto been: (1) that some of the habits and peculiarities of the male insane may make it unfit or undesirable to have them under female care; and (2) that in many asylums the structural arrangement makes it difficult or impossible to bring the male sick-room under systematic supervision by the female staff. Lately it was necessary to build a large addition to the Fife Asylum; and advantage was taken of this opportunity to get rid of the second objection mentioned. The new building is a hospital block, and is intended to receive recent admissions, cases requiring special observation on account of their mental state, and cases of bodily illness. Each side (male and female) is divided into three sections: 1st, sickroom proper (for cases of bodily illness); 2nd, special observation ward (intended for new cases, and cases needing continuous supervision on account of suicidal or other dangerous tendency); and 3rd, general observation ward. There are the usual dining-hall, kitchen, and administrative rooms in the centre of the building. The male and female sick-rooms are placed next to the administrative portion, one on each side; and as the doors here are unlocked during the day, with free communication by the corridor, the male sick-room is easily reached from the female side, and is administered by the matron, the head nurse (who has charge of both sick-rooms), and two junior nurses. Each sick-room communicates with a special observation dormitory, beyond which again is the special observation day-room. This dormitory is empty during the day, but receives at night the cases which require continuous supervision on account of suicidal tendency, and which come to it direct from the special observation day-room. On the male side the door between the sick-room and the observation dormitory is kept locked during the day; and there is thus no direct communication between the sick-room and those parts of the male side which are under the charge of attendants, except by the general corridor. When the Medical Officer makes the evening visit, this door is unlocked, and the sick-room and observation dormitory are thrown into one and come under the charge of a male attendant, who is on duty during the whole night, while the nurses return to the female side of the building. This plan was followed because our numbers are too small to require separate attendance in the two rooms; and in this way the sick-room is under female care during the day, but is supervised at night by the male staff.∗

[The following communication was sent for publication by a journalist of experience. The mental aberrations described were preliminary to an attack of acute mania, from which the author happily recovered some three years ago.—Ed.]

Experiences in the mystical borderland of science have generally so little to commend them to the consideration of practical intellects, and are so often narrated in terms calculated to offend common sense, that I have for some years refrained from giving publicity to this account of the strange impressions on the visual sense which marked a period of some months of physical weakness and nervous tension. and if I now write of these visions it is in the hope that a faithful narrative of the circumstances may lead to sounder views than are now obtaining, and being widely promulgated by certain would-be leaders of thought who, in the Press and on the platform, are confounding this age of materialism by reviving teaching which would disgrace a heathen priesthood, and which outrages our fondest hopes and beliefs.

The subject matter of this paper can hardly fail to be of special interest at the present time, when so much attention is being given to, and so much done for, the nursing staff of every asylum.

In the year 1879 Dr. Urquhart and Mr. W. S. Tuke each wrote an account in this Journal∗ of his visit to the asylum at Cairo, which was then, and is now, the only institution for the treatment of the insane in Egypt. Their impressions were most unfavourable. Dr. Urquhart says, “there is “in Cairo” no more melancholy and degrading fact than the common madhouse.” “The Conolly of Egypt has still his work to do.” “The whole place is so utterly beyond the ken of civilisation that it remains as hideous a blot on the earth's surface as is to be found in the Dark Continent.” Mr. Tuke said:—“The place looked intensely squalid;” “with regard to the means employed in Egypt for the cure of insanity, I find that bleeding is the chief therapeutic remedy.” No statistics could be obtained by either visitor. Since then the institution has been removed from its old site in a suburb of the city out to a palace and stable of the late Khedive Ismail at Abbasiyeh, about three miles north of Cairo. The weakness for palace building of his late Highness was one well-known feature of that sumptuous ruler's character. What to do with those gorgeous buildings was one of the difficulties of the English Government when it assumed the control of the country. One in which 200 of his wives and concubines had been magnificently housed is now turned into the zoological gardens. Where the fair Circassians lounged is the habitation of fierce beasts of prey. The marble walks laid out for the delicate feet of those ladies are now trodden by the gaping crowds of holiday Cairene visitors. Another palace has become a most sumptuous hotel. Another contains the priceless treasures of Egyptian antiquity at Gizeh. Several have been turned into soldiers' barracks, and many more are mouldering to decay. The insane of Egypt were not thought worthy of the best of those palaces. What was good enough for his Highness's horses was surely good enough for Egyptian lunatics. So to them was assigned the stable palace with its accessories. No doubt it was a great improvement on its predecessor, but under Egyptian management and control it was far from being an ideal hospital for the insane. Soon after Rogers Pasha was put at the head of the Sanitary Department, in which the treatment of the insane is merged, he saw that native management of the asylum was wanting in initiative, in honesty and in intelligence. So he got permission to appoint a British Medical Superintendent, and he has succeeded in investing him with large powers. Fortunately he secured the services of Dr. Warnock for the position. That gentleman's first Report, for 1895, now lies before us, and a most interesting document it is. We know from a visit we lately paid to the institution that the facts are true, and that the revolution from psychiatric darkness into light that has come about is very modestly understated. No man who has the welfare of the insane at heart but must rejoice that a great work is being thus carried out in behalf of the most helpless of mankind. Dr. Warnock's difficulties were at first enormous. He found dirt, disorder, and dishonesty rampant, neglect of the patients the rule, and modern scientific treatment of mental disease conspicuous by its absence. The patients were severely drugged, badly fed, insufficiently exercised, and vigorously restrained by means of the camisole. In and about one bed—a fair specimen of the rest—he counted 3,000 bugs, lice, and fleas, and now he fines the attendant in charge a piastre for every bug that is seen! In the year 1894 the death-rate was 33 per cent.; in 1895 it fell to 16½ per cent. on the average numbers resident, and in the last half of 1895 it fell one-third as compared with the first six months of that year. It must be kept in mind that the death-rate of the city of Cairo is about 40 per 1,000, or more than twice that of London. Organisation and order has been introduced everywhere. An almost entirely new and better staff has been engaged. When Dr. Warnock went there no female nurse could read the number on her ward door nor tell the time of day from the clock. Punctuality was unknown. There was no employment for either sex. Now we saw a very large number of men and women usefully at work. Noise by night and day has vastly diminished. Dr. Warnock says:—“Regularity and order are of slow growth, but in the end must prevail.” Parasites and the tubercle bacillus and the diseases they cause, have afforded the subordinate medical staff their chief employment, but Dr. Warnock looks hopefully forward to the time when a thorough mental and bodily examination of each case, systematised case-taking and the use of scientific methods, will bring his hospital up to the level of the British standard. The dietary has been improved in quality and service. There were 526 patients admitted in 1895, while the average number resident was only 465. We believe no such proportion of new cases to resident population exists in any asylum in Europe. This is not one of the least of the difficulties of proper treatment and management in the Cairo Asylum. Few of us would like to face such a yearly influx into our institutions. There is far too little land attached to this asylum, and it is too close to a public road. The structure and arrangements of the building fall far short of our European modern standard. Yet Dr. Warnock works on hopefully and successfully. He has to be doctor, steward, architect, clerk of works, and general manager. and all this with a staff of semi-civilised Arabs, scarcely one of whom he can trust as we trust our kitchen-maids! Let any man in Great Britain who is discontented with his asylum and his staff go to Cairo and spend a day with Dr. Warnock, and he will become profoundly thankful for his privileges. In his isolation from professional stimulus, with his stable-palace and its glaring structural defects, with his stolid Arab staff and his Arabian desert without a blade of grass as an outlook, he deserves our sympathy and admiration for what he has accomplished in his year of office, and for the pluck with which he faces his task. No one but an enthusiast could have done as much. All English officials in Egypt need to be young, healthy, hopeful, and tough. Their work takes a lot out of them.

“We very much doubt whether this table will ever show much diminution on these numbers, for as time goes on the work of special certification will become more difficult and intricate.” So writes in the January number of the Journal of Mental Science the reviewer of the last Report of the Commissioners in Lunacy for England and Wales regarding the Table (Appendix B) which gives the number of readmissions on fresh reception orders rendered necessary by the previous order having expired under the Lunacy Act, 1890, sec. 38.

When Lannelongue published his accounts of his first cases of craniectomy for microcephalus, the hope was raised that microcephalic idiocy would prove a curable form of mental deficiency, and would come to be classed among the ordinary surgical diseases of children, as being mainly a bony deformity to be remedied by the use of the knife and the saw; and though Lannelongue himself did not follow Virchow's teaching and regard premature ossification of the cranial sutures as the primary cause of microcephalus, but attributed it to its actual cause, namely, arrested development of the brain, still he considered that there was undue compression and consequent dwarfing due to bony pressure, and that craniectomy would relieve this and lead to increase of brain growth.

From time to time it is confidently asserted in the public Press that not only is insanity rapidly on the increase in English prisons, but that the present system of administration is largely responsible for this state of affairs. Such statements appear to be circulated without a real knowledge of the facts, and they tend to unsettle and mislead the public mind. With the object of showing that imprisonment, as at present conducted, has not the deteriorating effect on the nervous system that it is alleged to have, the following tables, founded on an examination of Table E, Commissioners of Local Prisons, Report, England, 1895, have been prepared. Before entering into statistical details it may not be out of place to state that increased interest has recently been displayed in things pertaining to criminality and to the physical, moral, and intellectual characteristics of the criminal. There can be no doubt that the somewhat extravagant views held by a section of continental criminologists have met with a ready acceptance in certain quarters in this country. Attempts have been made to prove that the stigmata, physical and psychical, said to have been observed amongst Italian criminals, are also present in English felons. These stigmata are to be found in varying and uncertain proportion amongst a part of the population of our prisons, but not, in my opinion, to such an extent as to warrant the assumption that there exists a special criminal type or a distinct criminal neurosis. Receding foreheads, square chins, large ears, and tattoo marks are but poor data on which to base a pathological criminology, but safer ground is reached in the presence of contorted and narrow palates, of heart disease, and tubercular affections, of the after-effects of syphilis and intemperance, all of which are to be frequently met with amongst criminals.

While at Belriguardo Tasso wrote a letter to the Cardinal, who directed the Inquisition at Rome complaining that the Inquisitor at Bologna had made too little of his confessions, and that he had granted him absolution rather as to a lunatic than to a heretic. He actually proposed to come to Home to be accused in serious form. and not only did Torquato suspect his friends of denouncing him to the Inquisition, but he also accused them of heretical opinions, perhaps founded on some expressions they had used in familiar conversation. The Duke of Ferrara had, indeed, reason not only to be annoyed, but even to be seriously alarmed, for, though the Inquisitor at Bologna took a sensible view of Tasso's revelations, it was by no means certain that the Inquisition at Borne should look upon the matter in the same light. To a shrewd man who took Tasso's whole conduct into consideration he might seem deranged; but the poet possessed a wonderful power of vivid letter writing, and could make his fancies wear plausible shapes. Then the Duke's own mother was known to have been a favourer of the doctrines of Calvin, and some of the taint of heresy might be supposed to cling to Alfonso himself. He had enemies at Rome, and nothing is more credulous of evil reports than hatred. Perhaps they might favour the accusations in the hope of dispossessing him of his principality and causing it to revert to the Papal States, as was actually done after his death. About the same time Torquato wrote to his friend Gonzaga, “Either I am not only of a melancholy humour, but as it were mad, or I am too cruelly persecuted.” After ten days' stay at Belriguardo Alfonso sent Tasso back to Ferrara to be treated by his own physician. According to the pathology of the times melancholy was owing to humours rising to the brain. To expel these purgatives were the proper remedy. The poet was far from being submissive to treatment, and if the doctors did him no good they could always defend themselves by saying that their patient did not carry out their prescriptions. Tasso was kindly received at the convent of the Franciscans at Ferrara, which he repaid by accusations founded upon his ever-brooding suspicions. At another time he avowed his intention of becoming a brother of the Order.

By using the expression pseudo-general paralysis I am quite aware that I lay myself open to criticism. It may be said that the term is not only useless, but even misleading. Some will say the diseases under question are either instances of general paralysis, or, if not of general paralysis, they are other forms of disease and ought to be named accordingly. In anticipation of such an objection I venture to remark that the term general paralysis, as at present used, tends to cover many cases which are not truly general paralyses, but rather cases of insanity associated with a form of paralysis which strictly speaking is only partial. Or, to put the matter conversely, are we not too apt to include under the term general paralysis cases which are really cases of special paralyses associated with insanity?

The object of this paper is to state briefly what appears to the writer to be the law as to voluntary boarders in asylums (under which term is included all English institutions for the reception of persons of unsound mind), to narrate the practice observed in such cases at Bethlem Hospital, and to gain information from those members of the Association who are engaged in the treatment of mental disease as to their practice.

Chapter I.

General Considerations—Normal Standards of External Brain Architecture—New Details of Unusual Forms of Convolutions and Furrows—Many Deviations from Type accepted from Several Observers—Chief Deviations from Usual Form in Brains examined by the Writer, and the lines on which they occur; their significance and appraisement from a general point of view.

In an Address' in the Section of Psychology at the Annual Meeting of the British Medical Association, London, 1895, I touched upon some of the results of an analysis of many necropsies I had made, with regard to abnormal forms and arrangements of brain convolutions, and mentioned the dissatisfaction one had felt with some of the accepted standards of convolutional form. With regard to unsatisfactory standards of normal brain-form, it was stated in the Address that “we may take it for granted, and need not tarry to prove, that a different normal standard of brain-form obtains in different stages of individual life, in different races of mankind, and, as a logical inference, must obtain also in different ages of the world and epochs of time; for what practically concerns us at the moment is the normal set of standards for modern British brains. The standards of the normal, hitherto chiefly in use, and with which I began, were unsatisfactory, defective, incomplete, insufficient in range, and even misleading. For their unsatisfactoriness there are several reasons. One is that some of them have been diagrammatic or schematic, thus unduly accentuating some features and minimising or omitting others. Another is that the brains from which certain figures and descriptions are drawn have been taken from dissecting-room subjects, or from patients—most of them ‘incapables’ of various kinds, dying in rate-supported or State-supported institutions—of whose life-history little or nothing is known in many instances; who often are failures in life—waifs and strays—broken fragments of the wreckage of civilisation, the indication of degeneracy and breakdown. and such failures, waifs and wreckage are they very often—most often, indeed—because of their mental defect or perverted aberrant type of mind, which not infrequently has as its accompaniment, sometimes pathological brain change; but sometimes also, or solely, has an abnormal brain development and aberrant gyral conformation. Indeed, knew we their ancestral and life-history fully, we would search such subjects for some of the most interesting forms of convolutional deviation from type. and still more would this be the case, if, especially in the past and in some countries, dissecting-room subjects have been largely recruited from the criminals dying in prisons, and the mentally decayed and defective dying in asylums. Therefore it is not surprising to find that sometimes the brains taken from the sources previously referred to, and published as typical, are what I do not hesitate to declare and describe as being brains of deranged or of defective development, and utterly misleading if taken as normal.”

Law is often, I fear, somewhat unsatisfactory. In no class of cases is it more so than in those in which it attempts to carry out the clauses of the last Lunacy Act relating to single patients.

Public opinion will have it that this is a neurotic age, and that insanity is increasing year by year. The facts which have called forth this opinion, and appear to confirm it, are not by any means flattering to our civilisation or to the resistive power of latter-day humanity. The multiplication of asylums, and the numerical increase of the insane written large on the statistical returns of every civilised country during the past decade, apparently admit of no dubiety in regard to this question. It is necessary, therefore, that we should scan these facts more closely, and thus endeavour to ascertain if the increase of lunacy is real or assumed.

It has always appeared to me that the various figures that are supposed to indicate an increase of insanity are not only inconclusive, but do not really show anything of the sort, and that there are even some vague and indefinite indications that there is really a decrease in the annual production of insanity. Some years ago I tried to find some figures amongst the various statistics we possess that would throw some light on this point, but practically without success. It seemed that such increase in the annual admissions to asylums as was beyond that due to increase of population was more than accounted for by slighter (i.e., less demonstrative) cases of acute insanity and various forms of chronic, senile, and degenerative disorders being yearly sent to asylums more freely, but I could get no figures proving this. A somewhat suggestive fact in this direction is the often-made remark that acute mania is less abundant, melancholia more so than formerly; acute mania of an active (i.e., demonstrative) type was always sent to asylums pretty well up to its actual amount. Melancholia used to be very largely left at home or treated in workhouses. But where shall we find such facts embodied in figures. Acute mania of our statistics includes the milder as well as the more demonstrative cases, and so shows an increase just as the total figures do. There are, then, so far as I know, no figures showing the real annual occurrence of insanity that are comparable year by year. There are, indeed, no figures that give the actual annual production of insanity apart from chronic and recurrent cases. There are no figures of any definite form and intensity of acute insanity. True the Commissioners' Reports give us statistics of general paralysis, but this is precisely the one form of acute insanity that is not an insanity; that is, it belongs to a different natural order of diseases from the other diseases we mean by insanity. I have elsewhere stated that this always appears clearly on a comparison of the statistics of general paralysis with those of insanity proper, and the same opinion has been expressed by authorities who have approached the matter from a pathological and therapeutical standpoint. Its remarkable geographical distribution and its specially urban character equally show it to be different from the other insanities, which have no similar features. That this disease is increasing owing to the more and more urban character of our population affords no ground for assuming a similar progress in the true insanities. The annual recoveries must, however, be largely dependent on, and proportional to, the annually occurring cases, but will, of course, so regarded, be vitiated by the increase of population and by the increased admissions of milder forms of insanity and by the recoveries of recurrent cases.