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 Volume IV No. I I 
 
 BULLETIN 
 
 MASSACHUSETTS DEPARTMENT 
 OF MENTAL DISEASES 
 
 
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 February, 1920 
 
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SOUTHARD MEMORIAL NUMBER 
 
 Volume IV No. 1 
 
 BULLETIN 
 
 OF THE 
 
 MASSACHUSETTS DEPARTMENT 
 OF MENTAL DISEASES 
 
 (PUBLISHED QUARTERLY) 
 
 Edited under the Provisions of Acts of 1909, Chapter 504, Section 6, by 
 
 WALTER E. FERNALD, M.D. 
 GEORGE M. KLINE, M.D. 
 
 February, 1920 
 
Publication of this Document 
 
 approved by the 
 Supervisor of Administration. 
 
CONTENTS. 
 
 Foreword, . . . . . 
 
 Resolutions adopted by Department, .... 
 
 Memorial Notice by Wm. N. Bullard, M.D., 
 
 An Appreciation of Elmer E. Southard by Richard C. Cabot, M.D. 
 
 Bibliography arranged by years, . . . 
 
 PAGE 
 
 5,6 
 
 7 
 
 8-13 
 
 14-29 
 
 30-199 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/bulletinsouthardOOmass 
 
SOUTHARD MEMORIAL NUMBER. 
 
 FOREWORD. 
 
 Dr. E. E. Southard was closely identified with the Massachu- 
 setts State Hospital service from May, 1906, to Feb. 8, 1920, 
 nearly fourteen years. His early (1902) friendship with Prof. 
 A. M. Barrett, then pathologist at the Danvers State Hospital, 
 and his association with him in the department of neuropathology 
 at the Harvard Medical School, made his appointment a natural 
 one at Danvers, when Dr. Barrett was called to Michigan to be 
 the director of the Psychopathic Hospital at Ann Arbor in 1906. 
 
 From May, 1906, to May, 1909, Dr. Southard was actively 
 engaged in conducting laboratory work, always exhibiting a 
 genial leadership, stimulating others to want to work, and col- 
 laborating with all in plans for scientific investigations. He 
 brought to the State service, even at this time, a perspective 
 which tempered the enthusiasms of aggressive staff workers, 
 while his outside interests kept him from the excessive loyalties 
 which narrow vision. He continued to be a pathologist to the 
 Danvers State Hospital until 1909, when gradually the general 
 needs of the State were recognized by Charles W. Page, super- 
 intendent of the Danvers State Hospital, as paramount, and Dr. 
 Southard was made pathologist to the State Board of Insanity. It 
 was his duty to supervise the hospital laboratories, to which visits 
 were made to stimulate scientific work, but his mind was more 
 particularly occupied with plans for the Psychopathic Hospital 
 of which he was appointed director in June, 1912. The same 
 year that he was made pathologist of the State Board of Insanity, 
 in 1909, he was also made Bullard Professor at the Harvard 
 Medical School, which title he held to the last. 
 
 His seven years' work in the Psychopathic Hospital is well 
 known; what his next decade of activities would have produced 
 as the director of the newly created Psychiatric Institute can 
 only be surmised. No doubt he would have continued to produce 
 new truths in whatever field; to attack the most puzzling psychi- 
 
atric problems; and to inspire his pupils with a passion for 
 knowledge. 
 
 The Department of Mental Diseases lost its most brilliant 
 officer Feb. 8, 1920, after an eventful week of medical addresses 
 in New York City. The publication committee, in token of 
 the esteem in which he was held by the Department of Mental 
 Diseases, prints this bulletin in his honor. 
 
 GEO. M. KLINE. 
 WALTER E. FERNALD. 
 
RESOLUTIONS ADOPTED BY THE DEPARTMENT OF 
 MENTAL DISEASES. 
 
 Whereas, The Commonwealth has lost a faithful servant 
 through the death of Dr. Elmer Ernest Southard, Director of the 
 Psychiatric Institute, on Feb. 8, 1920, we, the members of the 
 Department of Mental Diseases, desire to record our great 
 sorrow at his loss, and our high appreciation of his valuable 
 service to the Department, to the institutions under its super- 
 vision, and to the Commonwealth. Dr. Southard entered the 
 service of the State in 1906, at the Danvers State Hospital, 
 where his work attracted attention, and he was made pathologist 
 to the State Board of Insanity in 1909. "With the opening of the 
 Psychopathic Department of the Boston State Hospital in 1912, 
 Dr. Southard was chosen as its director, while still acting as 
 pathologist to the Board. He continued at the Psychopathic 
 Department until appointed as director of the Massachusetts 
 State Psychiatric Institute in 1919, where his work of usefulness 
 covered the entire State. His brilliancy of mind, far-sightedness, 
 unlimited capacity for work, and kindly disposition made him 
 invaluable to the Commonwealth he so ably served. His associ- 
 ates will miss him. 
 
 Those interested in scientific research for the mentally sick 
 and feeble-minded well know how great a debt of gratitude the 
 Commonwealth owes to Dr. Southard. 
 
 As a recognition of his service, the members of the Depart- 
 ment of Mental Diseases desire and order that this memorandum 
 be spread upon the records and a copy thereof sent to Mrs. 
 Southard. 
 
8 
 
 MEMORIAL NOTICE. 1 
 
 By William N. Bullard, M.D. 
 
 Dr. Elmer E. Southard was born in Boston in 1876, was 
 educated in the public schools, and entered Harvard College in 
 1893, graduating with the degree of A.B. in 1897, and A.M. in 
 1902. 
 
 As a boy he seemed to have been in no way unusual, except 
 that he took many medals and prizes at school. In college he 
 was much interested in philosophy, and studied under both 
 James and Royce. This interest lasted him throughout life, and 
 as long as Royce lived and taught, Southard attended his semi- 
 naries at Cambridge. Once, indeed, when Royce was incapaci- 
 tated, Southard took some of his work for a time. 
 
 His chief outside interest while in college was chess. He 
 became an expert amateur chess player, was chosen to represent 
 Harvard in the matches with Yale, and was a member of the 
 Harvard Chess Club. In later years, when he was working 
 hard in the medical school or hospital, he told me that his 
 relaxation used to be to go down to New Haven in the evening 
 and play chess all night. He sometimes played chess blind- 
 folded. The very unusual powers thus shown undoubtedly 
 displayed themselves later in his work. 
 
 On leaving Harvard College, Dr. Southard entered the Har- 
 vard Medical School, taking his M.D. degree in 1901. He was 
 made pathological interne in the Boston City Hospital in 1901, 
 and later assistant in pathology in 1903. In 1901-02 he was 
 abroad for a time at Frankfort and Heidelberg. In 1904 and 
 1905 he was assistant visiting pathologist at the Boston City 
 Hospital, and at this time (1904-05) became instructor in neuro- 
 pathology in the Harvard Medical School. From this time on he 
 continued steadily in the work of neuropathology, his life work, 
 becoming assistant professor in 1906, and in 1909 Bullard pro- 
 fessor of neuropathology, which position he held at the time of 
 his death. 
 
 Dr. Southard, in later years especially, was a prolific writer. 
 He read many papers before many medical societies and associa- 
 tions, and he was a member of all the prominent national med- 
 
 1 Published in the Boston Medical and Surgical Journal, April 8, 1920. 
 
9 
 
 ical societies in his line and many others. His first paper of 
 which we have record, published in 1901, was "A Case of 
 Glioma of the Frontal Lobe," a purely pathological account of a 
 cerebral condition. He wrote little in the next two years, but in 
 1904, or 1904-05, published six papers, all purely pathological. 
 In 1905 and in 1905-06 we find five papers written either alone 
 or in collaboration with others, all, as before, neuropathological 
 in the narrowest sense (pathological). In 1906 Dr. Southard 
 became pathologist at Dan vers State Hospital, and he held this 
 position and that of assistant physician in the same hospital from 
 1906 to 1909., We have records of four papers published in 1906 
 and two in 1907, all of the same pathological nature. The 
 "Outline of Neuropathology" was published in 1906. During 
 these years (1906-09) Dr. Southard was much occupied at 
 Danvers, not only in collating and arranging his thousand 
 autopsies in order to form a basis for his future work, but in 
 attending the early morning clinics at the hospital, and in very 
 interesting investigations with Dr. Gay into certain aspects of 
 anaphylaxis. This work was specially valuable to Dr. Southard, 
 as it was the first opportunity to widen and broaden his field of 
 work. How important this was he early perceived, and he under- 
 stood that neuropathology, as it should be conceived and as it 
 was defined from the terms of the gift of endowment of the pro- 
 fessorship, was not simply the study of pathological details, 
 however important a part these might play as a foundation or 
 basis for other investigations, but comprised many wide and 
 far-reaching issues, touching and forming links with many allied 
 subjects. Many of these allied subjects became, as they were 
 more nearly approached and more closely examined, so inti- 
 mately connected with and concerned in the stricter neuro- 
 pathological investigations that they necessarily became a part, 
 and were included in the observations and researches, of the 
 more experienced neuropathologist. They became an actual part 
 of the subject of neuropathology in its widest and truest aspect. 
 
 From this time on the scope of his work grew ever wider and 
 wider. He also studied other collateral lines of work, as when 
 he went to England in the summer of 1907 to work with Sher- 
 rington on physiology. 
 
 In 1907-08 he published with Dr. Gay the article "On Serum 
 Anaphylaxis in Guinea Pigs," which assumed much importance 
 at the time, and he also published at this time four other papers, 
 all on pathological subjects. 
 
10 
 
 In 1908 "The Relative Specificity of Anaphylaxis" was pub- 
 lished in collaboration with Dr. Gay, and also four articles, 
 entitled "Further Studies in Anaphylaxis," with the same 
 author. In addition to these there were seven other papers, 
 clinical or pathological. 
 
 In 1908-09 there was published in the "American Journal of In- 
 sanity" an article by Dr. Southard and Dr. H. W. Mitchell, entitled 
 " Clinical and Anatomical Analysis of 23 Cases of Insanity arising 
 in the Sixth and Seventh Decades, with Special Relation to the 
 Incidence of Arterio-Sclerosis and Senile Atrophy and to the 
 Distribution of Cortical Pigments." This was one of the first 
 contributions from the analysis of the Danvers cases which later 
 furnished the basis for so many observations. 
 
 It is not worth while to detail the many papers or articles of 
 so prolific a writer further than to point out work of special 
 interest from some standpoint. In 1909, besides many other 
 papers, Southard published three on bacillary dysentery, follow- 
 ing the epidemic thereof at Danvers in 1908. 
 
 In 1910 came the paper on "Senile Dementia," and his work 
 on "Dementia Prsecox" was started. 
 
 The year 1912 was, again, a very active one, with articles on 
 the Psychopathic Hospital, of which he had become director, 
 and on "Normal Looking Brains" from the Danvers material. 
 
 In 1914 a most suggestive paper on "Lesions of the Optic 
 Thalamus" was published, and one on "The Topographical Dis- 
 tribution of Certain Lesions and Anomalies in Dementia Prsecox." 
 
 These last years were more or less fully occupied with his work 
 at the Psychopathic Hospital, where he gave clinics. After the 
 details of management, arrangement and teaching at the Psycho- 
 pathic Hospital had been somewhat settled, Dr. Southard was at 
 liberty for a short time to give attention to the great problems 
 of neuropathology, and at this time he began to put into appli- 
 cation a principle which he had long carefully thought out. 
 This was the application of facts and classifications in one 
 branch of knowledge to another apparently only distantly re- 
 lated. His first attempt at this seems to have been "On the 
 Application of Grammatical Categories to the Analysis of 
 Delusions." The idea that the principles, categories and classi- 
 fications used in grammar could be applied with advantage in 
 the analysis of mental states was an illuminating one. Dr. 
 Southard studied grammars of various languages carefully, and 
 sought to obtain the principles on which the languages were built. 
 
11 
 
 He was also a great student of the dictionary, — of words, 
 and of the meanings and derivations of words. This knowledge 
 had a fascination for him, and led him not only to use many 
 words not in common or general use in his addresses and writings, 
 but also aided him greatly when, as often happened in later 
 years, he desired to coin new words to express new ideas, new 
 classifications or new connotations. 
 
 Dr. Southard was very decided in his view that brain diseases, 
 insanities and dementias as well as others, should not be con- 
 sidered simply as disorders of the nervous system, but as dis- 
 orders of the body as a whole. In every insanity the whole 
 body should be examined and considered. It was partly in 
 connection with this very strong feeling that he published in 
 1914-15 his article "On the Nature and Importance of Kidney 
 Lesions in Psychopathic Subjects." 
 
 He worked vigorously during these years, 1914-16, and pub- 
 lished several articles on conditions in dementia prsecox and in 
 manic-depressive insanity; also in epilepsy, which he had for many 
 years carefully studied. 
 
 In 1916 came his " Stratigraphical Analysis of Finer Cortex 
 Changes in Certain Normal-looking Brains in Dementia Prsecox." 
 
 In 1917 he published ten papers. 
 
 In 1918 his very important paper on classification of disease 
 for diagnosis, "Diagnosis per Exclusionem in Ordine" appeared; 
 also "The Kingdom of Evil," which has been of great sugges- 
 tiveness. 
 
 From 1916 onward Dr. Southard's interests broadened and 
 widened and his work extended in many different directions. 
 
 While still working at neuropathology in the narrower sense, 
 and studying the minute anatomy of the brain in dementia 
 prsecox and manic-depressive insanity, epilepsy, etc., he was 
 formulating ideas in relation to the conclusions to be drawn from 
 the facts thus obtained. He was also working in many other 
 directions. 
 
 I. In collaboration with Dr. Fernald he undertook the pub- 
 lication of a work on "The Brains of the Feeble-Minded," and 
 Part I of this was published in 1918. It may be fairly stated that 
 this is the first scientific work carried out with all the newer and 
 more exact means of research on the brains of the feeble-minded. 
 (Part II of this work is almost finished and shortly to be pub- 
 lished.) 
 
 II. He conducted investigations into the psychology and 
 
12 
 
 mental states of employees in various factories and establish- 
 ments, showing how the knowledge of specialists in his line could 
 be applied to great advantage in the choice and adaptation of 
 workers, thus entering the subject of industrial hygiene, and 
 proving its close connection with the studies of neuropathology. 
 
 III. In his work at the Psychopathic Hospital he had insti- 
 tuted a psychiatric social service. In this he was much in- 
 terested, and in several papers he explained what this service 
 was, what its value, and how it was differentiated both from 
 ordinary social service work and from psychiatric nursing. 
 
 In his later years Dr. Southard felt that the time had arrived 
 when it was advisable for him to place his knowledge before the 
 profession and others in books rather than in more or less fugitive 
 articles. He therefore devoted his attention to writing these, 
 usually in collaboration with some one. Of these books two have 
 been published: "Neurosyphilis," with Dr.. H. C. Solomon, in 
 1917, and "Shell Shock," in 1919. He, however, had in mind 
 other books at the time of his death, and some of these were 
 far enough along to enable us to hope for their future publica- 
 tion. 
 
 Dr. Southard was a neuropathologist, and all his work and 
 interests centered around neuropathology as he understood it. 
 Neuropathology, to his mind, comprised much more than the 
 mere cutting of sections and examining them microscopically, or 
 even the deducing of great and fundamental facts from them. 
 It embraced all or any research or work which bore on or related 
 to the action of the nervous system to its environment in health, 
 or, more especially, in disease. All his other work was subsidiary 
 to this central idea. But his other work in various lines was so 
 excellent, so valuable and so dominating that he has been 
 variously claimed as a philosopher or psychologist, as a social 
 worker par excellence, as an industrial health worker and as a 
 psychiatrist, and in each of these departments it has been said 
 that he belonged to that department pre-eminently. In reality, 
 all this work in these lines was secondary or collateral to his 
 great aim, — the knowledge of the formation and character 
 of the nervous system in disease, and its relations in the internal 
 and reactions to the external world. The unusual amount of 
 work which he accomplished, and the energy and enthusiasm 
 which he showed in working on these various problems which 
 were all correlated in his mind, is the excuse for the point of 
 view of the separatists. He has written 150 articles. He had at 
 
13 
 
 the time of his death seven books in his mind, most of them in 
 some degree of preparation. 
 
 I have not entered here into any description of his peculiar 
 abilities. He had remarkable powers of deduction, and in addi- 
 tion he had an extraordinary and most unusual capacity to per- 
 ceive the salient fact and the conclusions to be drawn or which 
 were suggested by any series of facts. A paper written by an 
 assistant, which seemed to be stupid, useless and uninteresting, 
 became under his hand both valuable and illuminating because 
 the important facts were brought out and placed clearly before 
 the reader. 
 
 Dr. Southard died in New York City of pneumonia, Feb. 8, 
 1920. He left a wife, Dr. Mabel Austin Southard, to whom he 
 was married in 1906, and three children, — Austin, Ordway and 
 Anne. 
 
14 
 
 AN APPRECIATION OF ELMER E. SOUTHARD. 1 
 
 By Richard C. Cabot, '89. 
 
 Prodigious personal energy, such as radiated from Ernest 7 
 Southard, often clothes itself in a hard dour exterior, like a steam 
 engine or a fighting bull. But the peculiarity of this great psy- 
 chiatrist was that he was always bubbling over with merriment. 
 No one more ready to laugh, though no one took the world more 
 seriously, if incessant systematic industry is a mark of serious- 
 ness. Such childlike merriment is not the common mien of 
 those who spend their lives in laboratory research and in contact 
 with the insane. The rollicking joviality of his boyhood might 
 well have left him altogether when he settled himself to hour 
 after hour of microscopic work on the shrunken brains of feeble- 
 minded children. How could he keep his sparkling, rosy-cheeked 
 good humor despite his contact with the black despairs, or the 
 vacant-minded animality of the insane? 
 
 Harvard is the answer. At Harvard he struck his roots so 
 deep in the solid ground of philosophy that he could live face to 
 face with the saddest and most discouraging of all human ex- 
 periences — feeble-mindedness and insanity — and yet preserve 
 not merely a stoic calm but an irrepressible happiness. He came 
 to Harvard with no social prestige, with no capacity for ath- 
 letics, with no single advantage except a leaping and brilliant 
 mind, which till then had never found itself an asset. He had 
 always loved to think and read, but it came to him at Harvard, 
 with a shock of delighted astonishment, that there was some- 
 thing of real value in the possession of an active mind. 
 
 His brilliancy in chess first brought this home to him. Finding 
 himself intercollegiate chess champion and one of the best am- 
 ateur chess players of the country, he began to realize that he 
 could achieve a standing by means of what came easy to him. 
 He did not discover philosophy at the outset and thought that 
 he could find what he wanted in the study of comparative gram- 
 mar! Strange point of attack on life, it seems, for an apparently 
 care-free undergraduate, but quite easily understood when we 
 see what he was groping for. He was fascinated by the psycho- 
 logical suggestion of the active and passive voices, the subjunc- 
 
 1 Reprinted from "The Harvard Graduates' Magazine." 
 
15 
 
 tive mood. In later life he was prone to express his objections 
 to the Freudian psychology, to the Hebrew temperament and to 
 the deterministic prejudice of psychiatrists by saying that they 
 were exclusively in the passive voice. And only a few hours 
 before his death he remarked with a twinkle to a companion, 
 when his nurse forced him to observe some detail of sick-room 
 routine, "You see, F., we are now in the passive voice." 
 
 But he was not so in college. His actively inquisitive mind 
 soon found that not with the comparative grammarians but 
 with the philosophers he was at home. Thus he became the 
 ardent student and follower of two great philosophers, — William 
 James and Josiah Royce. Perhaps the catholicity of his mind 
 was both the cause and the result of this unusual devotion, not 
 to either alone, but to both of these strongly contrasted masters. 
 Either he did not find their teaching contradictory or he grasped 
 from each of them the ideas and impulses that did not contra- 
 dict each other. At any rate, he became the genuine disciple 
 of each of them. He loved and revered them both. To carry 
 on their work and propagate their ideas was a large part of his 
 subsequent life work. "I give that course in psychopathology in 
 Cambridge," he said to me one day, " mostly as tribute to 
 James," and in a newspaper interview a week before his death, 
 he said, apropos of "psychical research," "In the first place, I 
 must explain that I am a pupil of William James, and that I 
 never have felt that I wanted to differ from him very much in 
 any of his beliefs regarding this sort of thing." Now this was 
 said in the present tense — "I am a pupil of William James," 
 despite the fact that Dr. Southard graduated in 1897 and had 
 not studied with James for at least twenty-three years. That 
 is the spirit of actual discipleship. 
 
 The degree of his attachment to Josiah Royce may be im- 
 agined when we realize that he took Professor Royce's Logic 
 Seminary year after year for thirteen years; indeed, up to the 
 time of Royce's death. During five of those years I was in the 
 seminary with him, and so am able to trace to that source many 
 of the ideas that came sprouting out later in his medical addresses, 
 often to the mystification of his hearers. 
 
 Both his masters stimulated and fed his natural craving for 
 research, which was, I think, the central passion of his life. 
 Jubilation at the birth of new truth seems more characteristic 
 of him than any single trait that I know. He was not soberly 
 pleased with a new idea. His mind gamboled and capered about 
 
16 
 
 it with radiant delight. He played with it, turned it upside 
 down and inside out, tossed it up and caught it again. Some- 
 times (alas !) he did this before an audience — discovered the 
 new idea there before their eyes (though quite invisible to them), 
 and proceeded to play a game with it in celebration of its birth. 
 New ideas! Then why not new words to clothe them properly? 
 And incontinently he would coin some new combination of 
 Greek roots, which in turn, perhaps, would remind him of 
 Charles Pierce (one of the three great American philosophers, he 
 thought, and certainly one of the most abstruse). A flow of 
 reminiscent metaphysics would gush forth, till his audience was 
 apt to think he was laughing at them instead of at his new-born 
 idea. 
 
 Probably the greatest limitation on his influence was thus 
 stubbornly entangled with his best and central characteristic, — 
 his tumultuous joy in new truth, new facts, new plans. Readers 
 were sometimes repelled, listeners mystified or annoyed, because 
 new truth was so precious to him that he must celebrate its 
 appearance, in season or out. Yet this ungoverned rejoicing was 
 the symbol and the starting point of his creative work. Nothing 
 in him was more precious than his originality. Nothing stimu- 
 lated so much the latent originality of his fellow workers. His 
 enthusiasm for research and his joy in its results was soon to 
 make him the soul of a new institution — the Boston Psycho- 
 pathic Hospital — and the originator of two largely new pro- 
 fessions. New work, new projects radiated from him in all 
 directions. 
 
 Yet there was nothing scattered or superficial in his work. His 
 profundity was greater than his brilliancy. He stuck to one 
 tough job for fourteen years, all the years of his working life — 
 the study, post mortem, of diseased or defective brain tissues. On 
 this task his hours at the microscope, added together, must have 
 totaled several years. Sixty-two published papers described the 
 results obtained in this study alone. Yet they were but the 
 surmounted foothills of the mountain of work planned by him 
 on this subject for the next fifteen years. "I would like to find 
 the minimum brain machinery with which speech and thought 
 processes get performed," he wrote last August (answering his 
 own question, "With the war over what for me to do?"), "and 
 I hold that a proper medical, pedagogic, physiological and 
 anatomical study of feeble-mindedness will bring this ideal 
 about more quickly than any other thing. I might be willing 
 
17 
 
 to spend my whole life on this problem, feeling that a knowledge 
 of feeble-mindedness would bring a knowledge of thought, and 
 thus the greatest deepening of philosophy of which I personally 
 am capable." 
 
 The closing phrase — the ultimate goal of the whole life 
 effort — is significant. It is amplified in another passage from 
 the same statement of his future plans: "Perhaps I believe that 
 the world can get forward most by clearer and clearer definition 
 of fundamentals. Accordingly, I propose to stick to tasks of 
 nomenclature and terminology, unpopular and ridicule-provoking 
 though they may be." He was aware of the unfashionableness 
 of a search for fundamentals, but this did not deter him — even 
 stimulated him, perhaps. "For I have to contend with a deep 
 desire not to be popular," he wrote. "I would like to understaud 
 this desire not to be popular coupled with as strong a desire to 
 stand well with certain people. This class needs defining. The 
 problem is linked up with that of aristocracy — the kind that I 
 believe in. The nearest I come to it is that the aristocracy I 
 like is that of people who want to dig out novelty. Underneath 
 this I seem to have a moral motive, a confidence that whatever 
 is new is likely, on the whole and in the long run, to be better 
 than what we have. Otherwise, what is the good of time, any- 
 how?" 
 
 Was he a scientist or a philosopher? His two weighty books 
 (on "Neurosyphilis" and on "Shell Shock") are certainly scien- 
 tific, as are the great majority of his 159 pamphlets, reports and 
 monographs thus far published. 
 
 But I think the truth is that he had learned from Royce and 
 James the true relation of science and philosophy, so that he 
 could use either as he needed it, or subordinate them both in the 
 art of psychiatry. He used, served, extended and revered 
 physical science. But he avoided its passing fashions, and never 
 mistook it for the only method of finding truth or the only guide 
 to action. He used the biologic point of view in his thinking. 
 But he was never hypnotized by the German fashion of applying 
 it indiscriminately to all fields of thought. The scientific fad of 
 determinism never fooled him because he knew how to use it 
 and when to lay it aside. His philosophic training under men 
 who used scientific method without becoming enslaved by it 
 had prepared him to avoid the philosophic pitfalls into which 
 biologists, psychologists and psychiatrists are apt to fall. 
 
 But this is something new in his field. An optimistic psy- 
 
18 
 
 chiatrist who believed in the soul, who was not a materialist or a 
 determinist and therefore not a Freudian — this was something 
 quite startling; in fact, quite scandalous, some thought. For 
 after graduating at the medical school in 1901 he had difficulty 
 in getting a position as assistant in pathology at one of our great 
 Boston hospitals, because he was known to be a disciple of 
 Royce and James. But I prophesy that his fame for pure 
 scientific work will far outlast that of those who then so nearly 
 rejected him for the crime of having studied philosophy. 
 
 It is an astounding fact that, despite the characteristics which 
 I have described, he became a public official, and held office 
 under the State of Massachusetts for fourteen years, from 1906 
 till his death in February, 1920. He, a philosopher, a research 
 man and (in his own sense) an aristocrat, distrustful of legal and 
 governmental methods, an outspoken individualist, was yet able 
 to enter and to hold public office, to deal with politicians, Legis- 
 latures and budgets, and to get his work done and still keep 
 smiling. It was, he said, a matter of technique. "Father's 
 word," said his little son, "is technique," and indeed he used this 
 word with catholicity. I have heard him speak of the technique 
 of dealing with Legislatures, and in almost the next sentence of 
 the technique of Jesus Christ. 
 
 But in a more usual and limited sense he used the technique 
 of the pathologist in the group of hospitals for the insane main- 
 tained by the State of Massachusetts. With the assistance of 
 Dr. Myrtelle M. Canavan he studied countless autopsies on 
 patients dying insane in these institutions, and pursued the 
 microscopic study of their brain tissues to and beyond the limit 
 of present knowledge. No one else, his assistants tell me, was so 
 skillful in this work as he. He could find what every one else 
 passed over. His touch was minutely sensitive to the consistency 
 of brain tissues, his eye expert in microscopic diagnosis. This 
 work covered at first the whole field of his teaching as Bullard 
 professor of neuropathology at the Harvard Medical School, and 
 was continued up to his death. One thought of him then as an 
 expert in the study of the dead brain — healthy, diseased or 
 defective. He studied especially the supposedly normal brains 
 of persons dying insane, and tried to correlate the microscopic 
 abnormalities which he found with the particular delusions of the 
 patient during life. Thus he suggested, for example, that de- 
 lusions of hearing (imaginary voices, bells, etc.) are linked with 
 microscopic disease in the brain centers of hearing. 
 
19 
 
 Such studies as these filled most of his time from 1902 to 1912. 
 They led him to define one of the leading issues of his science as 
 the difference between those who believed that mental disease 
 was due to a "brain twist," a psychological derangement, and 
 those who believed, as he did, that a "brain spot," a diseased 
 area in the brain, was the cause. ("The Mind Twist and Brain 
 Spot Hypotheses in Psychopathology and Neuropathology." 
 Psychological Bulletin, 1914, XI, 117.) 
 
 But he quickly began to make his own ideas tell in the ad- 
 ministration of the State institutions as well as in pathology. He 
 saw the deficiencies as well as the latent possibilities of the re- 
 mote and isolated State institutions for the insane, and began 
 at once to stimulate the men working there along the broad lines 
 of research. He established between the Danvers Hospital and 
 the Harvard Medical School "a voluntary but close co-operation 
 in neuropathology which continued for many years. He linked 
 together the different State hospitals in a co-operative research 
 on psychiatric problems that has continued to this day." 
 
 Any one who had known him only by his published work up 
 to 1912 might have pictured Southard as destined to sit con- 
 tentedly on a laboratory stool with his eye to a microscope for 
 the rest of his working life. But in that year the State of Massa- 
 chusetts showed extraordinary good sense by appointing him direc- 
 tor of the Boston Psychopathic Hospital, a new institution built 
 near the Harvard Medical School, and intended for temporary 
 care of patients who might or might not turn out to be insane, 
 — a diagnostic station for the study of mental defects or possibly 
 mental disease, without the ponderous shackles of legal commit- 
 ment. This was in itself a novelty and an important improve- 
 ment. But a still more original feature, adopted at Dr. South- 
 ard's suggestion, was an out-patient department; that is, a place 
 to which patients suspicious of their own mentality, and those 
 whose sanity seemed doubtful to parents, friends or social 
 workers, might be brought for examination and diagnosis. This 
 department he put under the charge, not at first of a psychiatrist, 
 but of a pediatrician, Dr. W. P. Lucas, in order to link neuro- 
 psychiatry into close union with general medicine. 
 
 The insane, the feeble-minded, the alcoholic, drug habitues, 
 cranks, " queer people," geniuses, criminals whose acts suggested 
 a "brain spot or a mind twist," doddering ancients near the edge 
 of insanity yet oftentimes not insane, people with disease of the 
 kidney, the thyroid or other organs capable of producing mental 
 
20 
 
 symptoms by poisoning the whole body and brain, germ diseases 
 with brain symptoms, — these and many others came to the out- 
 patient department of the new Psychopathic Hospital. 
 
 To this influx of heterogeneous misery can be traced four in- 
 ventions which Dr. Southard has left us to carry on. New 
 resources were called for if such a multifarious assortment of 
 living problems was to be met, studied and (to the limit of 
 knowledge and skill) solved. He rose to the greatness of the 
 challenging opportunity and evolved four new ideas: — 
 
 1. The idea of the neuropsychiatrist. 
 
 2. The idea of the psychiatric social worker — social psy- 
 chiatry. 
 
 3. The diagnostic scheme of the Kingdom of Evil. 
 
 4. The idea of orderly exclusion in diagnosis. 
 
 Each of these (like every other invention) can be challenged 
 as not wholly new. There had been other neurologists who 
 understood psychiatry also (the mind's diseases as well as the 
 nervous system), but few if any who considered their province 
 to be the whole human being in all his relations and aspects! Not 
 diseases of the mind and nervous system only, but all bodily 
 diseases which could affect the mind; not disease alone, but 
 congenital defect or feeble-mindedness which is ordinarily studied 
 by specialists in that defect alone; moreover, the effect of old 
 age, the character defects due to bad training, to economic evils, 
 to "gangs," the whole problem of delinquency, of litigation and 
 its attendant evils, of unemployment or wrong employment when 
 it upsets mental or moral health, — all this was the field of the 
 neuropsychiatrist such as he had set himself to become. 
 
 Why attempt to cover such an enormous area? Because all 
 these problems presented themselves at his hospital door, and 
 because in a single patient all or nearly all of them might need 
 to be inquired into and excluded one by one until the diagnosis 
 of one sufferer's troubles was found. The feeble-minded man 
 might be also alcoholic, syphilitic, delinquent, insane or merely 
 abused by his family. There could be no sorting out or passing 
 round of such an individual into various clinics without great 
 "loss of motion" in the process. 
 
 Of course the interest of such a profession was as great as its 
 area. It developed all sides of the doctor in order that he might 
 investigate all sides of the sufferer. It brought him in touch 
 with all the queer people interested in the hospital's still queerer 
 patients. It forced his mind across the professional boundaries 
 
21 
 
 of medicine and made him a leader in the movement of our time 
 against the inhumanly narrow specialism of twenty years ago. 
 
 But he was too wise to try to do everything himself. He as- 
 sociated himself with Dr. H. C. Solomon in a masterly and 
 original book on " Neurosyphilis." Moreover, he soon found out 
 that parts of his job could be done better by women. The natural 
 ups and downs of a woman's moods, the plasticity of her sym* 
 pathies, fitted her better than the rest of us (he believed) /o 
 enter into the mental and moral intricacies of his patient, and 
 especially into his domestic life, into the school life of children 
 and the whimsies of the eccentric. When properly trained in the 
 rudiments of psychiatry, a sensible and sympathetic woman 
 could follow up the clues hit upon by the doctor in his first 
 examination of the patient, bring back fresh data from study of 
 his home, his school or his work, and so contribute to a well- 
 balanced and accurate diagnosis. Moreover, she could do much 
 to carry out the re-education, the family readjustments* and the 
 institutional treatment which issued from the diagnosis. 
 
 Thus was born the idea of the psychiatric social worker as 
 established by him at the Psychopathic Hospital and in the other 
 State hospitals for the insane. Like his idea for an out-patient 
 department for psychiatric cases, this new profession was not 
 wholly new, yet it was at first ridiculed, and then partially 
 though widely adopted by the old-line members of his profession. 
 He was constantly reproached for his innovations, and as con- 
 stantly imitated in them. Finally Smith College, in the summer 
 of 1918, gave him the opportunity to establish the first school 
 for psychiatric social workers. The sixty enthusiastic graduates 
 of this school were intended originally for war work with "shell- 
 shocked" soldiers, but have since then found plenty of oppor- 
 tunities open to them in civilian institutions. In this course he 
 was but one of many teachers; yet the alnmnse considered and 
 named him "the Father of our Course." 
 
 Contact with the social aspects of his patients' troubles and 
 with the psychiatric social case studies undertaken by Miss Mary 
 Jarrett, took him far into the field of social work. He read Miss 
 Richmond's masterly book, "Social Diagnosis," and was led to 
 attempt a new diagnostic classification of all the evils that 
 poured pell-mell into his hospital in the persons of his patients. 
 Like all his classifications, this had .practical ends, — thorough- 
 ness, order and the saving of time./ The Kingdom of Evil, as 
 he saw it in his day's work, consisted of — 
 
22 
 
 1. Disease (physical or mental). 
 
 2. Ignorance (or error). 
 
 3. Character defect. 
 
 4. Legal entanglements (delinquency, litigation). 
 
 5. Poverty (or resourcelessness of some type). 
 
 To study anybody's troubles, anybody's melancholy, revolt or 
 weakness one must ask, first, is it due to disease (for disease is 
 the commonest and the most easily attackable of such evils). 
 Next, is it due to misinformation, deficient information or mis- 
 interpretation of fact? For this sort of trouble next to disease 
 it the simplest to deal with. If neither of these evils can be 
 found, character defect and legal entanglement must be sought 
 for, Finally (because it is least common), we may ask whether 
 pur? economic defect is the root of the evil. The evils of poverty, 
 he believed, can be shown to be due in almost every case to dis- 
 ease, ignorance, character defect or litigation. Pure poverty, asa 
 correct social diagnosis, he very rarely found. Yet if the orderly 
 search ?or the other evils is not undertaken first, poverty may 
 stand out so as to become not merely an element (as in the 80 
 cases listed below), but the only diagnosis. Then economic relief 
 may be given, with harm as a result. 
 
 Classified in this way he found in a preliminary survey of 430 
 problems studied at the Psychopathic Hospital 72 of disease, 
 16 of ignorance, 157 of character, 105 of legal difficulty and 80 of 
 poverty. 
 
 At the time of his death he had just begun to attack these 
 problems in detail. A book entitled the " Kingdom of Evil," 
 written by him in conjunction with Miss Mary Jarrett, was 
 nearly finished, and will be, I hope, published shortly. 
 
 In family difficulties he wished to find out, first of all, " Who 
 dominates this family?" For through the dominating member, 
 he thought, suggestions could best be introduced and improve- 
 ments wrought. "You will find some families dominated by 
 the mother — matriarchal, we might call them. Others are of 
 the patriarchal type; the father dominates. But in my family 
 the daughter is the central figure." (Whereupon he proceeded 
 to coin a new word denoting domination by the daughter.) 
 
 "Then we need to know how many parties there are to a 
 quarrel — how many opposing points of view. There are rarely 
 more than three. The situation, as we find it, is usually duadic. 
 There is the father's point of view versus the mother's; or the 
 parents' arrayed against the daughter's. The other children, 
 
23 
 
 friends and relatives usually espouse one or the other, so that 
 their testimony is merely cumulative. But the social worker's 
 own view may well be different from either of those existing 
 before she came into the problem. Then the situation becomes 
 triadic. Beyond that you will rarely find a fourth distinct stand- 
 point. Three is usually the limit." 
 
 In pure medicine, none of his ideas, I believe, will prove more 
 fruitful than that of "diagnosis by orderly exclusion." When we 
 hunt through our pockets for a letter, we pursue the diagnosis 
 (where's that letter?) by exclusion. We search one after another 
 the places where it may be until (perhaps) we find it. This 
 method is also used in medicine, but not always with good re- 
 sults. For the diagnosis may be in none of the pockets investi- 
 gated; perhaps we forget an out-of-the-way pocket (in another 
 suit, possibly). Dr. Southard proposed a plan (a) for an ex- 
 haustive search through all the known alternatives, such exhaus- 
 tiveness being shielded for errors of memory by making it (b) 
 orderly. The order was to be determined by various practical 
 considerations. In his own specialty he listed the best-known 
 and most curable diseases first. This involved an ordered tabula- 
 tion of mental disease or defect, in classes and subclasses. Within 
 some one (or more) of these the diagnosis must lie, in case it lies 
 anywhere among the diseases already known to medical science. 
 
 Had he lived and continued in control of the Psychopathic 
 Hospital he would, I believe, have applied in the examination of 
 all out-patients the tabulation of "The Kingdom of Evil." Then 
 if the evil proved to be of the nature of disease he would have 
 repeated the orderly exclusion with his finer-meshed scheme of 
 psychiatric classification. 
 
 So far as I can see, no one has a right for the future to use any 
 other method than this in medical and social case work, until he 
 can point a better one. One can trace in it both the pragmatism 
 of James and Royce's passion for the concept of order. One can 
 see also an example of Southard's type of originality; he applied 
 in a new field concepts or tools of method taken from an old one. 
 He brought grammatical categories (passive voice, subjunctive 
 mood) into psychiatry. He applied medical logic (diagnosis by 
 exclusion) in the field of social work, and so invented the diag- 
 nostic tool called the "Kingdom of Evil." He brought the 
 methods of social work into psychiatry, and combined the two in 
 the psychiatric social worker. All this was a peculiarly Roycean 
 idea. Such comparison and transference of concepts from many 
 
24 
 
 fields of thought was the central topic of Royce's Logic Seminary, 
 and made it possible to draw into it biologists, mathematicians 
 and theologians for mutual comparison of their working tools and 
 mental processes. Like a good disciple, Southard carried this 
 master's idea into new fields. 
 
 The memory of his other master, James, urged him to quite a 
 different venture. In the last few years of his overflowing life he 
 undertook, under a grant from the Engineering Foundation, to 
 study the psychiatric aspects of industry. Carleton Parker's 
 work interested him. Phenomena like the I. W. W. he wished 
 to analyze as Parker did by studying the men's state of mind and 
 the causes which produced it. Strikes, excessive "turn over" in 
 industry, the different types of labor union leadership, could be 
 profitably studied, he thought, under the "cross light of psychia- 
 try." An obsession, a queer temperament, a mental twist, a 
 psychopathic personality, might explain much for which economic 
 solutions are unsatisfactory, and so might give us the key to 
 remedial action. He had not time to go far in this direction. 
 Hopes and plans, not fulfilments, are what he left us in this field 
 which he thought of as part of a huge and shadowy project to 
 which he and others gave the name of "the mental hygiene move- 
 ment." 
 
 Mental hygiene was, he thought, a timely way to attack in a 
 fresh spirit the ancient problems of education (secular and 
 sacred), of recreation, family life, politics and social reform. 
 Ethics was for him best attacked as mental hygiene, and he had 
 planned to give under the department of social ethics at Harvard 
 some courses which in one of his last letters he called "Psychia- 
 try and social ethics" (or simply mental hygiene). I often asked 
 him what was really known about mental hygiene in the more 
 limited and ordinary sense. He always admitted that it was an 
 empty space to be pre-empted, rather than a body of doctrine to 
 be preached — a hope and a plan, not a fact. He wanted to 
 attack all the old problems in a new way, and so with a good deal 
 of opportunism he caught up the term "mental hygiene" as one 
 conveniently suited to the mood of our time. Adopting Dean 
 Pound's suggestion, he meant to divide the propaganda for 
 mental hygiene into three groups, (a) public (or governmental), 
 (6) individual, and (c) (intermediate between the other two) 
 social, including all groups such as colleges, labor unions, clubs. 
 
 He was somewhat torn between his propagandist ideals like 
 mental hygiene and his research ideals. In time I think the 
 
25 
 
 latter would have conquered. Yet in one of his latest writings 
 his propagandism was rampant and refreshing. 
 
 "May we not rejoice," he wrote, "as psychiatrists, that we, if 
 any, are to be equipped by training and experience better, per- 
 haps, than any other men to see through the apparent terrors of 
 anarchism, of violence, of destructiveness, of paranoia — whether 
 these tendencies are shown in capitalists or in labor leaders, in 
 universities or in tenements, in Congress or under deserted cul- 
 verts. It is in one sense all a matter of the One and the Many. 
 Psychiatrists must carry their analytic powers, their ingrained 
 optimism and their tried strength of purpose not merely into the 
 narrow circle of frank disease, but, like Seguin of old, into edu- 
 cation; like William James, into the sphere of morals; like Isaac 
 Ray, into jurisprudence; and above all, into economics and in- 
 dustry. I salute the coming years as high years for psychia- 
 trists." 1 
 
 He was, as I have said, a great disciple. He was also a great 
 gatherer of disciples. Nearly sixty men during the past twelve 
 years have worked under him in such close relations that each 
 felt him nearer than any other friend. Each confided to Southard 
 his love affairs, his financial worries, as well as his scientific prob- 
 lems. To him each poured out his soul as to no other, and, if at a 
 distance, kept up steady correspondence with him. Even men 
 who had been with him but a few hours felt themselves his in- 
 timates. Part of this devotion was due, no doubt, to his utter 
 freedom from jealousy. When men working under him used his 
 ideas, accomplished a piece of work and got credit for it, he 
 seemed more pleased than if he had done the work himself. Part 
 of their devotion also was a response to his clear sparkling jubi- 
 lant nature, always ready to go full speed in thought or work, 
 whether it was his own or other's. 
 
 He was too kind hearted to discharge any employee, no matter 
 how incompetent. He was so haunted by the thought of a moral 
 downfall precipitated by the discharge that he would not be 
 responsible for it. No doubt there was another element in his 
 leniency. He believed that his psychiatric training ought to 
 make him able to get on with people with whom no one else 
 could get on. But it was not his psychiatric training but his 
 power of rich mental association and his hopefulness that made 
 him always listen so patiently and attentively to any idea con- 
 
 1 Presidential address before the American Medico-Psychological Association, June 18, 1919. 
 American Journal of Insanity, October, 1919. 
 
26 
 
 fided to him by his assistants. " He could so easily have made us 
 feel foolish, but he always listened as if we had brought him 
 something profound. He did not always try to gloss over the 
 superficiality of the remark, but he saw lines and leads in it 
 which escaped many and certainly the original propounder." 
 
 A boyish simplicity was natural to him. He had no conscious- 
 ness of dignity, though he possessed it, and almost as little, 
 apparently, of his body, though it was a very imperfect one in 
 many ways. He never seemed to want rest, took practically no 
 vacations, worked every evening and every Sunday, and was 
 rarely forced to miss a day throughout the year. Though easily 
 amused, he took almost no recreation, except chess, which filled 
 one or two evenings a month. With this and his work and the 
 use of his mind in floods of talk and discussion he had all the 
 play he wanted. His idea of a holiday was to go to New York 
 and shut himself up in a library where he could get in fifteen 
 hours of reading uninterrupted. 
 
 From childhood up his reading was voracious, and though he 
 rarely read the whole of any page, he seemed to miss nothing. 
 Recently he spoke to me of having gone through the whole of 
 George Meredith's novels in search of character types (the sage, 
 the egoist, the silent man). On another occasion he had re-read 
 the book of Job to find examples of his five types of evil, and 
 galloped through a bunch of law books to catch the "spirit of 
 laws." Yet, despite his wide ranging generalizations and his 
 innumerable journeys for the reading of papers, he never lost his 
 grip of detail or his capacity for minute, laborious, inductive 
 work. The scholarly elaboration and minuteness of detail in his 
 last two books makes this abundantly clear. 
 
 Resiliency was one of his most endearing traits. By nature and 
 by principle he was bound to turn every misfortune into some 
 particular good, so that in the end it would be better than if the 
 misfortune had not occurred. In this he had in mind Royce's 
 doctrine of atonement. " To use the psychopathic by-products 
 of society to its betterment, a sort of similia similibus- curantur 
 idea," was the way he phrased this last summer. As Mme. 
 Montessori derived improvement in education from the methods 
 used to rouse the brains of the feeble-minded children, so he 
 hoped to get light on family life as it should be by the study of 
 families containing one or more psychopathic black sheep, and 
 on normal psychology by studying the mind diseased. 
 
 When dates were not kept or specimens spoiled in the labora- 
 
27 
 
 tory, "It doesn't matter" was his habitual expression. "Let's 
 have a polychromatic world, not a monochrome." Never to take 
 a passive, an oppressed, a down-hearted or disappointed attitude 
 was a principle with him. Passivity, he held, is disease; activity 
 is health. Every setback, every misfortune set him scheming 
 anew. In fact, as one of his close friends said, " Surely, he must 
 have turned his own death to some advantage." 
 
 He made some enemies by the directness and power of his 
 attacks on what he regarded as abuses or entrenched evils; also 
 by his habit of playing with ideas before an audience. " But 
 even his enemies loved him," one of his disciples told me. In a 
 world no more Christianized than ours, it is hard to think of a 
 higher tribute than that remark. 
 
 He refused to make money, as he easily could have done by 
 consultations or by accepting some of the high-salaried positions 
 offered him. He preferred to live on his small academic and 
 State salary because this allowed him time for the research work 
 which -he wanted most of all to do. In this sacrifice his wife 
 gladly shared. But it was hard for them both, and little time 
 was left for family life. The individuality of each of his children 
 was precious in his eyes. Yet on that very account he was 
 scrupulously careful not to interfere in their free development. 
 "Sometimes I feel," he wrote last summer, "that I should not 
 try to influence too much the children, — the poet in Austin, 
 the engineer in Ordway, the executive in Anne. Should they not 
 develop themselves?" It was safer perhaps to control family 
 life in the free field of fiction. " I have an idea for certain novels 
 which would contemplate family life from a special angle. To 
 execute this plan would mean a study of style and populariza- 
 tion." Novel writing was not exactly his usual business. He 
 had never attempted anything of the kind. But this seemed no 
 obstacle to him. He regarded it merely as another "technique" 
 to be acquired. The only difficulty was his desire (already men- 
 tioned) not to be popular. 
 
 His religion was clear and personal. He had a strong distaste 
 for organized Christianity and worked solidly through his Sun- 
 days. But what he considered the essentials of Christianity — 
 among them the crucifixion and its significance — meant a great 
 deal to him. Still more intimate and pervasive was his theism. 
 He hated to talk or hear others talk of such matters in a conven- 
 tional or hortatory way, or even with emphasis and solemnity. He 
 did not wish to underline his words on any subject, but especially 
 
28 
 
 not on this. The casual, off-hand tone was his favorite; and it 
 was while shifting the logs on our camp fire last summer that he 
 followed up some rather unflattering expressions about "the 
 church deacon type of personality" by suddenly dropping one 
 end of a log and holding his free hand close above his head, with 
 the brisk remark, "But God's always right there, you know." 
 After which he veered swiftly to another topic. 
 
 He believed in personal immortality, partly from the influence 
 of his two revered masters, partly from his own experience. 
 "You know I believe in immortality," he said one day. 
 "James's instincts were almost always right." But he did not 
 wish to dwell even on this. "Of course, why not?" he said, 
 when the question of personal immortality was raised in a group 
 of his medical friends. Because it was a matter of course to him, 
 he did not wish to stress it. He used his beliefs but would not 
 boast of them. A healthy mind, he thought, will not pause at 
 such a point. Lazy self-complacency and sanctimoniousness 
 might result. The greater the idea the more instant its demand 
 for activity, for new ideas, new research, new propaganda, such 
 as engaged him up to within a few hours before his death. "In 
 the hot fit of life, a tip toe on the highest point of being, he 
 passes at a bound on to the other side. The noise of the mallet 
 and chisel are scarcely quenched, the trumpets are hardly done 
 blowing when, trailing with him clouds of glory, this happy- 
 starred, full-blooded spirit shoots into the spiritual land." 
 
 Curriculum Vit^e of E. E. Southard. 
 
 E. E. Southard was born July 28, 1876, son of Martin and 
 Olive Wentworth (Knowles) Southard of Maine, in Boston, 
 Mass. 
 
 Graduate (Franklin medallist), Boston Latin School, 1893. 
 
 A.B., Harvard College (final honors in philosophy), 1897; 
 M.D., Harvard Medical School, 1901; A.M., Harvard Univer- 
 sity, 1902. Harvard University chess champion, 1895-96 to 
 1899-1900. Doctor of science, Georgetown University, 1917. 
 
 Student interne in pathology, Boston City Hospital, 1900-01. 
 Assistant in pathology and assistant visiting pathologist, Boston 
 City Hospital, 1901-05. 
 
 Student, Senckenberg Institute (Carl Weigert, Director) Frank- 
 fort, and at University of Heidelberg, 1902. (Kraepelin's clinics 
 and Nissl's Laboratory.) 
 
29 
 
 Instructor, 1904-05; assistant professor, 1906-09; Bullard 
 professor of neuropathology, 1909-20; and head of the Depart- 
 ment of Nervous and Mental Diseases, 1913-20. 
 
 Assistant physician and pathologist, Danvers State Hospital, 
 1906-09. 
 
 Pathologist to the Massachusetts State Board of Insanity, later 
 the Commission on Mental Diseases, 1909-19. 
 
 Director of the psychopathic department of the Boston State 
 Hospital, 1912-19. 
 
 Director of the Massachusetts State Psychiatric Institute under 
 the Massachusetts Commission on Mental Diseases, 1919-20. 
 
 Associate Editor of "Archives of Neurology and Psychiatry," 
 "Journal of Nervous and Mental Disease," "Journal of Clinical 
 and Laboratory Medicine," "Journal of Abnormal Psychology," 
 and "Bulletin of Massachusetts Commission on Mental Dis- 
 eases." 
 
 Member of the American Academy of Arts and Sciences, Asso- 
 ciation of American Physicians, American Association of Patholo- 
 gists and Bacteriologists, Society of Experimental Biology and 
 Medicine, American Medical Association, American Association 
 for the Advancement of Science, American Neurological Asso- 
 ciation, American Medico-Psychological Association, National 
 Association for the Study of Epilepsy, National Association for 
 the Study of Feeble-mindedness, New England Psychiatric So- 
 ciety, Massachusetts Medical Society, Boston Society of Psychia- 
 try and Neurology. 
 
 In 1906 Dr. Southard married Dr. Mabel F. Austin who, with 
 two sons and a daughter, survives him. 
 
 In the war he served as major in the Chemical Warfare Divi- 
 sion and as director of the Boston Unit of the Army Neuropsy- 
 chiatric Training School. 
 
 Books: "Outlines of Neuropathology," 1906 (J. L. Fairbanks 
 & Co., Boston); "Neurosyphilis" (with Dr. H. C. Solomon), 
 1917 (W. M. Leonard, Boston); Shell Shock and Neuropsychia- 
 try," 1919 (W. M. Leonard, Boston); "The Kingdom of Evil," 
 1920 (to appear). 
 
 Monograph: "Waverly Researches in the Pathology of Feeble- 
 mindedness." (Memoirs of the American Academy of Arts and 
 Sciences.) 
 
30 
 
 BIBLIOGRAPHY ARRANGED BY YEARS. 
 
 1901. 
 
 Southard, E. E. A Case of Glioma of the Frontal Lobe. Med- 
 ical and Surgical Report, Boston City Hospital, 1901, 138. 
 
 Remarks. 
 
 A series of fourteen cases warrants merely qualitative notice. 
 
 Frontal gliomata, judging from those so far reported, are not 
 large, affect spheroidal shape with ill-defined borders, depend 
 for color upon contained blood (often in normal channels only, 
 but characteristically in areas of infiltration, sometimes in shape 
 of blood-pigment), and exhibit degrees of consistency quite 
 various, but usually firmer in places than the surrounding tissue. 
 Cysts are common. Gross signs of pressure are shown, com- 
 monly by flattening of convolutions, by evident bulging, or by 
 internal hydrocephalus and pressure-ring about cerebellum. 
 
 So far as origin goes, they occur in the white matter scarcely 
 more often than in the gray; and the crucial cases where epen- 
 dymal origin is indicated are few (Pfeiffer, Henneberg). 
 
 Histologically, the pictures are occasionally quite nondescript 
 (though cases where the resemblance to sarcoma was too close 
 I have excluded). The Spinnenzelle, astrocyte, or what with 
 modern technique is more properly a cell within a sort of cage 
 of fibrillse, is the characteristic finding. In the absence of 
 fibrillar there must always remain some doubt as to diagnosis. 
 Examination of sarcoma elsewhere in the body with the aniline- 
 blue connective tissue stain always shows a well-marked fibrillar 
 (collagenous) intercellular substance or a reticulum. By this 
 method it should be possible to differentiate between sarcoma 
 and cellular glioma of the brain. Elements simulating ganglion 
 cells are occasionally found (Baumann-Stroebe, Neurath, Bo- 
 nome). Lymphoid infiltration of adventitia is found (Buchholz, 
 Sbuthard). Gliosis elsewhere than in the tumor is occasionally 
 found. Pressure-atrophy with loss of myelin is found according 
 to the area destroyed. 
 
 The clinical aspects are variable, and, so far as they do not 
 hang upon simultaneous affection (by tumor, by direct or in- 
 direct pressure) of the adjacent motor and (on the left side) 
 speech areas, almost uninstructive. Moria (Witzelsucht) and 
 
31 
 
 "cerebellar" ataxia seem the nearest to positive and intrinsic 
 symptoms; but these are certainly inconstant. Perhaps the best 
 case surgically is that of Obici. The most luminous diagnosis 
 seems to be that of Bruns. Here the localized pain and tympany 
 conspired with the ataxia, of cerebellar type, to secure good 
 localization; and the affection of the motor region was a fortu- 
 nate auxiliary, especially in its slightness. The diagnosis was 
 made of gumma affecting the area afterward found gliomatous. 
 I may here thank Drs. W. P. Bolles and H. W. Cushing for 
 the clinical records of the case, Dr. J. J. Thomas for suggestions, 
 and Dr. F. B. Mallory for kind supervision of the work. 
 
 1903. 
 
 Brinckerhoff, W. R., and Southard, E. E. Note upon Ery- 
 thragglutinins in a Cyst Pluid. Journal of Medical Research, 
 Boston, 1903, IX, 28-32. 
 
 Summary. 
 The cyst fluid exhibits — 
 
 1. Hetero-erythragglutinins for — 
 
 (a) Rabbit. 
 
 (b) Dog. 
 
 (c) Guinea pig (delaj^ed). 
 
 2. Iso-erythragglutinin for one man. 
 
 3. No other iso-erythragglutinins in cases examined (no auto-erythrag- 
 
 glutinin) . 
 
 The cyst fluid is capable of developing an anti-erythragglutinin. 
 
 The patient's serum, though equally hemolytic with the fluid, 
 shows no agglutinative power. 
 
 The rabbit erythragglutinin sustains a quantitative relation to 
 the amounts of corpuscles agglutinated. 
 
 A definition of the type of agglutinate obtained in work like 
 the above may serve to bring out more clearly the value of the 
 blood corpuscles in the study of agglutinins. The kind of aggre- 
 gate observed may be shortly termed poikilagglutinate in con- 
 trast with the homoagglutinate or rouleau. 
 
 Slight acquaintance with the red corpuscles shows that they 
 clump in two forms, in one of which the arrangement might be 
 simply termed streptic, in the other staphylic. But these terms 
 are scarcely definite enough, as further examination shows. 
 
 In the streptic type they adhere rim upon rim to form the 
 
32 
 
 coinrows or rouleaux. In the staphylic type they adhere by 
 prominent angles upon surfaces of apposition which are acci- 
 dental. In the rouleaux the elements preserve to a degree their 
 biconcavity. The corpuscles may remain biconcave in the 
 staphylic aggregates, but they may be variously crenate, 
 vesicular, or otherwise distorted. The elements of a rouleau 
 are alike, whereas the unlikeness in the elements of a tridimen- 
 sional clump may be striking. Thus the streptic agglutinate and 
 the clump in three dimensions might be more strictly termed, to 
 employ the usual prefixes, homoagglutinate and poikilagglutinate. 
 
 Nevertheless, though the elements of a rouleau tend to show 
 biconcavity, the elements of the poikilagglutinate (such as one 
 gets in experiments like the above) may be equally normal 
 looking. Though the streptic agglutinate may be said to depend 
 upon shape of elements with change of surface or change of 
 ambient fluid, the staphylic agglutinate is formed without regard 
 to element shape, consistently with great variety in surface 
 character of its units, and in the absence of its usual medium. 
 
 Striking molar changes in surface, certainly involving marked 
 molecular redistribution, are consistent with the constant and 
 regular occurrence of poikilagglutination. But these changes are 
 so many and so various (crenation, vesicularity, distortion, 
 laking tendency) that they can hardly be invoked as the cause 
 or necessary condition of the clumping. 
 
 The phenomena of corpuscular clumping thus serve to demolish 
 in a simple manner those theories of agglutination which regard 
 surface changes as the essence of clumping in general. That 
 demolition had indeed been long since practically accomplished; 
 but the blood corpuscles seem an especially fitting weapon. 
 
 The foregoing study emphasizes once more the quantitative 
 character of those phenomena of which hemoagglutination is 
 one representative, sets forth a certain advantage in studying 
 the blood corpuscles to make clear the nature of agglutination, 
 and indicates the desirability of further work upon agglutinins 
 and similar principles of natural occurrence in pathological 
 fluids. 
 
33 
 
 Southard, E. E. A Case of Carcinosis with Secondary Nodule 
 in the Eye. Boston Medical and Surgical Journal, 1903, 
 CXLIX, 287-289. 
 
 Pathological Summary and Discussion. 
 
 Anatomically the case shows carcinoma of prostate with ex- 
 tension into retroperitoneal pelvic tissues; carcinoma of intestine, 
 liver, spleen, lung, mediastinum, thoracic cage, pia mater, eye; 
 general arteriosclerosis; chronic interstitial and arteriosclerotic 
 kidney. 
 
 Histologically the carcinoma is fairly constantly composed of — 
 
 (a) Smooth masses of cells having indistinct borders and a 
 cytoplasm containing clefts or vacuoles in which lie oval vesicular 
 nuclei with prominent nucleoli. 
 
 (b) A stroma varying extremely in amount from organ to 
 organ. The minor differences are partly ascribable to locus. 
 Thus the finely serrate border found in the liver depends upon 
 the rapid growth of the tumor in the parenchyma of that organ; 
 with this may be compared the smooth lobular growth in the 
 lung. The growths in the pia and in the eye must be grouped 
 together from their tendency to the papillary form. The ten- 
 dency to hemorrhage shown by the pial growth is remarkable, 
 and is probably due to local compression of the veins. Notable, 
 also, is the choroidal pigment deep in the stroma of the nodule 
 of the eye. 
 
 From anatomical and histological evidence alone one would 
 scarcely be warranted in assigning the prostate as the original 
 focus of tumor formation. But the case as a whole — taken 
 clinically as well as pathologically — seems to warrant interpre- 
 tation as a case of carcinoma of prostate with multiple metastases. 
 
 1904. 
 
 Southard, E. E., and Roberts, W. F. A Case of Chronic 
 Internal Hydrocephalus in a Youth. Journal of Nervous 
 and Mental Diseases, New York, 1904, XXXI, 73-80. 
 
 Southard, E. E. Neuropathology: Outline. J. L. Fairbanks 
 & Co., Boston. (See also 1906.) 
 
 Southard, E. E. The Central Nervous System in Variola. 
 Journal of Medical Research, Boston, 1904, XI, 298-300. 
 (New series, Vol. VI.) 
 
34 
 
 Remarks. 
 The only finding in the nervous system which can be regarded 
 as an essential part of variola is the hemorrhagic tendency some- 
 times seen in the cortex and cord in variola hemorrhagica. The 
 majority of cases of abscess, meningitis, otitis media with sinus- 
 thrombosis, and disseminated myelitis can be safely attributed, 
 in the light of present knowledge, to secondary infection with the 
 streptococcus; but the pneumococcus is occasionally responsible. 
 There is a further series of phenomena the causes of which are 
 obscure; prominent here are aphasia (usually of muscular origin), 
 isolated motor paralyses, neuritis. The most constant nerve 
 finding from the clinical aspect is some degree of delirium, which 
 is, perhaps, best regarded as the delirium of exhaustion. Re- 
 covery is here the rule. There seems to be no reported case in 
 which the cortical state can be regarded as the cause of death. 
 In the interpretation of terminal deliria the possible effects of 
 the pushing of alcohol in the treatment must not be forgotten. 
 
 Southard, E. E., and Sims, F. R. A Case of Cortical Hemor- 
 rhages following Scarlet Fever. Journal of American Medi- 
 cal Association, Chicago, 1904, XLIII, 789-792. 
 
 Remarks. 
 
 The conception of encephalitis has suffered from a dearth of 
 adequate descriptive work. The systematic treatment has, there- 
 fore, not kept pace with that of inflammation in other tissues. 
 For example, it was possible to say in 1886 that we can as yet 
 present no unitary picture of processes which culminate in brain 
 softening, if we except those which result from vascular changes. 
 Yet in 1904, in the latest systematic treatise on encephalitis, we 
 hear that recent distinctions of encephalitis into various forms are 
 erroneous, and that all these phenomena can be produced by any 
 appropriate inflammatory agents, among which are numbered 
 the organisms of meningitis and of influenza, embolism, aseptic 
 trauma, corrosive substances and heat. It is probable, however, 
 that further study will make clear a difference in the effects of 
 members of this series of agents. 
 
 There are several characteristics of the lesion produced in the 
 brain by bacteria or their toxins which serve to obscure the issue 
 by drawing attention, on the one hand, to the vascular system, 
 
35 
 
 and, on the other hand, to the neuroglia. Thus a recent triadic 
 division of encephalitis into 1, purulent; 2, hemorrhagic; 3, 
 hyperplastic, is based on the predominance in the histologic 
 picture of suppuration, diapedesis and hemorrhage, or secondary 
 glia-cell changes. It is, however, probable that all these pictures 
 may be produced by identical agents. The omnipresence of the 
 meningeal and adventitial phagocyte has contributed toward a 
 false unification of the pictures of bacterial and those of mechani- 
 cal origin. 
 
 Herein we have sought to bring out the predominance of 
 hemorrhage and phagocytosis with destruction of cortical tissue, 
 — the focal effect of meningeal suppuration in a case of subin- 
 fection with the aureus during convalescence from scarlet fever. 
 The case is one of cortical hemiplegia caught in process, and 
 brings out the now frequently exemplified inflammatory origin 
 of this disease. 
 
 Howard, F. H., and Southard, E. E. A Case of Glioma in the 
 Sella Turcica. American Journal of Medical Science, Phila- 
 delphia and New York, 1904. (New series, Vol. CXXVIII, 
 679-686.) 
 
 Remarks. 
 
 The report may be summed up as follows: — 
 
 A new growth at the base of the cranium gives rise to some- 
 what characteristic symptoms ending in death after six years. 
 The tumor has gradually filled the interpeduncular space, giving 
 rise in the lower optic apparatus to certain degenerations, a part 
 of which are complete, a part still in process. The brain at large 
 shows little reaction save a subpial gliosis, perhaps incidental to 
 the heightened intracranial tension. 
 
 The nature of the growth is in question. The oldest portion of 
 the tumor (judging by the development of the fibrillse) is in the 
 locus of the posterior lobe of the pituitary gland, which lobe nor- 
 mally contains neuroglia cells developing fibrillae. The rest of 
 the tumor contains few demonstrable fibrillae, and could scarcely 
 be differentiated from a sarcoma. It is probably justifiable to 
 classify the case as one of glioma developing in the posterior lobe 
 of the pituitary body. We are not acquainted with previously 
 reported cases of such tumors. Definite proof of the existence of 
 this tumor type can only be brought when some fortunate case 
 shall be dissected showing such a growth in the midst of, or 
 patently growing from, an otherwise normal pituitary body. 
 
36 
 
 1905. 
 
 Southard, E. E. The Neuroglia Framework of the Cerebellum 
 in Cases of Marginal Sclerosis. Journal of Medical Re- 
 search, Boston, 1905, XIII, 487-498. (New series, Vol. 
 VIII.) 
 
 Summary. 
 
 The tissues of the human cerebellum show characteristic re- 
 actions to injury. There is a line of cleavage in the normal, and 
 especially in the macerating, cerebellum, in the layer known as 
 the layer of Purkinje cells. The cells of this layer suffer the 
 maximum injury both upon impairment of blood supply and in 
 acute diseases like tuberculous and pyogenic leptomeningitis. 
 The death of the Purkinje cells is attended with a loss of their 
 processes, so that the outer or molecular layer also tends to break 
 down. Severer injury destroys not only the Purkinje cells, but 
 also the nerve cells known as the granules of the inner or granular 
 layer. Throughout the varying degrees of such injury cells of 
 the neuroglia series persist. Neuroglia cells are found active in 
 foci which contain no nerve cells. 
 
 The neuroglia reaction differs characteristically in the various 
 layers making up a lamina. In the medullary center there is a 
 regular and homogeneous gliosis in which the pre-existent cells 
 produce fibrils which run in no given directions and form a felt- 
 work. In the other layers the neuroglia reaction is regular, but 
 is not homogeneous. 
 
 The neuroglia reaction of the marginal layers is such that a 
 quite regular stratification is preserved. The strata of a sclerotic 
 lamina are formed of fibrils running in fairly definite directions. 
 The former line of cleavage is replaced with a line of cells which 
 produce numerous fibrils forming three layers: (1) a layer of fine 
 fibrils lying flatwise to the outer limits of the medullary center; 
 (2) a layer of fine fibrils external and at right angles to these, 
 and also lying flatwise with relation to ■ the medullary center; 
 and (3) a layer composed of coarser radial fibrils running, verti- 
 cally with respect to the medullary center, out to the connective 
 tissue of the pia mater. Of these fibril systems the first to de- 
 velop is the mass of radial fibrils known as Bergmann's fibers. 
 It is now possible to doubt the accuracy of Golgi pictures, which 
 make these fibers branch from cells of the inner layers. Their 
 true cells of origin lie along the line of cleavage in a cerebellar 
 lamina. 
 
37 
 
 Southard, E. E. A Case of Glioma of the Pineal Region. 
 
 American Journal of Insanity, Baltimore, 1905, LXI, 
 
 483-489. 
 
 Remarks. 
 There are in the literature somewhat over fifty accessible ob- 
 servations upon tumors (and cysts) arising in the pineal region. 
 Of these a few only relate expressly to glioma or gliosarcoma. 
 No plates accompany these accounts, which in the main antedate 
 the neuroglia knowledge of the last decade; and there is no 
 means of divining the intercellular structure from descriptions 
 of cell-pictures which fit the diagnosis equally of glioma and 
 of sarcoma. It is, nevertheless, probable that a number of these 
 cases were truly cases of pineal glioma, and that further un- 
 doubted cases will be recorded if interest can be stretched to 
 include a differentiation of the intercellular substances. It 
 is, moreover, plain that, if there be a type of psammoma related 
 to the sarcomata or endotheliomata, there exists in any event 
 also a type of sand tumor belonging to the gliomata. 
 
 Southard, E. E., and Keene, C. W. A Study of Acute Hem- 
 orrhagic Encephalitis (Staphylococcus Pyogenes Aureus). 
 American Journal of Medical Science, Philadelphia and 
 New York, 1905. (New series, Vol. CXXIX, 474-491.) 
 
 Resume. 
 
 1. The staphylococcus pyogenes aureus produces in the meninges 
 and brain substance of man a type of inflammation in which 
 hemorrhage is prominent. 
 
 The picture post-mortem in man varies from red softening or 
 multiple ecchymosis and small abscess to frank and sometimes 
 voluminous hemorrhage. The site of election for the hemorrhagic 
 lesions is the subcortical region, supplied by the long or medullary 
 branches of the cortical vascular system. 
 
 The histological picture varies from diapedesis and slight 
 leukocyte emigration to abscess and acutely destructive hem- 
 orrhage with phagocytosis. Collections of mononuclear cells 
 phagocytic for cells and cell detritus often quite obscure the 
 acute inflammatory appearance of the lesion. 
 
 Six fatal cases in man were examined, all but one, cases of 
 general infection with the staphylococcus aureus. 
 
 A history of antecedent disease was the rule. The syndromes, 
 
38 
 
 which were chiefly of sudden onset and rapid course (three to 
 fifteen days), were pysemic, meningitic, or cerebral in type. The 
 cases of slower course were the most plainly cerebral. 
 
 2. The staphylococcus pyogenes aureus produces in the brains 
 of guinea-pigs an inflammatory process which tends to subside 
 within a limited period (two weeks), and, as a rule, remains 
 without clinical signs throughout. 
 
 No hemorrhages other than miliary perivascular ones were 
 observed in the guinea pig. The lesions are seldom grossly evi- 
 dent. 
 
 The cell pictures are of meningitis (discernible in six hours), 
 ependymitis (twelve to fourteen hours), and exudation into the 
 brain substance (twenty-four to forty-eight hours). 
 
 The four and five day cases show numerous cells of the lympho- 
 cyte series as well as mononuclear cells phagocytic for exudative 
 cells. Examples of such phagocytic cells have been found as 
 early as twenty -four hours after inoculation. 
 
 The exudation into the meninges is discernible earlier, and its 
 traces are demonstrable later, than are the processes in the 
 ependyma and the encephalon; but the meningitis is never so 
 extensive or striking a process as the encephalitis or the cho- 
 roiditis. 
 
 In two weeks to a month there is little sign of the previous 
 infection. 
 
 3. The staphylococcus pyogenes aureus, of the strains and 
 in the doses experimentally used, produces in the guinea 
 pig a curable encephalitis, that is a process which in logic is 
 termed reversible. The same organism produced in our human 
 cases extensive brain lesions which surely look as a group irrep- 
 arable. Perhaps, however, there are in man also certain cases of 
 encephalitis which reverse themselves, and which in their course 
 are taxed with being "functional" diseases and furnish "func- 
 tional" symptoms during and after tissue repair. 
 
 We wish to thank Drs. Mason, Shattuck, Sears and Coolidge 
 for the use of their clinical records, and Drs. Brinckerhoff, 
 Thompson and Wolbach for the anatomical data in their autop- 
 sies. Drs. Councilman and Mallory have looked over the histo- 
 pathological work, and Dr. W. N. Bullard has interested himself 
 in its neurological aspect. The work was done under the Bullard 
 gift to the pathological department of the Harvard Medical 
 School for 1904. 
 
39 
 
 Southard, E. E. A Case of Cholesterin Stones in the Brain 
 and Cord. Journal of American Medical Association, 
 Chicago, 1905, XLV, 1731-1733. 
 
 Summary. 
 Male of fifty-six years. General and extensive arteriosclerosis, 
 extending to gross involvement of some secondary branches of 
 the circle of Willis. Death from heart failure. Small masses of 
 pure or almost pure cholesterin crystals in several parts of the 
 cortical and central ganglionic gray matter and in the white 
 matter of the spinal cord. Largest mass, 2 centimeters in diame- 
 ter, in middle of left lenticular nucleus. Thin capsules due to 
 fibrillary overgrowth of neuroglia surround the masses. The 
 relation of cholesterin to miliary glioses in the spinal cord may 
 readily escape attention. 
 
 1905, 1906. 
 
 Bullard, W. N., and Southard, E. E. A Case of Idiocy in a 
 Child with Cystic Hemispheres. Medical and Surgical 
 Report, Boston City Hospital, 1905, 77-86. Also under 
 title, Cystic Aplasia of the Cerebral Hemispheres in an 
 Idiot Child. Journal of Medical Research, Boston, 1906, 
 XIV, 431-438. (New series, Vol. XI, 272.) 
 
 General Summary and Remarks. 
 
 1. An infant, born in the eighth month of pregnancy, one of 
 twins (the other stillborn), was backward in development, gave 
 evidence of extensive nervous defect, with numerous convulsive 
 seizures, and died, when thirty-seven months old, of broncho- 
 pneumonia. 
 
 2. The autopsy showed gross cerebral changes. The ground 
 plan of the cerebrum was preserved, but the substance of each 
 hemisphere was largely replaced by a closed cystic cavity, inde- 
 pendent of the ventricles. The interiors of the cystic cavities 
 were traversed by delicate strands of neuroglia tissue. The 
 pyramidal tracts failed to develop. The cerebellum had devel- 
 oped almost normally. 
 
 3. The nature and time of the original injury cannot be ex- 
 actly fixed. The agent was probably focal and just severe enough 
 to destroy the nerve cells or nerve cell producing cells, but leave 
 the neuroglia cell-series intact and capable ultimately of produc- 
 
40 
 
 ing fibrils. The effect of this differential aplasia is that neuroglia 
 tissue alone serves to maintain much of the ground plan of the 
 cerebral cortex. 
 
 4. Although the original injury may have been quite limited in 
 extent, the failure of cell-processes and whole fiber systems to 
 develop co-ordinately with the expansion of the cerebrum has 
 increased the ultimate loss of solid tissue manyfold. 
 
 5. It is probable that the cystic chambers in the cerebrum are 
 in part due to the dilatation of perivascular spaces, with eventual 
 rending apart of their walls, as the brain plan continues to en- 
 large and the neuroglia masses contract. There are phagocytic 
 cells in recesses along the fibrous walls of the cystic spaces. It 
 is not clear whether the neuroglia tissue or one of the brain 
 envelopes is the leading tissue in the enlargement of the brain 
 plan. 
 
 6. The case showed very little thymus tissue, which was largely 
 overgrown by cells of the connective tissue series. The kidneys 
 were backward in development. There were some peculiarities of 
 the spleen. It is not yet possible to say what part is played 
 herein by the cerebral defect. 
 
 Southard, E. E. A Case of Potts' Disease in the Monkey. 
 Medical and Surgical Report, Boston City Hospital, 1905, 
 166-171. Also entered in 1906 (exactly same title), Journal 
 of Medical Research, Boston, 1906, XIV, 393-398. (New 
 series, Vol. XI.) 
 
 Summary. 
 
 1. A half -grown pet macacus, autopsied several weeks after 
 onset of paraplegia, showed tuberculosis of the spleen and of the 
 lumbar spine. There were extra dural masses opposite the upper 
 three lumbar vertebrae, together with penetration of the dura 
 and compression of the cord at the second lumbar vertebra. 
 
 2. The neuroglia fibrils in Macacus cynomologus can be demon- 
 strated well by the use of the phosphotungstic acid hematein 
 method after fixation in Zenker's fluid. The picture approxi- 
 mates that of the human cord similarly treated. The extent and 
 character of the neuroglia changes found in this case suggest 
 profitable lines of experimental work on cellular and fibrillary 
 gliosis in the monkey. 
 
 3. Areas of secondary degeneration in this case, studied com- 
 paratively by the methods of Marchi for fat, of Weigert for 
 myelin, and of Mallory for neuroglia and for connective tissue, 
 
41 
 
 demonstrate active neuroglia changes with new fibril formation 
 in an early stage of secondary degeneration. The fatty degenera- 
 tion is attended with fibrillary gliosis, the onset of which ante- 
 dates a demonstrable loss of myelin. 
 
 4. The connective tissue cells in degenerated nerve bundles in 
 the cauda equina show activity analogous to the neuroglia cell 
 changes found in the cord. 
 
 Bullard, W. N., and Southard, E. E. A Case of Diffuse 
 Gliosis of the Cerebral White Matter in a Child. Medical and 
 Surgical Report, Boston City Hospital, 1905, 19-25. Also 
 under title, Diffuse Gliosis of the Cerebral White Matter in 
 a Child. Journal of Nervous and Mental Disease, New 
 York, 1906, XXXIII, 188-193. 
 
 Summary. 
 
 1. Boy of six and a half years. Measles at three years. One 
 year before death fell backward down three steps in a cellar, 
 with epistaxis, and possibly bleeding from ear. Afterward "nerv- 
 ous." A month later began to stagger in walking, became grad- 
 ually deaf and stupid, later blind and dumb. Operation for 
 chronic internal hydrocephalus. Death two days after opera- 
 tion. 
 
 2. The autopsy showed sclerosis of the white matter of the 
 occipital, parietal and temporal lobes on both sides with scle- 
 rosis of optic thalami and of small, roughly symmetrical areas in 
 the white matter of the cerebellum. 
 
 3. The microscopic examination shows a cellular and fibrillary 
 overgrowth of neuroglia, sharply limited to the white matter. 
 The picture gradually varies from that of masses containing giant 
 cells and few fibrils to that of active fibril-producing cell masses 
 or that of stratified areas of inactive fibrillar gliosis. 
 
 4. The lesion involves the destruction of myelin sheaths and 
 considerable axis-cylinder material. The lesion may be described 
 as a multiform gliosis of the white matter with extensive mildly 
 destructive properties. The nutrition of the areas is maintained. 
 The overgrowth of neuroglia substitutes for, and to some extent 
 destroys, the involved tissues, but fails to invade, in the sense of 
 invasion by glioma. The overlying cortex fails to show important 
 changes. The origin of the condition is unknown. 
 
42 
 
 1906. 
 
 Southard, E. E. A Case of Glioma of the Frontal Lobe with 
 Invasion of the Opposite Hemisphere. American Journal of 
 Insanity, Baltimore, 1905-06, LXII, 561-570. 
 
 Summary. 
 
 1. Man of forty-one, dying ten weeks after onset of symptoms 
 pointing to cerebral disease, showed three apparently discrete 
 nodular lesions of the right frontal lobe, one of which had pierced 
 the pia mater of the longitudinal fissure and invaded the left 
 rostral convolution. 
 
 2. Examination of the hemorrhagic and edematous tissue of 
 the medullary center beneath the nodules showed bands of tissue 
 like that in the nodules. If the tumor started from one focus in 
 the medullary center, the extent and character of the lesion may 
 be due to rapid growth, unequal along different radii. Throm- 
 bosis accounts, for the necrotic and cystic center of the mass. 
 
 3. The tumor is a glioma, rapidly growing and malignant in a 
 sense unusual for cerebral gliomata, in that it invades non- 
 nervous tissue. 
 
 Southard, E. E. Outline of Neuropathology (revised from edi- 
 tion of 1904). J. L. Fairbanks & Co., Boston, 1906. 
 
 Southard, E. E., and Keene, C. W. A Study of Brain Infec- 
 tions with the Pneumococcus. Journal of American Medical 
 Association, Chicago, 1906, XL VI, 13-21. 
 
 General Summary and Remarks. 
 The foregoing is a report of cases grouped together as showing 
 effects of pneumococcus brain infection. The clinical and ana- 
 tomical varieties which they exhibit are only in part explained on 
 present evidence. A long series of cases with parallel differential 
 work on the best bacteriologic lines will be required to settle 
 questions brought up by the various extent and effect of lesions 
 like arteritis and phlebitis, by the varying prominence of poly- 
 nucleosis and mononucleosis in the meningeal exudate, by 
 variation in the phagocytic properties of the cells involved, and 
 by the varying extent and character of the attendant cellular 
 gliosis. 
 
43 
 
 Clinically viewed, these cases are quite ill assorted. The 
 group includes fulminant and wholly obscure cases; cases not 
 to be told from severe pneumonia; clearly otitic cases; septi- 
 cemic phenomena; and cases a week old or longer which are 
 clearly cerebral or meningitic in character. 
 
 Anatomically viewed, the pneumococcus produces in the 
 meninges and brain substance of man a type of inflammation in 
 which cellular exudation and fibrin formation are prominent. 
 
 The picture post-mortem varies from focal or diffuse red 
 softening to purulent leptomeningitis and ependymitis and occa- 
 sionally abscess formation. The meningeal exudate is almost 
 constant on the convexit}'. The base is frequently involved, 
 and with the base, often also the ventricles and the cord. 
 
 The histologic picture is more various than the anatomic 
 picture. The meninges contain a cellular exudate which varies 
 in the proportion of polynuclear leucocytes and mononuclear 
 cells. Phagocytosis on the part of mononuclear cells for poly- 
 nuclear leucocytes is best marked in cases in which the mono- 
 nuclear cells outnumber the polynuclear leucocytes. The meninges 
 in individual cases are fairly constant in the cell proportions found. 
 Fibrin is found about the veins and adjacent to the nerve tissue. 
 
 The arteries characteristically show lifting of the endothelium 
 by cellular exudate. The veins often show proliferative changes 
 in the intima with infiltration by polynuclear leucocytes (char- 
 acteristic in large sulcal veins). Two cases showed mural 
 thrombus formation in the veins. 
 
 Seven cases out of twelve showed increase or other signs of 
 change in the neuroglia, especially of the subpial layer. 
 
 Penetration of the cortical tissue by polynuclear leucocytes is 
 almost constant. 
 
 Orbital inoculations in the guinea pig showed remarkable 
 variety in the results with different cultures. With the cultures 
 yielding positive results a general but not constant tendency is 
 to the production of exudates with a high proportion of mono- 
 nuclear cells of the phagocytic series. A series of orbital inocu- 
 lations with culture identical throughout exhibited clearly the 
 same tendency. The exudation of polynuclear leucocytes is 
 primary, however, and may be noted in six hours. The exudate 
 is at its height in three, four or five days, and leaves no trace 
 in from two to five weeks. Ependymitis and encephalitis are not 
 prominent. The guinea pig inoculations, as a rule, produce no 
 clinical sign. 
 
44 
 
 Southard, E. E., and Stratton, R. R. A Study of Acute 
 Leptomeningitis (Streptococcus Pyogenes). Journal of 
 American Medical Association, Chicago, 1906, XL VII, 
 1271-1277. 
 
 General Summary and Remarks. 
 
 Cases of streptococcus brain infection are of interest in com- 
 parison with the cases of pneumococcus brain infection described 
 last year. The main results may be stated in connection with 
 those of the pneumococcus study. 
 
 As with the pneumococcus series, the questions of main 
 interest are brought up by the varying extent and effect of 
 lesions like (1) arteritis and phlebitis, (2) the cellular infiltration 
 of the meninges with its variation in respect to phagocytosis, 
 and (3) the attendant cellular and, in certain cases, fibrillar 
 gliosis. 
 
 Clinically viewed, the cases are of various duration and run 
 a trifle longer than the pneumococcus cases. The relation of 
 streptococcus meningitis to lung lesions is less suspicious than 
 that of staphylococcus or pneumococcus brain infections to lung 
 lesions. The part played by lung lesions in bringing about 
 meningitis has probably been overestimated. The streptococcus 
 cases seem to be more pronouncedly "cerebral" or "meningitic" 
 from the very start of acute symptoms than are the pneu- 
 mococcus and staphylococcus cases, which are a little more 
 "primary." 
 
 Anatomically viewed, the streptococcus cases preserve their 
 resemblance to the pneumococcus cases, even to the production 
 in some cases of small abscesses. Particular attention may be 
 called to the case simulating meningitis serosa (Case 4). It 
 would be well to review the cases of this disease to be found in 
 the literature, and exclude those without bacteriologic exam- 
 ination. 
 
 Considered histologically, the streptococcus cases again re- 
 semble the pneumococcus cases. The same relations of bacteria 
 to leucocytes, of leucocytes to cells of the macrophage type are 
 shown in the two series. The intimal infiltration of the arteries 
 and the intimal proliferation and exudative lesions of the veins 
 run parallel in the two cases. The occurrence of early fibrillar 
 gliosis (in the sense of the production of new fibrils by the 
 swollen neuroglia cells) is important. The interpretation of early 
 fibrillar gliosis is not easy, since it is necessary to exclude ex- 
 
45 
 
 traneous causes (eld age, arteriosclerosis, chronic active lesions) 
 for its occurrence. 
 
 An extensive series of guinea pig inoculations, which need not 
 be reported in detail, confirmed the main result, viz.: the par- 
 allelism in action of the two organisms, pneumococcus and strep- 
 tococcus. Orbital inoculations simultaneously in numerous 
 animals with histologic examination of animals killed on succes- 
 sive days were employed as in previous work. The inoculations 
 of the strains used, as a rule, produced no clinical sign, despite 
 the suppuration present. As in the human cases, each of the 
 lesions found is apparently wholly curable taken by itself. 
 
 The reversible character (to use a phrase from books' of logic) 
 of the phenomena is shown in the strikingly various pictures 
 presented by the exudate in Case 9 taken from the vertex 
 downward. 
 
 Indeed, it is rare to find in streptococcal, as in other forms 
 of acute leptomeningitis, any single lesion which is necessarily 
 incurable. It is probable that in many cases the patients die of 
 toxemia. This toxemia may vary with the extent of the exudate. 
 The amount of exudate which we see at an autopsy may mislead 
 us in our idea* of the proportions of the toxemia, since wide 
 reaches of the pia mater may be sterile, though other parts 
 contain multiplying organisms. Differential studies of the 
 exudate in several places are essential if we are to get a fair 
 sample of the conditions. Such studies might readily assume 
 clinical importance. 
 
 The early glioses found in several cases are of some importance 
 both in general and clinically. These glioses will be best con- 
 sidered in connection with those in tuberculous meningitis in a 
 subsequent paper. 
 
 Ruston, W. D., and Southard, E. E. Cerebral Seizures with 
 Suboccipital Pain; Miliary Cerebral and Gross Vertebral 
 Aneurysms. Boston Medical and Surgical Journal, 1906, 
 CLIV, 312-314. 
 
46 
 
 1907. 
 
 Southard, E. E., and Hodskins, M. B., General Encephalo- 
 malacia. (Abstract.) Journal of Nervous and Mental Dis- 
 ease, New York, 1907, XXXIV, 267-268. 
 
 Remarks. 
 
 The speakers proposed to define a type of soft brain differing, 
 on the one hand, from encephalomalacia, due to plugging of 
 vessels, and, on the other hand, from autolytic softening of post- 
 mortem origin. They termed the condition general encephalo- 
 malacia. The condition is characterized by (1) diffuse axonal 
 reactions in many types of cell; (2) diffuse fatty degeneration 
 demonstrated by the Marchi method; (3) absence in increase of 
 weight (important in distinguishing grossly from edema); (4) 
 absence of exudative changes. 
 
 Epileptics are somewhat prone to exitus with soft brain. The 
 condition seems to be associated with a 'terminal exhaustion. 
 The illustrative case, that of an epileptic dying at forty-two, was 
 of importance in that it showed the same histological changes in 
 the midst of a sclerotic area as were shown by the remainder of 
 the brain and cord. Thus the lysis, while it appears to be a 
 general histolysis, is actually a differential cytolysis or axonolysis. 
 Enlargements were shown from photomicrographs of axonal re- 
 actions in various types of cell from the illustrative case. 
 
 Southard, E. E. Late Epilepsy in a Woman over Sixty Years 
 of Age. (Abstract.) Journal of Nervous and Mental Dis- 
 ease, New York, 1907, XXXIV, 399. Also as under the 
 title, Diffuse and Focal Lesions in a Case of Late Epilepsy. 
 Transactions, National Association for the Study of Epilepsy 
 and Care and Treatment of Epileptics, 1906, IV, 131-145. 
 
 Collins, A. N., and Southard, E. E. Gliotic Cyst of the Right 
 Superior Parietal Lobule. (From the Laboratories of the 
 Boston City Hospital and the Danvers Insane Hospital.) 
 American Journal of Insanity, 1907, LXIV, 299-304. 
 
 Remarks. 
 We have to deal in the present case with a condition of cyst 
 with gliosis in the right superior parietal lobule. The cyst was 
 2.5 centimeters in diameter, and did not communicate with 
 
47 
 
 the lateral ventricle. The origin of the cyst comes in ques- 
 tion. 
 
 We are able to do no more, perhaps, than enumerate possi- 
 bilities. 
 
 Without reference to the subject's history we might propose 
 that this condition of gliotic cyst could be labeled anatomically 
 as follows : — 
 
 1. Agenesia, defining a condition in which the original tissue 
 had never been deposited in embryonic life. 
 
 2. Aplasia, defining a condition in which the original elements 
 laid down in this focus failed to develop for some reason. 
 
 3. Necrosis of focal character, defining a condition in which 
 the necrotizing agent destroyed cells which had normally de- 
 veloped. Under this head might be considered — 
 
 (a) Infarction of embolic or thrombotic origin. 
 
 (&) Hemorrhage with absorption and incomplete repair. 
 
 (c) Abscess, tubercle, gumma or other infective lesion, fol- 
 lowed by absorption of disease products without adequate re- 
 placement with scar-tissue or gliosis. 
 
 (d) Echinococcus disease. 
 
 4. Tumor formation with cystic degeneration (cystic glioma 
 or gliosis with cyst formation). 
 
 The history of the subject fails to support several of the 
 possibilities mentioned, and indeed seems inconsistent with a 
 number of them. Perhaps the earliest symptoms were due more 
 to heightened intracranial pressure than to the focal lesion. The 
 greater emphasis at times of right parietal headache might be 
 ascribed to the focal lesion. In any event, the results of the focal 
 lesion and the results of the consequent increase of intracranial 
 pressure can hardly be separated clinically at this time. 
 
 The woman had been perfectly normal up to the onset of her 
 disease six years before death. She had been a capable trained 
 nurse. Clinically there could be no suspicion of maldevelopment, 
 or of any form of bacterial or parasitic infection. 
 
 Disregarding the clinical data for the time being, we are in a 
 position to exclude the likelihood of most of the possible condi- 
 tions mentioned above. The absence of vessel lesions and of 
 phagocytic cells is striking. The normal character of tissues a 
 few millimeters distant from the gliotic wall of the cyst is sug- 
 gestive of an acquired, rather than of a congenital, lesion. 
 
 We have thought it worth while to present the case as a 
 phenomenon to be explained. No explanation seems so satis- 
 
48 
 
 factory as that of glioma with cystic degeneration. This diag- 
 nosis fails, however, to explain much, since the significance, both 
 of glioma and of cystic degeneration, remains unclear. The best 
 suggestion we can offer is that the condition is analogous to 
 syringomyelia. Gliotic cysts of the cerebrum will be understood 
 when syringomyelia is understood. Both conditions depend for 
 their explanation upon the theory of neuroglia changes. Let the 
 nerve tissues of a part of the superior parietal lobule in this case 
 undergo a slow death like that in the tissues of the posterior horn 
 of the spinal cord in a case of syringomyelia. Vascular lesions 
 fail to ensue. The neuroglia attempts to fulfil the function 
 usually attributed to it, — replacement-gliosis. The attempt is a 
 failure, as in the banal condition of cerebral infarction, and a 
 condition grossly resembling a cyst of softening follows. Altera- 
 tions in the amount of enclosed liquid ensue, just as in syrin- 
 gomyelia, and effect alterations of symptoms, complicated, how- 
 ever, to an extent not possible in syringomyelia, by heightened 
 intracranial pressure. 
 
 Just as in syringomyelia, it is perhaps not possible to allege 
 that the destruction of nerve elements in the area which after- 
 wards becomes cystic is a primary or direct destruction of nerve 
 elements. Is it possible that the gliosis is primary and not wholly 
 a replacement-gliosis? 
 
 Further cases may determine whether there is a cerebral disease 
 which proceeds on the lines of syringomyelia. 
 
 Southard, E. E. Lesions of the Granule Layer of the Human 
 Cerebellum. Journal of Medical Research, Boston, 1907, 
 XVI, 99-116. 
 
 Southard, E. E. On the Mechanism of Gliosis in Acquired 
 Epilepsy. American Journal of Insanity^ Baltimore, 1907- 
 08, LXIV, 607-641. 
 
 Summary. 
 The theory of epilepsy expounded in the present paper is 
 founded mainly upon structural considerations. The histological 
 data have been interpreted largely from a functional point of 
 view. The theory lays claim to some originality in two directions, 
 in setting forth, namely, the properties of a typical epileptogenic 
 focus in the cerebral cortex, and the nature of that change in 
 cortical tissue which favors epileptic discharges. The charac- 
 
49 
 
 teristic feature of a typical prime focus is described as the sepa- 
 ration of a normal cell-group from its normal control by other 
 cell-groups, and the impact upon the receptive surfaces of these 
 normal cells of a steady, intimate, abnormal pressure, both seg- 
 regation and compression effected by neuroglia overgrowth. That 
 feature of cortical tissue which , favors the spread of epileptic 
 discharges is described as due to a simplification of cell arrange- 
 ments, arising in the destruction of controlling elements with 
 maintenance of motor elements. In the production of both prime 
 focus and the abnormal tissue which permits uncontrolled dis- 
 charge, the neuroglia tissue plays a characteristic part — exerting 
 an active continued pressure in the first instance, and readily 
 permitting lateral discharges and the activation of great groups 
 of motor cells in the second instance. In the former case we see 
 a fresh example of the irritative property of heightened tension 
 — only here exhibited quite in miniature. In the latter instance 
 we are dealing with conditions of still greater theoretical interest, 
 approximating, though with diverse outcome, the loss of insula- 
 tion seen in foci of disseminated sclerosis. The findings suggest 
 the widely different effects upon nervous tissues of active and of 
 quiescent gliosis. 
 
 From a review of pertinent literature, it appears that physio- 
 logical interest is converging upon the field here considered. 
 Fiber-tract studies have failed to cope with other problems than 
 those of linear transmission along well-insulated paths. Only in 
 the case of multiple disseminated sclerosis and certain studies in 
 interstitial neuritis have the occurrence and nature of lateral dis- 
 charge from fiber to fiber and the effects of intimate fiber pres- 
 sure been considered. And in these instances it may well be 
 proposed that a fresh abnormal type of synaptic tissue has been 
 provided. Physiological interest is now leveled upon the synap- 
 tic tissues in general. And, if a synapse is a physical surface of 
 separation between neurones, it is serviceable to inquire what are 
 the conditions which can readily modify the synapse. The neu- 
 roglia tissue, formerly regarded as purely supportive in function, 
 here rises to a high scale of importance. The present essay points 
 out two effects of gliosis upon synaptic tissues, the one an 
 active irritative one, the other a passive effect. A review of the 
 fundamental views of Hughlings Jackson serves to demonstrate 
 the perfect generality of epileptic phenomena at all levels, and 
 makes clear why the writer sought knowledge about epilepsy in 
 organic cases. If the writer advances a case in which the prime 
 
50 
 
 epileptogenic focus consists in an active gliosis within a space of 
 1 cubic centimeter in the cornu ammonis, he cannot be charged 
 with holding that all cases of epilepsy are so brought about. He 
 describes what he regards as a typical prime focus. He conceives 
 fundamentally that similarly forcible and lasting stimulation of 
 a receptive surface, standing in important relations to the motor 
 system, might produce epileptic convulsions just as effectively as 
 the gliosis he describes. In this sense complex emotions or intes- 
 tinal worms might conceivably stand in as effective a relation to 
 the nervous system as the intimate pressure of early gliosis upon 
 the expansions of elements whose currents eventually play upon 
 the muscular system. 
 
 "Wholly distinct from these considerations about epileptogenic 
 foci are those points which are developed concerning tissues 
 facilitating discharge. A review of various authors discovered 
 much difference of opinion and considerable interpretation of 
 phenomena as secondary. The phenomenon of gliosis has not 
 escaped numerous observers, among them the very observers that 
 have emphasized the alterations of the second cortical layer as 
 important in epilepsy. But this gliosis has been regarded as 
 secondary, and our attention has been diverted rather to certain 
 cell and nuclear characters which are looked upon as specific. 
 The writer has been tempted to regard these nerve-cell changes 
 as vegetative, and at any rate as not further analyzable,.but to 
 accept them as examples of a lesion which will interfere with 
 normal control of muscular elements. The cases presented here 
 go far to prove that the nerve cells of the outer layers are the 
 first to disappear in cases of atrophy, and even along the edges of 
 ischemic areas. The tendency to the formation of tissue favor- 
 able to epileptic discharge is, according to this view, a somewhat 
 general tendency in cerebral tissue so long as the destroying 
 forces stop short of the motor elements and permit any com- 
 munication, however slight, between the motor elements and the 
 receptive side of the body. A reduction or simplification of the 
 system through destruction of the smaller elements of the cere- 
 bral cortex procures new reflex arcs with fresh surfaces of separa- 
 tion which are perhaps even simpler and more automatic than 
 the spinal arcs and synapses. The peculiar features of the epilep- 
 tic discharge depend upon the inertia of currents travelling in 
 simplified arcs, and upon the lack of energy-absorbents en route. 
 The cerebral arcs normally escape automatism through a multi- 
 tude of synaptic connections; under epileptic conditions the cere- 
 
51 
 
 bral mechanism approaches in fatality the spinal mechanism. 
 Under this conception epilepsy and phenomena like clonus are 
 readily perceived to belong to a single logical group. 
 
 The phenomenon of epilepsy, in short, requires the intactness 
 and even the normality of some well-defined route from stimulus 
 to muscles. If we conceive the stadia of this route set end to 
 end, with the cerebral synaptic tissue in the middle, we perceive 
 that toward the two ends of the linear series it becomes increas- 
 ingly difficult to provide conditions which will produce general- 
 ized and spreading convulsions. Destruction of elements at any 
 point in the route should at first sight exclude the production of 
 epilepsy. And so, in most cases, the destruction of the efferent 
 paths will exclude epilepsy. In the afferent paths, however, the 
 very process of destruction often constructs new and potent sur- 
 faces of stimulation which act as epileptogenic foci; and, in the 
 cerebral synaptic tissue, the strata are so constructed that the 
 loss of smaller, central, modifying and inhibitory elements is 
 effected prior to the loss of the major elements which are es- 
 sential to the intactness of the great route. And these major 
 efferent elements can themselves be subject from time to time to 
 stimulation afforded by the contractile energies of growing 
 neuroglia. Epileptogenic stimuli are applied in all cases to those 
 elements having a forward direction, so that the reaction is in 
 most cases, if not necessarily, a sensorimotor reaction in Hugh- 
 lings Jackson's sense. 
 
 What are the applications of this theory to the phenomena of 
 idiopathic epilepsy? In certain cases of idiopathic epilepsy there 
 seems to be grave- doubt whether any adequate epileptogenic foci can 
 be discovered. There is more hope that tissues faoorable to epileptic 
 discharge shall be discovered, if the proper methods are employed. 
 
 We can see some reason for the absence of effective foci in 
 hereditary cases, particularly if we bear in mind the epileptic 
 offspring of Brown-Sequard's injured guinea pigs. With the 
 onset of topographic and stratigraphic knowledge of the cerebral 
 cortex we shall approach more nearly to a definition of tissues 
 suitable for the propagation of epileptic discharges. So far it 
 seems that such synaptic tissues are characterized by abnormally 
 simplified arcs whose impulses are the more automatic through 
 the lack of countercurrents from surrounding cells. Whether 
 we are to look in inherited serum properties for the production 
 of such conditions, the future will decide. Destroying agents of 
 moderate power tend to alter tissues in this direction. 
 
52 
 
 Gay, F. P., and Southard, E. E. On Serum Anaphylaxis in the 
 Guinea Pig. Journal of Medical Research, Boston, 1907, 
 XVI, 143-180. (New Series, Vol. XL) 
 
 Conclusions. 
 
 1. The well-known susceptibility to intoxication by horse 
 serum, which is demonstrable in guinea pigs previously injected 
 with horse serum, is due to the non-neutralization and non- 
 elimination by the animal body of a factor in the serum, for 
 which we suggest the name anaphylactin. The intoxication 
 caused by the second injection depends upon factors of the serum 
 other than anaphylactin. These factors correspond to con- 
 stituents of the serum eliminable by the animal body. The 
 reaction of intoxication would seem to be a cellular one, de- 
 pendent upon a heightened power of assimilation on the part of 
 cells which have been subjected to the anaphylactic substance 
 over a definite period of incubation. 
 
 2. The tissues of guinea pigs, examined during the anaphylac- 
 tic phase, show no characteristic lesions. Striking multiple 
 hemorrhages, for some reason hitherto undescribed, accompany 
 the toxic phase. The hemorrhages are more frequent in the 
 stomach, cecum, lungs and heart than elsewhere. 
 
 Microscopic study demonstrates that the hemorrhages are 
 largely associated with widespread fatty degeneration of the 
 capillary endothelium. The heart muscle, the voluntary muscle, 
 the peripheral nerves and the gastric epithelium show striking 
 focal fatty changes which are independent of the vascular lesions. 
 
 The task of the anaphylactin is apparently so to prepare 
 various cell structures that their contained fat is made to flow 
 rapidly together upon exposure to the toxic agent. The rapidity 
 of this degeneration is striking, though it presents histologically 
 the features of so-called "chronic" degeneration. 
 
 Southard, E. E. and Hodskins, M. B. Note on Cell Findings 
 in Soft Brains. American Journal of Insanity, Baltimore, 
 1907-08, LXIV, 305-310. 
 
 Remarks. 
 The anatomist is prone to neglect the general feel of the brain 
 and cord at autopsy. He is familiar enough with focal altera- 
 tions of consistence; thus, with foci of induration (scars, focal 
 
53 
 
 glioses) and with foci of subnormal consistence (focal encephalo- 
 malacia, focal encephalitis). A state of general induration is 
 recognized as due to diffuse fibrillar gliosis. General reduction 
 of consistence is least easy to interpret. 
 
 The plastic softness and swelling of edematous brains may be 
 told from the dimuence of brains as autolyzed post-mortem. We 
 have here noted a condition of general encephalomalacia which 
 we take to be of ante-mortem origin, though doubtless it is 
 speedily emphasized by post-mortem changes. 
 
 The soft brains and soft cords of this group are not produced 
 by vascular lesions, and, unlike edematous organs, show no essen- 
 tial increase of volume or weight. This type of general encephalo- 
 malacia (myelomalacia) seems not unlike the state of the brain 
 and cord after post-mortem autolysis, and is possibly due to a 
 similar process. 
 
 Although the process has the appearance of a general histo- 
 lysis, yet histological study shows that the lysis is essentially 
 differential (diffuse axonal reactions in nerve cells and still more 
 diffuse Marchi degenerations). Where, as in the illustrative case, 
 a focal induration also occurs, the histolysis is readily seen to be 
 differential because the nerve cells and fibers which still live in 
 the sclerotic focus are subject to the same cytolyses (axonolyses) 
 as are the cells and fibers of the brain at large. W r hat the lytic 
 agent is remains obscure. 
 
 General encephalomalacia (myelomalacia, neuromalacia?) is 
 clinically related with a late, terminal, or agonal exhaustion, and 
 is sometimes seen following epilepsy as well as in other conditions. 
 
 1908. 
 
 Bullard, W. N., and Southard, E. E. A Case of Syringal 
 Hemorrhage complicated by Meningitis. (Abstract.) Jour- 
 nal of Nervous and Mental Disease, New York, 1908, 
 XXXV, 37. 
 
 Remarks. 
 The readers interpreted the data of this case as illustrating the 
 following series of events: (1) gliosis with cavity formation in 
 the spinal cord; (2) hemorrhage into cavity with defects tanta- 
 mount to those of transverse myelitis; (3) extensive decubitus 
 with erosion of bone and exposure of spinal canal; (4) ascending 
 meningitis. 
 
54 
 
 Mitchell, H. W., and Southard, E. E. Melancholia with De- 
 lusions of Negation: Three Cases with Autopsy. Journal 
 of Nervous and Mental Disease, New York, 1908, XXXV, 
 300-314. 
 
 General Summary and Remarks. 
 
 The disease group melancholia has a somewhat precarious 
 footing in present-day psychiatry. The purest cases appear to 
 occur in or about the climacteric era. The practical alienist is 
 always reluctant to place a case in the group melancholia lest it 
 shortly transpire that the case should rather have been counted 
 senile or arteriosclerotic, or, in some other way, frankly organic. 
 Moreover, it frequently appears that error may creep in the 
 opposite direction, and the patient, alleged to have melancholia, 
 turn out to be actually a victim of some constitutional defect or 
 of some acute psychosis. 
 
 We have found difficulty in resolving our ideas about the dis- 
 ease group melancholia, and were for a time inclined to believe 
 that any given case could perhaps be transmuted, as a matter 
 of diagnosis, into some other group. 
 
 As a beginning in this group we have here introduced three 
 cases which, whether they fit any acknowledged grouping or not, 
 appear to have certain features in common as well as certain 
 instructive differences. The psychological color and, to some 
 extent, the course of these cases recall some features of Cotard's 
 syndrome. 
 
 In every case there were a few established instances of in- 
 sanity in the direct line on one or other side. The hereditary 
 features, interesting in each case, appear to have little in common 
 except the terminal continuous depressions in the mothers of 
 two patients (Cases II and III). 
 
 The lives of the three patients showed little which can be 
 regarded as underlying their ultimate conditions. Case I used 
 no alcohol, Case II drank beer with meals, Case III used alcohol 
 moderately. Venereal history practically negative in all cases. 
 
 Occupations: clerk, I; mason, II; shoemaker, III. 
 
 Previous diseases: lumbago, I; pneumonia seven years before 
 commitment, II; scarlet fever and purulent otitis media, set. 3, 
 and typhoid fever and la grippe with delirium, set. 61, III. 
 
 Ages at onset: 48, I; (69) 75, II; 65, III. 
 
 Durations: 8 months, I; (8 years) 2 weeks, II; 24 weeks, III. 
 
 Onset: gradual, I, III; sudden, II. 
 
55 
 
 Assignable causes: financial worry, I; senility and domestic 
 worry, II; nothing, set. 65, III. 
 
 Physical conditions: arteriosclerosis in all cases; Case III 
 showed emaciation, nephritis, cystitis, increase of reflexes. 
 
 Mental states: ideas of negation in all cases, developing in 
 Case I after slowly increasing depression and agitation with delu- 
 sions about self and family and questionable hallucinations; in 
 Case II, after gradual senile failure, as sudden deep depression 
 with agitation, delusions of ruin of self and family, and suicidal 
 attempt; and in Case III, after slowly developing hypochondri- 
 acal depression. 
 
 The feelings of unreality and ideas of negation presented a 
 certain variety in the three cases. Case I showed an alteration 
 of personality, uttered frequently in such phrases as "I'm all 
 gone. I'm dead to the world. I'm not G. E. H. I've made my- 
 self as Gibbs. I've been here as G. E. H." Case II showed a 
 feeling of unreality, both as regards the outer world ("sunlight 
 not real, sky not blue, people not real human beings") and as 
 regards himself ("I can't move. I can't die"). Case III showed 
 an alteration of point of view as to the outer world ("You're all 
 great big men, and so strong; you must weigh over 400 pounds") 
 and nihilistic ideas ("I am so small you can't see me. I've got 
 no brains, and I can't talk. I've got no heart, and no stomach, 
 and I can't swallow. I wouldn't burn if you threw me in the 
 burning furnace"). 
 
 The anatomical side of these cases presents several common 
 aspects, but little which promises to explain the disease. Arterio- 
 sclerosis, when confined to the large branches of the circle of 
 Willis, can scarcely be invoked as underlying symptoms of such 
 specialized character as those under consideration. 
 
 Just as the patients showed strikingly little in alterations of 
 reflexes (increase in Case III), so the brains showed strikingly 
 little in the shape of gross or focal ilterations (small old cyst of 
 softening in Case II and mild chronic exudative process in Case 
 III). 
 
 Moreover, the brains gave little evidence of general or focal 
 atrophy. No striking alterations in cortical topography and 
 arrangement of layers could be detected on microscopic examina- 
 tion. Pigment-bearing cells in perivascular spaces were con- 
 stantly found; and, in default of any suspicious localization of 
 these, we must attribute them rather to the results of advancing 
 years than to a special factor. 
 
56 
 
 Neuroglia cell pigmentation was also quite constantly found; 
 but this was not so universal in distribution as was the case with 
 the perivascular cell pigmentation. Common to all three cases 
 was a neuroglia cell pigmentation in the intermediate layers of 
 the areas of cortex examined. The relation of the neuroglia 
 cell pigmentation to cortical activity could not be made out. 
 Satellite-cell pigmentation was not constant. 
 
 Nerve cell pigmentation was constantly found in the elements 
 of moderate size in all parts of the cortex examined. This pig- 
 mentation was strikingly brought out by the use of iron hema- 
 toxylin. The pigmentation in question has a somewhat charac- 
 teristic locus in the affected cells, fails to destroy their contours, 
 and lies apparently in interstices in the cells. This interstitial 
 nerve cell pigmentation, as brought out by iron hematoxylin, is 
 to be sharply distinguished from the familiar yellow sack pig- 
 mentation of the major elements. 
 
 Pending the increase of knowledge concerning the pigments 
 and fat-like deposits in general, we can at least investigate their 
 occurrence topographically. It seems to us that however frag- 
 mentary the present findings are, and however far we may be 
 from bringing such findings into relation with disorders of ap- 
 perception, we have at least a promising field for investigating 
 the conditions of what seems to be a truly cortical disorder. We 
 are at present at work upon accessible cases of melancholia. 
 
 Gay, F. P., and Southard, E. E. Further Studies in Anaphy- 
 laxis: I. On the Mechanism of Serum Anaphylaxis and In- 
 toxication in the Guinea Pig. Journal of Medical Research, 
 Boston, 1908, XVIII, 407-431. (New series, Vol. XIII.) 
 
 Gay, F. P., and Southard, E. E. Further Studies in Anaphy- 
 laxis: II. On Recurrent Anaphylaxis and Repeated In- 
 toxication in Guinea Pigs by Means of Horse Serum. Jour- 
 nal of Medical Research, Boston, 1908, XIX, 1-4. (New 
 series, Vol. XIV.) 
 
 Gay, F. P., and Southard, E. E. Further Studies in Anaphy- 
 laxis: III. The Relative Specificity of Anaphylaxis. Pro- 
 ceedings, Society of Experimental Biology and Medicine, 
 New York (Conclusions only), 1907-08, V, 83. Also in 
 Journal of Medical Research, Boston, 1908, XIX, 5-15. 
 (New series, Vol. XIV.) 
 
57 
 
 Conclusions. 
 
 The anaphylaxis in guinea pigs caused by the previous in- 
 jection of any one of the protein substances — horse serum, 
 egg white or milk — is only relatively specific. The maximum 
 reaction on second injection is always obtained when the sub- 
 stance which has sensitized is used, but in certain combinations 
 intoxication can be produced by the other two substances. This 
 intoxication by a heterologous proteid is "partial," and does not 
 occur if the "complete" intoxication produced by the homologous 
 proteid has been effected. When partial intoxication has been 
 produced by one or both of the heterologous substances, com- 
 plete intoxication may still be effected by the homologous sub- 
 stance. The intensity of an homologous' intoxication, after 
 anaphylaxis by a single substance, would seem to depend some- 
 what on the substance used, the order of toxicity ranging, egg 
 white, serum, and last of all milk. After combined anaphy- 
 laxis, produced by initial injection of all three substances, the 
 first intoxication, allowing of course a proper incubation period, 
 may be produced by any one of the substances in question. 
 When intoxications are effected with each substance in turn, the 
 serial set of symptoms varies according to the order in which 
 the substances are injected on the subsequent days. When in- 
 jected as the second or third of the series, egg white alone pro- 
 duces maximal symptoms at all times. Horse serum is diminished 
 in toxicity if used after either egg or milk, and has lost markedly 
 if used after intoxication with both substances. Milk is very 
 slightly toxic if given second in order, and absolutely non-toxic if 
 given third. This would compare with the actual toxic power of 
 each substance as noted after homologous sensitization. 
 
 The mixed anaphylaxis, moreover, is only relatively specific, 
 since egg and horse serum will completely pre-empt the possibil- 
 ity of intoxication by milk if this substance is given last. 
 
 Gay, F. P., and Southard, E. E. Further Studies in Anaphy- 
 laxis: IV. The Localization of Cell and Tissue Anaphylaxis 
 in the Guinea Pig, with Observations on the Cause of Death 
 in Serum Intoxication. Journal of Medical Research, .Bos- 
 ton, 1908, XIX, 17-35. (New series, Vol. XIV.) 
 
 CoxcLrsioxs. 
 The results of this work are in part confirmatory of our previ- 
 ous results, and consist in part of novel data. 
 
58 
 
 Eighty-five per cent of guinea pigs which, after sensitization 
 with horse serum and intoxication by a second dose of horse 
 serum, die in the critical phase, or are killed within twenty -four 
 hours of the second injection, exhibit macroscopic hemorrhages 
 in one or more organs. The stomach leads the other organs in 
 frequency of involvement (58 per cent); the lungs stand next 
 (40 per cent). Three unusual localizations of hemorrhage, not 
 noted in our previous paper, are brain, spinal cord, perito- 
 neum. 
 
 The cause of death, when it occurs, is respiratory. Respira- 
 tion ceases in the inspiratory phase, and shows itself anatomi- 
 cally and histologically as emphysema. Death does not occur, 
 as a result of this disease, except in a critical phase, which 
 occupies at most one hour. 
 
 The most striking functional feature of the critical phase, after 
 the second or toxic injection of horse serum, is severe diaphrag- 
 matic spasm. The spasms are often accompanied by similar 
 shock-like spasms of the accessory inspiratory muscles and of 
 other trunk and limb muscles. 
 
 The most rapid deaths are produced by intracarotid, intra- 
 jugular, post-orbital, and paraneuraxial injections. The occur- 
 rence and rapidity of death in the critical phase, as well as the 
 severity of respiratory symptoms throughout the toxic phase, 
 appear to vary with the nearness of the toxic injections to the 
 respiratory central apparatus. 
 
 A new line of research is opened up by the paraneuraxial in- 
 jections of horse serum in sensitized guinea pigs. These seem to 
 prove that differential irritative and paralytic reactions can be 
 secured by small localized injections of horse serum adjacent to 
 various parts of the sensitized central nervous axis. 
 
 Severe respiratory symptoms can be produced in sensitized 
 (but not in normal) guinea pigs by local applications of horse 
 serum (not by salt solution) to the exposed vagus. This is inter- 
 preted to signify a conveyance of impulses over at least three 
 neurones to the diaphragm, that is, to the medulla, thence to the 
 phrenic center, and thence to the diaphragm. We have not pro- 
 duced death by these vagal applications of horse serum. 
 
 To explain these respiratory symptoms, we offer an hypothe- 
 sis of local tissue anaphylaxis expressed in a relatively specific 
 sensitization of the respiratory centers. We regard as unfounded 
 those hypotheses which consider the respiratory (and other) 
 centers and tissues as unaltered in the anaphylactic or sensitizing 
 
59 
 
 phase, and which allege the manufacture of antibodies in the 
 blood serum which later unite with the second dose of horse 
 serum to form new specific respiratory toxines. We regard this 
 change induced in the respiratory centers as of a physical rather 
 than a chemical nature, so far as this distinction is of importance 
 in this connection. 
 
 Neither hemorrhage nor respiratory death is an indispensable 
 feature of this disease. Some guinea pigs show no hemorrhages. 
 Some show slight symptoms. The hemorrhages do not vary in 
 frequency or extent with the severity of the symptoms in all 
 cases. 
 
 But all guinea pigs so far examined in the toxic phase do show 
 focal fatty changes in many tissues of several genetic types. 
 These changes are, in many regions, of an extremely focal char- 
 acter, involving often a single muscle fiber, nerve fiber, or other 
 cell, as the case may be. The toxic phase is characterized by 
 focal cytolyses of wide distribution. Except in areas of hemor- 
 rhage (where local mechanical destruction complicates findings), 
 and in certain diffuse fatty changes in the gastric epithelium 
 (where the local action of the gastric juice may come in play), 
 groups of contiguous cells are not characteristically affected by 
 fatty change — focal histolysis is not the rule. 
 
 And, if focal cytolysis (rather than focal histolysis) is the rule 
 in the toxic phase, then it appears that the work of the anaphy- 
 lactic phase is to sensitize cells in a variable degree (rather 
 than to sensitize several contiguous or regionary cells in a like 
 degree). 
 
 Southard, E. E. and Richards, E. T. F. Typhoid Meningitis: 
 Cultivation of Bacillus Typhosus from Meninges and Mes- 
 enteric Lymph Node in a Case of General Paresis, with a 
 Note on Experimental Typhoid Meningitis in the Guinea 
 Pig. Journal of Medical Research, Boston, 1908, XIX, 
 513-531. 
 
 Conclusions. 
 
 The points of the paper are as follows: — 
 
 1. A classical case of taboparesis, with previous history of 
 syphilis, but without history of typhoid fever, succumbs after a 
 week's acute illness to broncho-pneumonia and to purulent 
 cerebrospinal meningitis. 
 
60 
 
 2. A typical strain of Bacillus typhosus was isolated in pure 
 culture from a swollen mesenteric lymph node and from the 
 meningeal pus. The blood failed to yield Bacillus typhosus. 
 There were no typhoidal lesions in the intestines. 
 
 3. The meningeal exudation contained polynuclear leucocytes 
 in great numbers. This finding, in connection with the older 
 findings of Ohlmacher, W. G. MacCallum, and Henry and 
 Rosenberger, leads to the hypothesis that Bacillus typhosus 
 within the meninges may exert a directly pyogenic action. 
 Should this hypothesis be upheld, the direct action of the bacillus 
 stands in sharp contrast to the proliferative effects of the typhoid 
 toxine described by Mallory in the intestine, lymph nodes and 
 elsewhere in the viscera. The indications are, therefore, that 
 Bacillus typhosus may have two separate effects, the one pro- 
 duced by a diffusible toxine (Mallory) characteristically in the 
 intestinal tract, and the other produced in the meninges either 
 by direct local action of the bacilli or through an endotoxine, 
 due to destruction of the bacilli. 
 
 4. In confirmation of the results of Tictine, Bacillus typhosus 
 was experimentally found to inflame the meninges of guinea pigs. 
 In accordance with the hypothesis stated above, guinea pig brains 
 proved to show an exudation containing many polynuclear 
 leucocytes. Mononuclear elements arrive by the seventh day 
 after inoculation. 
 
 5. Research is desirable to determine whether the local action 
 of Bacillus typhosus in the meninges is, or is not, of endotoxic 
 type. 
 
 Southard, E. E., and Ayer, J. B., Jr. Dementia Prsecox, Par- 
 anoid, associated with Bronchiectatic Lung Disease and 
 terminated by Brain Abscesses (Micrococcus Catarrhalis). 
 (From the Laboratory of the Danvers Insane Hospital.) 
 Boston Medical and Surgical Journal, 1908, CLIX, 890-895. 
 
 Discussion. 
 We have presented the case of an American youth of average 
 capacity, a chair maker for some six years, who became insane 
 (depressed, paranoid, suicidal, later at times katatonic) after 
 facial disfigurement in a Fourth of July accident at the age of 
 twenty-five. We were tempted to a more particular study of this 
 case because of the clear-cut features of an autopsy five years 
 after onset (chronic and acute lung disease with abscesses, mul- 
 
61 
 
 tiple abscesses of other organs, including the brain), which 
 seemed to point to bronchiectases and lung disease of ancient 
 date. 
 
 The clinical history and the autopsy findings are so far con- 
 sistent that a "psychogenic" origin for this case of (possibly) 
 dementia prsecox can be safely discounted. It seems safe to 
 conclude that the lung disease was already in process of pro- 
 duction in the six months subsequent to the episode of facial 
 disfigurement. It is possible that this disease antedated the 
 facial injury, and that masses of bacteria in dilated bronchi had 
 begun to affect the patient long before frank pulmonary signs 
 set in. 
 
 However this may be, the lung disease, whose progress was 
 carefully followed on account of its clinical resemblance to pul- 
 monary tuberculosis, had a peculiar effect upon the course of 
 the mental symptoms. Both lung disease and mental disease 
 came in attacks, but these attacks did not coincide in time. 
 
 The lung disease would affect in each attack a fresh area, and 
 was characterized by exhaustion, bloody and purulent expectora- 
 tion (no tubercle bacilli) and high fever. 
 
 During the toxemic phases of the lung disease the patient was 
 quiet, but would yield depressive delusions on questioning. Just 
 as earlier the patient had been depressed ostensibly on account 
 of his disfigurement, so throughout his disease he tended to 
 delusions concerning his somatic condition. ("This is leprosy I 
 am spitting up.") But his delusions were at all times of wider 
 range than his bodily disease ("given up by God," "world is 
 degenerating," "murdering the whole world"), and were some- 
 times of extreme metaphysical ingenuity ("passed both ends of 
 the world and got behind everybody"). 
 
 After some years the paranoid picture had become emphasized 
 by mild and episodic katatonic features (wild beast simulations, 
 mannerisms and peculiar contortions). 
 
 It is, of course, possible that the lung disease and the mental 
 disease are merely interpenetrating entities in this case. The 
 autopsy showed that the brain, in common with the kidneys and 
 the spleen and other structures, had undergone abscess-formation. 
 There is, however, no evidence that the brain abscesses were of 
 long standing, and, though the fatal issue was pyemic, it is 
 probable that previous attacks had been merely toxemic, or, at 
 most, mildly septicemic. The microorganism engaged in the 
 abscess-formation is not in all respects well defined, but seems to 
 
62 
 
 belong to the micrococcus catarrhalis group. There is no con- 
 vincing evidence that this organism was in any way responsible 
 for the clinical features of the disease as a whole, but it seems 
 not easy to exclude, in a more general way, the presumably 
 highly toxic masses of bacteria and detritus in the pulmonary 
 tissues from the field of factors in the mental disease. 
 
 Just as it has long been suspected by some workers that there 
 is a somewhat close relation between lung disease and brain 
 disease (and, in particular, between bronchiectases and brain 
 abscesses), so there may possibly obtain a more delicate and 
 elusive connection between toxic lung conditions and brain 
 conditions. It would be of extreme value could we learn more 
 precisely the paths taken by bacteria and toxins from the lungs 
 to the central nervous axis. 
 
 Southard, E. E., and Rickshek, C. A Complicated Case of 
 Brain Tumor. American Journal of Insanity, 1908, LXIV, 
 695-702. 
 
 Clinical Summary. 
 
 It is extremely difficult to ascribe the various symptoms to 
 definite lesions. The pontine lesions are of such a degree that 
 they might easily modify any symptom which could ordinarily 
 be ascribed to the tumor or the meningitis. 
 
 A tumor in the frontal region rarely, if ever, gives definite 
 localizing symptoms. In this case the apathy and indifference to 
 her surroundings and also the early headache may be due to it. 
 Its position near Broca's convolution suggests some connection 
 with the speech defect, but it is more probable that the lesions in 
 the pons have more to do with it. 
 
 The ptosis may be accounted for by the extension from the 
 Gasserian ganglion, but it seems very probable that there may 
 have been a nuclear lesion. The visual hallucinations may be 
 accounted for by the meningitis and the dulling of consciousness 
 following it and the tumor. 
 
 The lesions in the pyramidal tract explain the Babinski reflex, 
 but there hardly seems to be enough difference in the two tract 
 lesions to explain why it should exist on one side and not on the 
 other. There was probably some focal lesion in the cervical cord 
 which interfered with the reflex arc of the left arm and slightly 
 with that of the right which could explain the arm reflexes. 
 
 The paralysis of the left side was due directly to the destruc- 
 tion of the Betz cells, and this destruction can be accounted for 
 
63 
 
 by toxic influences from the meninges or by pressure from the 
 tumor, but one would be inclined to give more to the toxic 
 hypothesis. , 
 
 The case offers nothing new so far as localization is concerned, 
 but it does call attention to the vast changes which may be 
 caused by arteriosclerosis, and also to the meningeal conse- 
 quences of a chronic otitis media. In a large number of the 
 cases which have come to autopsy in this institution in the last 
 six months pus has been found in the middle ear. There is no 
 doubt that the middle-ear infection has in some cases influenced 
 the clinical picture. The diagnosis of such cases is almost an 
 impossibility as yet, but it is worth while to keep such things in 
 view, especially as they influence so much the prognosis. 
 
 1908-09. 
 
 Southard, E. E., and Mitchell, H. W. Clinical and Anatom- 
 ical Analysis of 23 Cases of Insanity arising in the Sixth 
 and Seventh Decades, with Especial Relation to the Inci- 
 dence of Arteriosclerosis and Senile Atrophy and to the 
 Distribution of Cortical Pigments. Proceedings, American 
 Medico-Psychological Association, 1908, 179-222. Also in 
 American Journal of Insanity, Baltimore, 1908-09, LXV, 
 293-336. 
 
 Conclusions. 
 Arteriosclerosis and senility, separately or combined, have been 
 very handy terms in psychiatrical diagnosis. However, we be- 
 lieve we have proved conclusively, by the present analysis, that 
 neither old-age changes nor arterial disease have any necessary 
 connection with the development of insanity in the later years of 
 life, at least in the sixth and seventh decades. It seems probable 
 that arteriosclerosis, senility and various forms of insanity are 
 entities which frequently interpenetrate, but are logically and 
 genetically quite separate. Even the degree to which old age and 
 arterial disease serve as complicating factors in insanity has been 
 much overestimated. 
 
 The constructive part of our paper looks in the direction of the 
 distribution of intracellular pigments, a species of work harking 
 back to the somewhat neglected field of Bevan Lewis (1890). 
 The perivascular cell pigments, according to our comparisons, 
 seem to afford some index of the degree of faulty metabolism of 
 the cerebral tissue; these pigments are deposited in like amounts 
 
64 
 
 throughout a given brain. The neuroglia cell pigments, in the 
 light of the present material, vary rather with the age of the indi- 
 vidual. The nerve-cell accumulations are subject to the greatest 
 variations even in a single brain, certainly do not vary with the 
 age of the individual, and vary according to some undetermined 
 principle. 
 
 We have omitted literary references in the present paper, but 
 wish to express our gratitude to Prof. A. M. Barrett for the use 
 of some of his Danvers Hospital material. Our work may be re- 
 garded as in some sense a complement to Barrett's Study of Men- 
 tal Diseases associated with Cerebral Arteriosclerosis (American 
 Journal of Insanity, LXXII, 1, 1905). Our cases are from the 
 same general source as Barrett's cases, but are in no instance 
 identical therewith. 
 
 It would be of some value to fuse with the present analysis a 
 similar analysis of the frankly organic cases of the same epoch, in 
 order to pick out, if possible, the special constituents of the 
 mental picture produced by the gross lesions. This task we have 
 in hand. 
 
 Our results briefly are: — 
 
 1. Twenty-three cases of insanity, presumed to arise in the 
 sixth and seventh decades, have been studied clinically and ana- 
 tomically. Two of these were alcoholic in origin. Five were 
 paranoic. Four were cases of delirium. Three were maniacal. 
 Xine were cases of depression. 
 
 2. Two of the paranoic cases developed katatoniform symp- 
 toms, and might be placed in the dementia prsecox group. 
 
 Seven cases are possibly classifiable in the manic-depressive 
 group. Two of these had attacks of retardation. One case re- 
 mained maniacal for thirteen years. One recovered from a single 
 suicidal depression and died eight years later of intercurrent 
 disease. 
 
 3. Neither general nor cerebral arteriosclerosis bears an essen- 
 tial causative relation to the insanities developed in the sixth and 
 seventh decades by the 23 cases clinically and anatomically 
 studied. 
 
 4. The insanities arising in these decades are not character- 
 istically due to the premature onset of senile atrophy. Eight out 
 of 11 female brains were atrophic: the average age at death was 
 69.8; the average duration 10.8 years. Five out of 12 male 
 brains were atrophic: the average age at death was 65.6; the 
 average duration 2.7 years. 
 
65 
 
 Either the female cases are more liable to brain atrophy and 
 to live longer with atrophied brains, or else the atrophy is merely 
 a function of their greater age at death. The average age at 
 death in all 11 females is 67.2; the average duration 8.8 years. 
 The average age at death in all 12 males is 62.3; the average 
 duration 2.8 years. The differences in age at onset — female 
 average 58.4 (atrophies, 59.8), male average 59.5 (atrophies, 
 62.9) — are not great. 
 
 5. A comparative study of the distribution and extent in 
 several cortical areas of certain pigmented materials demonstrable 
 by iron-hematoxylin (among other methods) brings out extreme 
 and interesting variations in the cases examined. 
 
 Perivascular cell pigmentation is almost uniform in different 
 areas of the same case, bar focal destructive lesions, but varies in 
 degree in different cases. 
 
 Neuroglia cell pigmentation, when of general distribution, prob- 
 ably varies more or less directly with age. 
 
 Nerve-cell pigmentation (iron-hematoxylin) is not a function 
 of age. It is premature to relate the amounts and distributions 
 of nerve-cell pigments with different mental diseases. 
 
 Cotton, H. A., and Southard, E. E. A Case of Central Neuritis 
 with Autopsy. American Journal of Insanity, Baltimore, 
 1908-09, LXV, 633-652. 
 
 Summary and Conclusions. 
 
 The present case is a fresh example of Adolf Meyer's central 
 neuritis, and shows, as did some of Meyer's cases, an involve- 
 ment of the peripheral and sympathetic nervous system, to- 
 gether with the central nervous system, in a condition of severe 
 and extensive lytic change. These lytic changes are exhibited in 
 characteristic Marchi degenerations of the medullated fibers, and 
 in the axonal reaction of Nissl in certain nerve-cell types. 
 
 These fiber and cell changes are, it is probable, only the evi- 
 dent fraction of a large series of changes of a lytic nature, most 
 of which cannot be demonstrated by present histological methods. 
 Thus the Marchi degenerations invariably surpass in amount the 
 axonal reactions, doubtless because many of the fibers which 
 show fat drops are connected with cells that are too small or too 
 scantily supplied with Nissl bodies to exhibit the axonal reaction 
 of Nissl. As shown by the Scharlach method, the small cells have 
 
66 
 
 undergone a serious form of degeneration, and are filled with fatty 
 pigment. 
 
 Another evidence of the universality of these changes is the 
 characteristic reduction of consistence on the part of both the 
 encephalon and the cord. Attention has been called to this 
 alteration of consistence by Southard and Hodskins. In the case 
 reported by them, the reduction was striking in all parts except 
 an area of sclerosis in one hemisphere. Examination of the 
 tissues by the Marchi and Nissl methods showed that the pre- 
 served nerve cells and fibers in the sclerotic area exhibited the 
 same changes as the cells and fibers elsewhere. The disease, 
 therefore, seemed due to some lytic agent differential for nerve 
 elements, possibly an autolytic agent. The present case again 
 illustrates the generalized reduction of consistence of central 
 nerve tissues (general encephalomalacia and myelomalacia), to- 
 gether with some indication of the process in the peripheral 
 elements, the result, perhaps, of a lysis or autolysis yet more 
 general (neuromalacia). 
 
 The question may well arise whether the cells or the fibers 
 are the first to be involved in the lysis. Despite the extent and 
 severity of the Marchi degenerations in the medullated fibers, it 
 is nevertheless probable that the lysis primarily affects the 
 nervous elements rather than the myelin investments. This 
 point ■ is borne out by the extensive changes, simulating the 
 axonal reaction, in the nerve cells of Auerbach's plexus in the 
 present case. Reasoning from this finding to the interpretation 
 of central nervous findings, it seems possible to argue that the 
 hypothetical lytic agent attacks elements largely proteid in char- 
 acter. The Cajal fibril preparations, so far as decisive, are con- 
 sistent with this hypothesis. The nerve cells, stained with Schar- 
 lach Roth, show no accumulations of fat within the central or 
 chromatolyzed area in the first stages of degeneration, but later, 
 as degeneration proceeds, the whole cell is filled with fatty pig- 
 ment. 
 
 When such cytolytic changes prove to be so extensive as ia the 
 present case, involving various groups of axis-cylinders and 
 eventually various nerve cell bodies and nuclei, as well as myelin 
 sheaths in many regions, it may well be that the change here 
 particularized is only an expression of a still more general lysis 
 or autolysis which will be best attacked along chemical lines. 
 
67 
 
 1909. 
 
 Southard, E. E., and Richards, E. T. F. The Lesions of Bacil- 
 lary Dysentery. Boston Medical and Surgical Journal, 
 1909, CLXI, 694-703. 
 
 Southard, E. E. Conclusions from Work on the Danvers Dysen- 
 tery Epidemic of 1908. Boston Medical and Surgical Jour- 
 nal, 1909, CLXI, 709-714. 
 
 Southard, E. E., aided by McGaffin, C. G. Nervous System 
 in Bacillary Dysentery. Boston Medical and Surgical 
 Journal, 1909, CLXI, 703-705. 
 
 Conclusions. 
 
 1. The brains of reduced consistence in our series can scarcely 
 be regarded as showing effects of dysentery toxin, since in many 
 cases of this group paraneuraxial infection with other organisms 
 (terminal or secondary invaders of the cerebrospinal fluid) was 
 established. 
 
 2. Organic disease of the central nervous system has no special 
 effect in favoring fatal issue. 
 
 3. Severe fatty degeneration, demonstrated by the Marchi 
 method, and indicating lesions probably of several days' standing, 
 was characteristic of the non-ulcerative cases, and may point to a 
 differential feature in the organism or toxin of the first phase of 
 the epidemic. (See Articles IV, VI and X.) Or, on the con- 
 trary, this finding may point to the importance of secondary in- 
 fection in dysentery. 
 
 4. Hemorrhagic lesions in the anterior horns of the spinal cords 
 were not present. 
 
 5. Two cases of thrombosis of superficial cerebral arteries have 
 been noted in cases before the epidemic. 
 
 Henderson, L. J., and Southard, E. E. The Cultural Value of 
 Certain Medical Studies and the Elective System in Medical 
 Education. Boston Medical and Surgical Journal, 1909, 
 CLXI, 981-983. 
 
 Remarks. 
 All that we contend for in the matter which Professor D wight 
 has discussed is, first, that there are broadly scientific courses in 
 the medical school whose nature is fixed by the consensus of 
 
68 
 
 opinion of the teachers of such subjects throughout the world; 
 and secondly, that it is at least an open question, not to be 
 settled by a judgment ex cathedra or on medical grounds, whether 
 or not they are well suited to count for the bachelor's degree. 
 
 Southard, E. E., and Henderson, L. J. Education in Medicine. 
 (Letter.) Boston Medical and Surgical Journal, 1909, 
 CLXI, 948-949. 
 
 Gay, F. P., Southard, E. E., and Fitzgerald, J. G. Neuro- 
 physiological Effects of Anaphylactic Intoxication. Journal 
 of Medical Research, Boston, 1909, XXI, 21-40. (New 
 series, Vol. XVI.) 
 
 Summary and Remarks. 
 
 The work of Gay and Southard upon the localization of cell 
 and tissue anaphylaxis (serum type) in the guinea pig has been 
 continued. The work of 1908 had brought out sharply the strict 
 comparability of intravascular and orbital injections in their 
 capacity to produce violent respiratory symptoms or death. As 
 was then stated, " The occurrence and rapidity of death in the 
 critical phase, as well as the severity of respiratory symptoms 
 throughout the toxic phase, appear to vary with the nearness of 
 the toxic injections to the respiratory central apparatus." 
 
 But evidence was further adduced to show that the sensitiza- 
 tion of the respiratory centers was but relative, and that those 
 who claim that the toxic effects are due to a specifically respira- 
 tory toxin are inexact. 
 
 The theoretical significance of injections alongside the nervous 
 system (paraneuraxial injections) was shown to consist in the 
 capacity of such injections to spread directly through the cerebro- 
 spinal fluid to the respiratory centers. Such direct paraneu- 
 raxial drenching of the sensitized nervous system was shown both 
 theoretically and experimentally to be approximately equivalent 
 to intoxication by the intravascular route. 
 
 The evidence from paraneuraxial injections has now been 
 strengthened, and so supported by evidence from several kinds of 
 intraneuraxial injections as to warrant confirmation of our tenta- 
 tive statement of 1908, "that differential irritative and paralytic 
 reactions can be secured by small localized injections of horse 
 serum adjacent to various parts of the sensitized central nervous 
 system." 
 
69 
 
 The most lethal form of paraneuraxial injection is the orbital. 
 The orbital method of injection is the method of election for 
 determining toxicity, in Besredka's sense, since the complicating 
 features of intravascular injection and of trephining are avoided. 
 The orbital method permits immediate drenching of the bulb 
 through the cerebrospinal fluid. 
 
 Many varieties of paraneuraxial injection have been practiced. 
 To secure non-respiratory phenomena and avoid lethal outcome, 
 it is only necessary to inject the serum into the muscular and 
 interstitial tissues outside the nervous system, thus permitting a 
 slower absorption and a differentiation of results analogous to 
 that secured by comparative intraperitoneal and subcutaneous 
 injections. 
 
 Both irritative and paretic non-respiratory symptoms can be 
 produced by paraneuraxial injections of various dosage appro- 
 priately localized. 
 
 It is not probable that these paraneuraxial injections act by 
 intoxicating the nerves suspended in the cerebrospinal fluid; at 
 any rate, no comparable degree of intoxication has been secured 
 by paraneural applications of serum outside the enclosing sheath 
 of the central nervous system (trigeminus, sciatic nerve). Nor 
 has death ever followed applications to the vagus in its extradural 
 course despite the production of severe respiratory symptoms 
 thereby. 
 
 Intraneuraxial injections (e.g., intracerebellar, intramyelic, in- 
 tracerebral) in sensitized animals effect a variety of symptoms, 
 sometimes irritative, sometimes paretic. It is easy to distinguish 
 respiratory and non-respiratory phenomena. 
 
 Intramyelic injections in the cervical region produce not merely 
 the expected respiratory symptoms, but also brachial paraplegia. 
 
 The effects of .intracerebellar injections must be interpreted 
 with caution, on account of symptoms producible by purely me- 
 chanical means. Opisthotonus and nystagmus appear to be 
 characteristic of anaphylactic intoxication. But with respect to 
 nystagmus, the proximity of the restiform body and of the cor- 
 pora quadrigemina must be considered. 
 
 Intracerebral injections produce a variety of symptoms, such 
 that the locus of injection becomes important to consider. We 
 are able to distinguish a motor from a sensorimotor (olfactory) 
 type of reaction. These observations open a field of considerable 
 neurological interest, since heretofore electrical stimulation in 
 normal animals has been the best means of attack on localizing 
 
70 
 
 problems. Obviously extirpation experiments before and after 
 sensitization and subsequent anaphylactic intoxication will un- 
 earth many novel facts. 
 
 We are not disposed to emphasize unduly the dualistic or 
 anaphylactin hypothesis of Gay and Southard as applied to the 
 phenomena of anaphylaxis. We would only once more call to the 
 attention of the supporters of the antibody hypothesis how much 
 more difficult that hypothesis becomes in case the alleged anti- 
 bodies are intracellular and lodge in varying degree in different 
 loci of the nervous system as well as elsewhere in the body. 
 
 Southard, E. E. A Study of Errors in the Diagnosis of General 
 Paresis. (Abstract.) Journal of Nervous and Mental Dis- 
 ease, Lancaster, Pa., and New York, 1909, XXXVI, 545- 
 549. Also in Journal of Nervous and Mental Disease, 
 Lancaster, Pa., 1910, XXXVII, 1-16. 
 
 Conclusions. 
 
 1. An effort has been made to establish the accuracy of diag- 
 nosis in general paresis. The method has been to analyze clini- 
 cally the data of cases in which several experienced workers h.id 
 agreed upon the diagnosis, and to compare their findings with the 
 anatomical and histological data of the autopsies. 
 
 2. Thirty-five out of 41 cases unanimously diagnosed general 
 paresis ante mortem proved to be cases of general paresis (85 
 per cent accuracy). 
 
 3. Six cases of erroneous diagnosis have been especially studied. 
 None of these showed plasma cells in the nerve tissues (Nissl's 
 methylene blue and L. Ehrlich's pyronin methods), but all showed 
 a variety of lesions which warrant placing them in an "organic" 
 group. 
 
 4. The lesions probably responsible for the errors in diagnosis 
 were: (a) Meningomyelitis and subcortical encephalitis (luetic?), 
 Case V; (6) tabes dorsalis and non-paretic cerebral disease, Cases 
 I, IV; (c) arteriosclerotic brain disease with severe cerebellar in- 
 volvement (dentate nuclei), Cases II, VI; (d) cerebral sclerosis 
 (type, perivascular gliosis), Case III. 
 
 5. Although at first sight a probable error of 15 per cent in 
 the diagnosis of general paresis might suggest difficulties in pos- 
 sible medicolegal cases, it is obvious that, were the diagnosis con- 
 fined to "incurable insanity" or even to "organic brain disease," 
 the error would disappear. However, 2 cases proved to be gen- 
 
71 
 
 eral paresis (on the plasma-cell criterion) in a series of 186 
 cases similarly examined in which the diagnosis of general paresis 
 was not considered. 
 
 6. Improvements in our diagnostic ability could perhaps be 
 introduced by lumbar puncture and cytological examination in a 
 greater proportion of cases. But it is doubtful whether 3 of the 
 ,6 errors here studied would have been resolved by cyto-diagnosis 
 (meningomyelitis, tabes dorsalis). One other case (VI, arterio- 
 sclerotic brain disease) actually did show plasma cells in the lum- 
 bar puncture fluid, the source of which was not made out at 
 autopsy. 
 
 Henderson, L. J., Ph.D., and Southard, E. E. Education in 
 Medicine. The Relations of the Medical School and the 
 College. The Harvard Bulletin, Nov. 3, 1909, XII, 1-3 and 
 6. See also Science, 1909, XXX, 679-680. 
 
 Southard, E. E., and Henderson, L. J. Education in Medicine. 
 The Elevation of the Medical Directorate. The Harvard 
 Bulletin, Dec. 8, 1909, XII, 2. 
 
 Southard, E. E. Communication: Cultural Value of the Medi- 
 cal Sciences. The Harvard Bulletin, Dec. 15, 1909, XII. 
 
 1910. 
 
 Putnam, J. J., and Southard, E. E., aided by Ruggles, A. H. 
 Observations on a Case of Protracted Cerebrospinal Syphilis 
 with Striking Intermittency of Symptoms: Attempt at Cor- 
 relation with Ascending Meningomyelitis, Cranial Neuritis, 
 Subcortical Encephalitic, and Focal Encephalomalacia found 
 at Autopsy. Journal of Nervous and Mental Disease, 1910, 
 XXXVII, 145-163. 
 
 Conclusions. 
 
 The very varied problems and considerations of this case may 
 be set forth as follows: — 
 
 1. A protracted case of cerebrospinal syphilis shows at the 
 end of sixteen years after infection and eleven years after initial 
 nerve symptoms a multiplicity of chronic lesions, but shows few 
 acute lesions save (a) lymphocytic exudation in the upper spinal 
 cord segments (preferring the posterior root regions), and (6) 
 
72 
 
 certain interesting leukeneephalitic foci in the brain. Possibly 
 both (a) and (b) are related to intercurrent infection from exten- 
 sive decubitus; this is more likely in the case of (&). Search for 
 spirochetal so far negative. 
 
 2. On the basis of gross and histological findings it is possible 
 to correlate many of the various clinical features: (a) trans- 
 verse myelitis, (b) intermittent cranial nerve and other symptoms, 
 with structural disorder. But there were hysterical tendencies 
 throughout which rendered exact correlations difficult intra vitam. 
 
 3. The intermittency of symptoms just mentioned 2 (b) was 
 most striking, and an enumeration of histological possibilities 
 is given which might account for this intermittency (acute and 
 reparative changes in the pia mater; cellular and fibrillar gliosis, 
 whether nuclear, periradicular, or, in some cases, intra -radicular; 
 and the corset-like contraction of whole regions subject to 
 sclerosis, with consequent herniation of small bits of nerve 
 tissue). 
 
 4. The intermittency and varied structural origin of the symp- 
 toms, as well as the maintenance to the last of acute changes 
 mentioned under 1, are reasons for optimism in pushing anti- 
 syphilitic treatment. 
 
 5. Incidentally, the post-mortem data show how lumbar 
 puncture might fail to reveal lymphocytes in cerebrospinal 
 syphilis, provided that there is an occlusion of the intermeningeal 
 space by adhesions above the point of puncture. 
 
 6. The case presented a kind of reversal of the biological 
 tendency that the structures later evolved shall be destroyed first, 
 since the course of lesions in this case was largely ascending 
 throughout, and the cerebral cortex was left at the last a species 
 of shell from which the lower functioning mechanisms had been 
 successively scooped out by disease. 
 
 Southard, E.E. Anatomical Findings in Senile Dementia: A 
 Diagnostic Study bearing especially on the Group of Cerebral 
 Atrophies. American Journal of Insanity, Baltimore, 1909- 
 10, LXVI, 673-708. Also in Proceedings, American Medico- 
 Psychological Association, 1909, XVI, 511-548. 
 
 Summary and Conclusions. 
 1. Forty-two cases unanimously diagnosed "senile dementia" 
 at the Dan vers Hospital clinics have been reviewed clinically and 
 anatomically, with a surprisingly low general percentage of ac- 
 
73 
 
 curacy (66 per cent) where either cerebral atrophy or cortical 
 arteriosclerosis or both were regarded as confirmatory, and with 
 still lower percentages: (48 per cent) where cortical arterioscle- 
 rosis was considered essential, and (38 per cent) where cerebral 
 atrophy was considered essential, for a correct diagnosis. 
 
 2. The 14 cases which showed neither cerebral atrophy nor 
 cortical arteriosclerosis (with obvious damage to the cortical 
 tissues) are cases which probably should not have been termed 
 senile dementia, and perhaps more properly belong in a group of 
 acute psychoses or other mental diseases occurring in old age but 
 not dependent on recognizable senile changes. 
 
 3. Of the residuum, it is clear that cases in which cerebral 
 atrophy and cortical arteriosclerosis are combined are not suitable 
 for exact study, and attention has been concentrated upon eight 
 cases of relatively pure brain atrophy, regarded as representing 
 more nearly genuine senile dementia than the arteriosclerotic 
 cases, which should be classed under the head of organic dementia. 
 
 4. True senile or senile atrophic dementia includes (1) cases in 
 which the loss in brain weight proceeds pari passu with a general 
 loss of weight in the other viscera, and (2) cases in which the loss 
 in weight of the nerve tissues is differential. 
 
 5. The mental diseases of old age, therefore, include — 
 
 (a) Mental diseases occurring in, but not characteristic of, 
 old age. 
 
 (6) Organic dementias due to cortical arteriosclerosis. 
 
 (c) Senile atrophic dementias, attended with (1) general vis- 
 ceral atrophy and (2) differential atrophy of the nerve tissues. 
 
 6. Obvious suggestions for research in the two groups of senile 
 atrophic dementias as above stated are that the phenomena of 
 general visceral atrophy may depend upon general decadent 
 agencies (dehydration?), and that the more differential atrophy 
 indicates special metabolic flaws or toxic agencies. 
 
 7. Since such a grouping has not been hitherto rigorously borne 
 in mind, it is not possible to state the clinical features of these 
 cases in detail. 
 
 8. Taking the group senile atrophic dementia as a whole, we 
 find all the eight cases female, without special indications of in- 
 heritance, with very various antecedent factors (social factors not 
 prominent), all markedly defective in vision (though for a con- 
 siderable variety of reasons), often defective in hearing, all sub- 
 ject to various degrees of arteriosclerosis (in some instances not 
 clinically made out), all showing the characteristic external signs 
 
74 
 
 of senility, and all showing either chronic diffuse nephritis (inter- 
 stitial type predominant) or renal arteriosclerosis'. 
 
 9. Neurologically, the eight cases showed characteristically 
 tremors, absence of certain superficial reflexes, variations in some 
 deep reflexes (tendency to loss of leg reflexes), defective organic 
 reflexes, alterations of gait, and occasional slight speech disorder. 
 
 10. Psychiatrically, communication with the patients is difficult 
 and impressibility or general perceptual capacity is deficient. 
 The amnesia for recent events is characteristic and constant. 
 The patients are perhaps unoriented rather than disoriented. 
 Amnesia for remote events is also frequently present. Delusions 
 are not prominent. Visual or auditory hallucinations (or illu- 
 sions) characterized some cases. Motor excitement and nightly 
 restlessness and noise are characteristic, though not quite con- 
 stant, and are not in all cases certainly due to hallucinations. 
 Garrulity was surprisingly uncommon in this group. 
 
 11. Anatomically the pia mater was in general remarkably free 
 from chronic changes, and, as the condition of the vessels was the 
 basis of selection of the cases, the vessels naturally showed noth- 
 ing grossly beyond involvement of the larger or pipe arteries 
 (basal cerebral arteriosclerosis). The cerebral wasting was not 
 in all cases quite uniform. One case even showed a slight granu- 
 lar ependymitis. The consistence of the brain tissue was in gen- 
 eral increased. 
 
 12. A high percentage of obsolete tuberculosis characterized the 
 autopsies. 
 
 13. Aortic sclerosis is probably constant in these cases. 
 Sclerosis of other vessels is frequent but variable. The constancy 
 of renal changes is interesting. 
 
 14. The cause of death is pulmonary in many cases, and is per- 
 haps in some way bacterial in all. 
 
 15. No intensive microscopic examination has been under- 
 taken, as the object has been rather to define the group of senile 
 atrophic dementias. The satellite cell findings are consistent with 
 Metchnikoff's hypothesis concerning phagocytic processes in old 
 age. It is believed, however, that cell and fiber changes are very 
 probably primary and "neuronophagia" secondary, or at any 
 rate that these processes run pari passu. 
 
 16. A few cases showed satellite cells preferring the apical cell 
 processes rather than the basal regions of the pyramidal cells. 
 
 17. It is alleged that no convincing evidence has been brought 
 of a causal relation between local vascular changes and diffuse 
 senile nerve-cell atrophy. 
 
75 
 
 Southard, E. E. Acute Encephalitis and Brain Abscess. In 
 Osier's "Modern Medicine," 1910, VII, 624-653. Also in 
 second edition, 1915, V, 359-386. 
 
 Southard, E. E., and Fitzgerald, J. G. Discussion of Psychic 
 and Somatic Factors in a Case of Acute Delirium dying of 
 Septicemia: Note upon Experimental Guinea Pig Infection 
 with Staphylococcus Albus. Boston Medical and Surgical 
 Journal, 1910, CLXII, 452-458. 
 
 Discussion. 
 
 It is possible, by shifting the emphasis in a clinical history, to 
 convey two quite separate notions as to the genesis of a given 
 case of mental disease. Yet an answer to the question whether 
 somatic or psychic (hereditary, individual, social) factors are the 
 more important in many cases of mental disease would be de- 
 cisive in the inclination of research upon these factors. It is our 
 opinion that research should be inclined upon the side of the 
 bacteria and the toxins in appropriate cases. 
 
 Although no single logical step in the process is absolutely 
 safe, we feel that a reasonable account of our case might be as 
 follows: — 
 
 1. A cluster of nervous symptoms, compounded from the 
 effects of uterine growths and unhappy married life. 
 
 2. Latent blood infection (staphylococcus albus bacteriemia) 
 possibly related, through some unidentifiable atrium of infection, 
 with acne. 
 
 3. Rapid and massive enlargement of uterine growths (deter- 
 mining in some obscure way the sexual trend of symptoms?) and 
 pressure upon the iliac veins. 
 
 4. Thrombosis of iliac veins and vena cava (date not clear, 
 possibly at the onset of the mental symptoms, possibly fifteen 
 days later) and its sequela?. 
 
 5. Acute delirium, difficult logically either to connect with or 
 to disconnect from the thrombosis and bacteriemia discovered at 
 autopsy. 
 
 6. Death from septicemia and pulmonary thrombosis. 
 
 The case detailed above raises the question whether the in- 
 cidence of bacteria of low toxicity can determine insanity of the 
 type of acute delirium. Many textbooks seem to admit some- 
 thing of the sort in their groups of infectious deliria. It must be 
 conceded, however, that the precise relationship of infection to 
 delirium in its psychiatric sense is still far from clear. 
 
76 
 
 As to the toxic value of staphylococcus albus, writers are not 
 wholly clear. Genuine cases of albus septicemia are not un- 
 known. The remarkable work of Winslow on the Coccaceae has 
 served to unify rather than separate the staphylococci of various 
 sorts. Kraus and Pribram (1906) have shown that many 
 varieties of staphylococci produce a true toxin which will pass 
 into the culture nitrate and produce an antitoxin; the toxin in 
 question appears to poison the heart especially. Panichi (1906) 
 was able to cultivate the albus repeatedly over weeks and months 
 from the blood of two subjects who otherwise gave no note- 
 worthy signs of infection. Similar results with other organisms, 
 especially in convalescence, are serving to overthrow our older 
 notions of the essential injuriousness of bacteriemia. Such bac- 
 teriemia of unknown atrium may readily permit infection and 
 thrombosis of tissues under such conditions as those of the iliac 
 veins in the case above described. Moreover, it does not overstep 
 the bounds of probability to state that a variety of symptoms, 
 among them mental, may accrue from such low-grade infections. 
 
 The hypothesis that drug-like products of bacteria, or bacteria 
 themselves drug-like in action, may produce mental symptoms is 
 certainly far from unlikely, though it is also true that idiosyn- 
 crasy or special sensitization may be essential to permit the 
 development of such symptoms. 
 
 It is obvious, however, that psychiatric clinics are not working 
 this field intensively, and for such work we wish to put in a plea. 
 Routine blood cultures and carefully chosen immunity tests 
 (especially those just recently developed for other purposes as a 
 result of the work of Bordet and others) in such cases would go far 
 to clear up these obscure relations. Perhaps only by such intensive 
 work can the mechanism of certain types of insanity be learned. 
 
 Gay, F. P., and Southard, E. E. The Significance of Bacteria 
 cultivated from the Human Cadaver: A Study of 100 Cases 
 of Mental Disease, with Blood and Cerebrospinal Fluid. 
 Cultures and Clinical and Histological Correlations. Cen- 
 tralblat f. Bakteriologie (etc.), 1. Abt., Jena, 1910, LV, 
 Orig., 117-133. (From the Laboratory of the Danvers State 
 Hospital.) 
 
 Conclusions. 
 1. The results of bacterial cultivations from the heart's blood, 
 and the cerebrospinal fluid post mortem in 100 cases of mental 
 disease, have been correlated with the histopathological findings 
 
77 
 
 (Marchi impregnations of the spinal cord at three levels) and the 
 clinical histories, having special reference to a history of terminal 
 disease over or under four days' duration (regarded as a period 
 in which typical Marchi alterations might ensue). 
 
 2. The bacteria were cultivated upon agar plates inoculated 
 with 1 to 1.5 cubic centimeters heart's blood and others with the 
 same amount of cerebrospinal fluid. The cerebrospinal fluid was 
 removed from the third ventricle through the infundibulum, 
 severed at its origin. 
 
 3. Forty-one per cent of our heart's blood cultures remained 
 sterile (c/. Gradwohl, 22 per cent; Otten, 42 per cent; Simmonds, 
 48 per cent). 
 
 4. Twenty-eight per cent of the cerebrospinal fluid cultures 
 remained sterile. 
 
 5. Under the conditions of our laboratory the statistics show 
 (Table I) that there is no significant difference in the percentage 
 of positive cultures from either source at varying hours post 
 mortem, and that the danger of contamination must be limited 
 to a brief interval after death. 
 
 6. Our findings point definitely, if indirectly, to the intravital 
 significance of the bacteria found, despite the fact that in no 
 particular instance is the chain of evidence complete. 
 
 7. Since the same bacteriolytic substances are found in blood 
 serum both before and for some time after death, there is no 
 reason for supposing that bacteria can grow better post mortem. 
 
 8. We now show that bacteriolytic substances are absent in 
 the cerebrospinal fluid, so that there appears to exist therein no 
 extracellular mechanism for the disposal of bacteria. 
 
 9. The fact just stated (7 and 8) may account for the higher 
 percentage of organisms in the cerebrospinal fluid. 
 
 10. Among the facts concerning the incidence of bacterial forms 
 (Table II) are these: cocci were found in the blood in 26 cases, 
 in the cerebrospinal fluid in 34 cases; streptococci, blood, 8 
 times, cerebrospinal fluid, twice; pneumococci, blood, 3 times; 
 B. coli aerogenes group, blood, 11 times, cerebrospinal fluid, 25 
 times; B. proteus group, cerebrospinal fluid, 7 times. 
 
 11. The absence of diphtheroid organisms from our series is 
 noteworthy, since in previous years cultivations at the Danvers 
 Hospital had yielded such organisms in several cases. 
 
 12. Cultivations from thirteen general paretics are listed 
 (Table III); in the positive cases cocci prevail. 
 
 13. Nine bacteriologically negative cases are listed (Table 
 
78 
 
 IV); reasons are adduced for certain histopathological changes, 
 possibly independent of bacteria, in these cases. 
 
 14. Ten cases which failed to show specified histopathological 
 changes are listed (Table V), from which it appears that coli 
 is not found associated with such cases unless the terminal dis- 
 ease happens to have been brief. On the other hand, cocci are a 
 frequent finding in this group. 
 
 15. Thirty-one cases which had terminal symptoms less than 
 four days in duration are listed (Table VI); 29 per cent of these 
 failed to show spinal cord degenerations by the Marchi method 
 (as against 10 per cent in the total series). 
 
 16. Of 10 cases selected as showing most numerous spinal 
 fatty degenerations (diffusely scattered blackenings in white and 
 gray matter), 9 showed coli communis either in heart's blood or 
 in cerebrospinal fluid or in both, and 8 in large numbers. 
 
 17. Of 18 cases yielding 40 or more colonies of coli communis 
 from one or each source, 8 showed extreme degrees of Marchi 
 degeneration, 5 relatively severe changes (intraspinal and intra- 
 radicular), and the 5 remaining cases showed considerable intra- 
 spinal change. 
 
 IS. Of 13 cases showing generalized softening of brain tissue 
 (general encephalomalacia), 10 yielded coli communis. 
 
 19. A definite relation must be assumed to exist between coli 
 communis or its toxines and nerve-fiber degeneration. 
 
 Southard, E. E. The Laboratory Work of the Danvers State 
 Hospital, Hathorne, Mass., with Especial Relation to the 
 Policy formulated by Dr. Charles Whitney Page, Super- 
 intendent, 1888-98, 1903-10. Boston Medical and Surgical 
 Journal, 1910, CLXIII, 150-155. 
 
 Remarks. 
 What has been brought out in extenso refers to the more purely 
 scientific side of the Danvers work, as largely favored, advocated 
 and mechanized by Dr. Page, to whom we wish to present the 
 product of our recent work in the articles of this series. The 
 chief considerations are as follows: — 
 
 1. The insane hospital gets no vital support from a medical 
 profession ill-educated in mental disease. 
 
 2. The situation is apt, in America at large, to be dominated 
 by the per capita cost rather than by the humanitarian considera- 
 tions which underlie the whole system of treatment of the insane. 
 
79 
 
 3. The superintendency of a State hospital for the insane has 
 become a position requiring generalship; is strategic rather than 
 tactical. 
 
 4. Since the superintendent has oversight of the science as 
 well as the art of psychiatry, as exemplified in his hospital, it 
 becomes his duty continually to improve the laboratory as well as 
 the ward facilities, and this in the interest of the patient. 
 
 5. Dr. Page's Danvers work has contributed to the economics 
 underlying the proper co-ordination of the two aspects — the 
 ward and laboratory aspects — of the large problem of diagnosis 
 and treatment of insane patients in State hospitals. 
 
 6. Special attention may be drawn (a) to the appointment of 
 specially (though very variously) trained men to the pathologist- 
 ships; (b) to the encouragement by maintenance of special labo- 
 ratory internes; (c) to the daily clinic system with its republican 
 feature of rotating leaders; and (d) to the complete index of 
 symptoms now on file for all Danvers patients. 
 
 7. The maintenance of clinico-pathological laboratories in 
 State hospitals for the insane is argued as a method for general 
 adoption on account of improvements in diagnosis, and hence in 
 treatment, which follow their establishment. 
 
 Southard, E. E. The Margin of Error in the Diagnosis of 
 Mental Disease: Based on a Clinical and Anatomical Re- 
 view of 250 Cases examined at the Danvers State Hospital, 
 Massachusetts, 1904-08. Boston Medical and Surgical 
 Journal, 1910, CLXIII, 155-159. 
 
 Summary. 
 
 1. A series of 250 cases of mental disease, with intra-vitam 
 diagnoses by several physicians, recorded at the Danvers State 
 Hospital daily clinics, 1904-08, has been subjected to anatomical 
 review for the sake of learning where lie the greatest difficulties 
 in diagnosis. 
 
 2. Ten cases (4 per cent) remain both clinically and anatomi- 
 cally obscure. 
 
 3. Seven cases (2.8 per cent) had diagnostic doubts settled 
 after the clinic either intra-vitam or post mortem (one case each of 
 general paresis, cortical arteriosclerosis, cerebral sclerosis with 
 Graves' disease, streptococcus septicemia, epilepsy, streptococcus 
 meningitis, cerebellar abscess). 
 
 4. Sixty-six cases (26 per cent) were doubtful clinically, but 
 
80 
 
 the correct diagnosis was obtained by one or more diagnosticians 
 in 49 of the 66 (74 per cent of the doubtful group). 
 
 5. One hundred and eighty-four cases (74 per cent) were 
 clinically certain, and the clinical diagnoses were confirmed (or 
 not altered) by autopsy in 163 of the 184 (89 per cent of the 
 unanimous group). 
 
 6. The correct diagnosis was obtained by one or more diag- 
 nosticians in 49 + 163 = 212 cases in 250 (85 per cent). 
 
 7. The "correctness" of these diagnoses is subject to some 
 reservation, (1) since within the "organic and senile dementia 
 group" differentiation proved difficult, and (2) since anatomical 
 "consistency" often signifies absence of characteristic lesions. 
 The acute psychoses have been reviewed, however, bearing in 
 mind modern views. Several alcoholic cases failed to exhibit 
 striking brain lesions. 
 
 8. The majority of the real diagnostic difficulties uncovered by 
 this analysis would appear to require more intensive work in the 
 field of clinical pathology. For such work in psychopathic hos- 
 pitals this paper is an appeal. 
 
 Southard, E. E., and Canavan, Myrtelle M. Bacterial In- 
 vasion of the Blood and Cerebrospinal Fluid by Way of 
 Mesenteric Lymph Nodes: A Study of 50 Cases of Mental 
 Disease. Boston Medical and Surgical Journal, 1910, 
 CLXIII, 202-209. 
 
 Summary. 
 
 1. Following the same technic chosen by Gay and Southard 
 for their study of the post-mortem bacteriology of the heart's 
 blood and cerebrospinal fluid in 100 cases of mental disease, the 
 writers have examined 50 further cases from the same source 
 (Danvers State Hospital, Massachusetts), with the addition of 
 cultivations from mesenteric lymph nodes. 
 
 2. The material was unselected, save (1) that cases without 
 readily palpable nodes were not examined, and (2) that 30 of 
 the 50 cases gave macroscopic signs of intestinal disease of greater 
 or less severity (15 from an epidemic of bacillary dysentery). 
 
 3. As in the former work, there were no detectable differences 
 in the proportion of bacteria grown at different intervals post 
 mortem. (Table I.) 
 
 4. Positive cultivations (excluding a few frank contaminations) 
 were obtained in (a) cerebrospinal fluid, 85 per cent; (6) blood, 
 80 per cent, and (c) node, 78 per cent. 
 
81 
 
 5. Growths from all three regions were obtained in 55 per 
 cent. 
 
 6. Growths from two out of the three regions were most fre- 
 quently obtained in cerebrospinal fluid and lymph node (17 per 
 cent), a fact which may be interpreted as due to an effective 
 bacteriolysis in the blood (compare previous article). 
 
 7. Table II gives the incidence of various organisms found: 
 Cocci in the blood, 20 cases; in the cerebrospinal fluid, 22 cases; 
 and in the lymph node, 16 cases (staphylococcus aureus in these 
 sources, 5, 6 and 3 cases, respectively; streptococci, 2, 1 and 
 cases). Bacilli in- 1, 8 and 10 cases in the respective sources. 
 
 8. The colibacilloses are especially interesting in the light of 
 the relation between colibacillosis and "soft brains" suggested 
 by the results of Gay and Southard. Our one case of colibacil- 
 lemia failed to show a "soft brain." Two of three cases of pure 
 cerebrospinal colibacillosis yielded "soft brains," and the third 
 (doubtful bacteriologically) was negative. The three combined 
 lymphnodal and cerebrospinal invasions were unsuitable, being 
 all three instances of extreme sclerosis. Two of the 3 pure 
 lymphnodal colibacilloses showed "soft brains" (one only in non- 
 sclerotic parts) and the third was negative. Thus 4 out of 7 
 cases suitable for such display showed palpably soft brains in 
 association with colibacillosis. 
 
 9. Analyzing in the other direction, there were 7 "soft brains" 
 in the series, 3 of which showed colibacillosis; 2, infection with 
 special pathogenic bacilli (under special study); 1, contamination 
 of node; and 1, generalized invasion with certain unidentified cocci. 
 
 10. Appropriate atria for the invasions and infections are 
 demonstrable in the majority of instances. 
 
 11. Our findings seem consistent with the hypothesis that in 
 the terminal exhaustions of the insane bacterial invasions are 
 almost the rule. Perhaps otherwise normal and quite healthy 
 subjects may, more often than hitherto suspected, show bacterie- 
 mia or even cerebrospinal fluid invasions. 
 
 12. The intestinal wall is a leading atrium for such invasions, 
 — an atrium perhaps the more penetrable by reason of atrophic 
 processes frequently displayed. The livers and especially the 
 spleens are much underweight in the majority of our cases. 
 
 13. Mesenteric and bronchial lymph nodes lead the other nodes 
 in proportion of diseases displayed in the total Danvers collection. 
 Often only one or two of the lymph nodes in the group exhibited 
 gross lesions. 
 
82 
 
 Southard, E. E. A Study of the Dementia Prsecox Group in the 
 Light of Certain Cases showing Anomalies or Scleroses in 
 Particular Brain Regions. American Journal of Insanity, 
 Baltimore, 1910-11, LXVII, 119-176. Also in Boston Medi- 
 cal and Surgical Journal, 1910, CLXIII, 159-182. 
 
 Conclusions. 
 
 1. Existent evidence for the organic nature of dementia prsecox 
 is not wholly convincing, since (a) the cytological changes de- 
 scribed are found also in cases of toxic deliria and in cases com- 
 plicated by severe visceral disease, and (b) the stratigraphic 
 changes described are found also in certain senile cases without 
 characteristic symptoms of dementia prsecox. 
 
 2. Resort must, therefore, be had to the topographic idea, for 
 the adequate exploitation of which total brain sections, with 
 cytological exploration of all areas, are ideally necessary. 
 
 3. Random blocks of brain tissue with demonstration of satel- 
 litosis, infrastellate gliosis, or disintegration products of cell dis- 
 order will throw little light on the mechanism of dementia 
 prsecox. 
 
 4. The data of the functionalists (dissociation, sejunction, in- 
 trapsychic ataxia, and the like) are of the utmost importance as 
 indicating the essential focality of the pathogenic process and the 
 focal variations in its severity. 
 
 5. The curability of certain cases, the remissive character of 
 some cases, the speedy disappearance of particular symptoms, the 
 persistent complexity of reaction in some instances, the absence 
 of characteristic severe projection-system symptoms, all indicate 
 that the process is histopathologically mild, and that the focal 
 changes found will be but slightly destructive or even irritative 
 (in the sense of slight injuries readily repaired or compensated 
 for). 
 
 6. Grossly destructive lesions of a transcortical character in 
 Wernicke's sense might conceivably effect, e.g., a permanent 
 katatonic complex, and doubtless will be found to do so occasion- 
 ally; but the protean and progressive character of dementia 
 prsecox will exclude such transcortical injuries from playing a 
 large part in the pathogenesis. 
 
 7. The focal lesions to be sought for will doubtless escape 
 macroscopic notice in many instances, since the volume of appa- 
 ratus engaged in effecting very prominent symptoms is often 
 slight and spread very thin in numerous areas. 
 
83 
 
 8. Studies of the "soft brain" and of gliosis in epilepsy have 
 proved, however, that even comparatively slight degrees of corti- 
 cal gliosis can often be palpated at autopsy. 
 
 9. Palpable glioses of a focal or variable character, combined 
 in numerous instances with visible atrophy and microgyria, have 
 been found in over half the series under examination, in cases 
 regarded as clinically above reproach and not subject to coarse 
 wasting processes, focal encephalomalacia, cortical arteriosclerosis, 
 or diffuse chronic pial changes. 
 
 10. The frequent co-existence of several foci of sclerosis or 
 atrophy in the same brain and the microscopic observation of 
 milder degrees of nerve-cell disorder and gliosis in regions with- 
 out gross lesions tend to the conception that the agent is more 
 general and diffuse in its action than would seem at first sight, 
 so that future research may well demonstrate that certain in- 
 stances of coarse brain wasting, and even of diffuse chronic lepto- 
 meningitis, belong in the group (microscopic corroboration neces- 
 sary for assigning values to focal variations). 
 
 11. The microscopic examination of the residue of cases in 
 which gross lesions or anomalies were not described shows the 
 same tendency to gliosis and satellitosis in numerous instances, 
 and the same tendency to focal variations from gyrus to gyrus 
 exhibited by the gross lesion group. These findings suggest that 
 the minor gross lesions and anomalies of several cases actually 
 escaped notice (the protocols, though drawn up with a certain 
 system, are by various hands) at autopsy, so that the probable 
 actual proportion of gross lesions is 68 per cent. If microscopic 
 evidence is resorted to, the "organic" proportion in our series 
 rises to 86 per cent. 
 
 12. Several groups of cases were classified from the distribu- 
 tion of macroscopic lesions, although the focal purity of these 
 cases can often be brought in question from the results of micro- 
 scopic examination (infrastellate gliosis and satellitosis also in 
 macroscopically "normal" areas). 
 
 (a) Pre-Rolandic group, including a superior frontal-prefrontal 
 sub-group of paranoidal trend (c/., e.g., Case 1062). 
 
 (b) Post-Rolandic group, including (a) postcentral-superior- 
 parietal (sensory-perceptual) sub-group in which katatonic fea- 
 tures are the common factors (c/., e.g., Case 1298); (b) occipital 
 sub-group (c/. Case 1149). 
 
 (c) Infra-sylvian group (too small for clinical correlations). 
 
 (d) Cerebellar group (katatonic features). 
 
84 
 
 13. If these data find general confirmation, they will doubtless 
 go far to unify discussion, since mild, variable and progressive 
 intracortical lesions, proceeding at different rates in different 
 parts of the apparatus, and having the peculiar distributions in- 
 dicated above, would explain adequately some of the contentions 
 of the dissociationists, while remaining not wholly inconsistent 
 with Kraepelinian ideas. 
 
 14. The frontal-paranoid correlation is in line with modern 
 physiological ideas, but it must be granted that the occipital and 
 temporal regions, as elaborating important long-distance impulses, 
 may well play a part also in paranoid states. 
 
 15. The cerebellar-katatonic correlation is doubtless in line 
 with some contentions of the Wernicke school, and obvious com- 
 ments might be made in connection with the proprioceptive func- 
 tions of the cerebellum (Sherrington). 
 
 16. The postcentral-superior-parietal relations to katatonic 
 symptoms are perhaps theoretically the most novel suggestion 
 from the work, but here again the results are not inconsistent 
 with modern physiology. 
 
 17. The topographic study of dementia prsecox brains, both 
 gross and microscopic, is commended as likely to shed new light 
 on the pathogenesis of certain symptoms, notably paranoidal and 
 katatonic symptoms. 
 
 1912. 
 
 Lucas, W. P., and Southard, E. E. Contributions to the 
 Neurology of the Child. I. Convulsive Tendencies during 
 and after Encephalitis in Children. (Reprinted also as 
 Encephalitis and Epilepsy.) Boston Medical and Surgical 
 Journal, 1912, CLXVI, 323-328. 
 
 Conclusions. 
 
 1. The records of the Children's Hospital from 1905 to date 
 have been searched for possible instances of encephalitis. Cases 
 of "encephalitis," "toxic encephalitis," "meningitis(?)," and 
 " (?), encephalitis (?)" have been considered. 
 
 2. Twelve cases have been chosen which may with some reser- 
 vations be regarded as cases of encephalitis. These show onset 
 always sudden. Paralysis or paresis in all cases (oculomotor 
 paralysis in 7). Deep reflexes altered in 10. Mental symptoms 
 in 10. Rigidity of neck in 9. General convulsions, 7 (absent in 
 4). Nausea or vomiting, 5 (not noted in 7). 
 
85 
 
 3. The results fall into three groups: (a) death during acute 
 attack, 2 cases (X and XI); (b) recovery from acute attack, 
 with subsequent epilepsy and mental deficiency, and death after 
 twenty-one months, 1 case (II); (c) recovery from acute attack, 
 with residual symptoms, 5 cases (I, III, V, IX, XII); 2 normal, 
 except for strabismus and possible slight mental change (IV, VI); 
 2 epileptic and mentally defective (VII and VIII). 
 
 4. With respect to epilepsy, the total incidence of convulsions 
 during the acute attack was 7 in 12. Of 9 cases still living 5 
 showed convulsions during the acute attacks, and 2 of the 5 
 (VII and VIII in chart) are epileptic. 
 
 5. In both epileptic cases there was a brief interval between 
 recovery from the acute attack and the onset of epilepsy. 
 
 6. The detailed histories of a case developing epilepsy and of a 
 fatal case with autopsy are presented. 
 
 Southard, E. E. Psychopathology and Neuropathology: The 
 Problems of Teaching and Research contrasted. Journal of 
 American Medical Association, Chicago, 1912, LVIII, 914- 
 916. Also in American Journal of Psychology, 1912, XXIII, 
 230-235. 
 
 Southard, E. E. Note on the Geographical Distribution of 
 Insanity in Massachusetts, 1901-10. Boston Medical and 
 Surgical Journal, 1912, CLXVI, 479-483. 
 
 Summary and Conclusions. 
 
 The eugenic area or areas of a region are characterized by the 
 operation of hereditary factors in either (a) the improvement of 
 the contained human stocks, or (b) the maintenance of these 
 stocks in statu quo. 
 
 The aristogenic program is that extreme eugenic program 
 which seeks to produce more and greater great men for the world 
 by more effective mating. 
 
 Against an ideal aristogenic program are operating certain 
 deteriorating factors of hereditary nature (cacogenic factors). 
 
 The data immediately available in Massachusetts may be used 
 in the study of eugenic areas in the second or negative sense (see 
 (6) above) with respect to insanity. 
 
 The morbidity rate of the Massachusetts insane commitments 
 is not the same as the accumulation rate, as an effect of many 
 combined causes (Owen Copp's data). 
 
86 
 
 One possibly eugenic area exists in Massachusetts in three 
 island townships; another, in nine more scattered western town- 
 ships (seven in the Berkshire Hills region). 
 
 The twelve possibly cacogenic towns have produced 236 new 
 cases of insanity and allied conditions, being 15 per 1,000 in the 
 population of these towns in 1910 (total Massachusetts rate, 7 
 per 1,000); highest single town rate considered, 19 per 1,000; 
 Suffolk County (Boston, etc.) rate, 9 per 1,000; highest single 
 city rate, 10 per 1,000. 
 
 These possibly cacogenic townships lie chiefly in the midland 
 county of Worcester, and in no case west of the Connecticut 
 River or on the seacoast. 
 
 The possibly eugenic and possibly cacogenic towns as con- 
 sidered from the commitment standpoint remain so to a degree 
 when considered from the standpoint of the census of the same 
 four classes enumerated in the townships May 1, 1905, viz., 2.6 
 per 1,000 in the former, to 3 per 1,000 in the latter, group. 
 
 A more striking numerical disparity was shown by the census 
 of social defectives (prisoners, juvenile offenders, paupers and 
 neglected children) May 1, 1905, viz., 8 per 1,000 in the eugenic 
 group against 20 per 1,000 in the cacogenic group. 
 
 The population of the eugenic group is small (2,945 in 1910) 
 as compared with that of the cacogenic group (15,415 in 1910); 
 the eugenic group is falling somewhat, the cacogenic group rising 
 somewhat, in general population. 
 
 The nativity of the general population in the two groups 
 differs little, — 830 per 1,000:840 per 1,000, — but the eugenic 
 group has a somewhat higher percentage of native-born parents, 
 and a still higher percentage of native-born grandparents, and 
 may, therefore, represent somewhat stabler stocks than the caco- 
 genic group. 
 
 The general medical and social picture presented by the census 
 of 1905 is distinctly worse for the cacogenic group than for the 
 eugenic group, suggesting that the insanities and allied conditions 
 are apt to occur in a background of more general diseases. 
 
 If we assume that active eugenic measures are the duty of 
 society on the principles of self-preservation or of self-improve- 
 ment, then such measures must begin somewhere. The present 
 note has no measures to propose, but merely displays certain 
 concrete social differences in different regions of Massachusetts. 
 The prevailing laissez-faire policy cannot safely fall back on the 
 idea that all the stocks are "just generally degenerating," and 
 
87 
 
 that we "should not know where to begin." I should, therefore, 
 advocate more intensive locality studies in Massachusetts as well 
 as elsewhere, and the collection of social statistics through every 
 public and private channel in preparation for that active eugenic 
 program which the concrete data will be sure to indicate. 
 
 If there be a statistical correlation between insanity, crime, 
 pauperism and disease, there may be a deeper causal relation 
 between some of these factors. 
 
 Southard, E. E. The Significance of a Homoeopathic Founda- 
 tion for Clinical Research and Preventive Medicine. Boston 
 Medical and Surgical Journal, 1912, CLXVI, 585-587. 
 
 Southard, E. E. The New Psychopathic Department of the 
 Boston State Hospital. Boston Medical and Surgical 
 Journal, 1912, CLXVI, 882-8.86. 
 
 Southard, E. E., and Canavan, Myrtelle M. Second Note 
 on Bacterial Invasion of the Blood and the Cerebrospinal 
 Fluid by Way of Lymph Nodes: Findings in Bronchial and 
 Retroperitoneal Lymph Nodes. Boston Medical and Surgi- 
 cal Journal, 1912, CLXVII, 109-113. 
 
 Summary. 
 
 1. Following the same technic adopted by Gay and Southard 
 in their study of the post-mortem bacteriology of the blood and 
 cerebrospinal fluid (100 cases), and that of Southard and Canavan 
 in their study of the blood, cerebrospinal fldid and mesenteric 
 lymph nodes (50 cases), the writers have studied the post-mortem 
 bacteriology of 50 further cases, replacing mesenteric by bron- 
 chial lymph nodes, and 30 cases adding retroperitoneal lymph nodes. 
 
 2. The conclusion of two former papers is further established, 
 viz., that post-mortem cultures from the cerebrospinal fluid are 
 more likely to yield growths than cultures from the blood. 
 
 3. Just as the cerebrospinal fluid proved more frequently 
 positive than did the mesenteric lymph nodes, so, too, the fluid 
 remains more frequently positive than the bronchial lymph nodes 
 (nota bene, the difficulty of taking cultures from the usually small 
 available amount of lymph node material). Retroperitoneal 
 lymph nodes, however, are found more frequently invaded than 
 either blood or cerebrospinal fluid in our series. The 84 per cent 
 positive retroperitoneal nodes (1912) are only exceeded by the 
 
88 
 
 85 per cent positive cerebrospinal fluid series of Southard and 
 Canavan (1910). 
 
 4. Both bronchial and retroperitoneal lymph nodes exceed the 
 blood in frequency of positive cultures; the excess is, however, 
 slight. 
 
 5. The most frequent two-out-of-three positive combination, 
 found in 1910, was the combination of positive cerebrospinal fluid 
 and positive mesenteric lymph node. This led to the hypothesis of a 
 lymphogenous blood-borne invasion of organisms lodging in the men- 
 inges and later killed out in the blood by bacteriolytic substances. 
 
 6. This condition is reversed in the present series, where the 
 combination of positive cerebrospinal fluid and positive bronchial 
 lymph node is very rare. 
 
 7. The exceptional nature of our mesenteric node results was 
 suspected when they were obtained, and was thought to depend 
 somewhat upon the selected character of the nodes tested (large, 
 succulent or easily palpable nodes were chosen for culture, and 
 cases without such nodes omitted from the series). In respect to 
 bronchial and retroperitoneal nodes, fewer cases had to be 
 omitted on the score of unavailable nodes. It may perhaps be 
 surmised, then, that the majority of bronchial and retroperi- 
 toneal lymph nodes examined were executing their defensive 
 duties with considerable success, and were not letting through 
 great numbers of organisms. The majority of mesenteric nodes 
 in our series were doubtless reactive to unusual conditions, and 
 were permitting more organisms to get through the lines. 
 
 8. The retroperitoneal nodes are on a different footing from the 
 bronchial nodes in that they more frequently contain organisms 
 (84 per cent versus 64 per cent). The combination of positive 
 retroperitoneal node and positive cerebrospinal fluid is the most 
 frequent two-out-of-three combination (recalling in this respect 
 the mesenteric series) . 
 
 9. Positive growth from all three loci were found in (a) mesen- 
 teric node combination, 55 per cent; (b) retroperitoneal node 
 combination, 52 per cent; (c) bronchial node combination, 35 
 per cent. 
 
 10. These combinations of growths are of interest, whether one 
 subscribes to the intravital or to the post-mortal invasion theory, 
 since without doubt the tissues and their juices, including blood 
 bacteriolysins, remain active for some time after apparent death. 
 
 11. Our results, as before, incline us to the idea of intravital 
 significance of the organisms found. The statistics show similar 
 
89 
 
 frequencies early and late post mortem, and the same high per- 
 centages of sterile cultures which the post-mortalist finds it so 
 hard to explain. 
 
 12. Tables are presented showing the main types of organism 
 cultivated. Special remark is made of a protracted period in 
 which an anthrax-like organism kept appearing in certain autop- 
 sies. The question of ward and laboratory epidemics or pseudo- 
 epidemics of saprophyte forms is brought up. 
 
 13. On the basis of this work important researches into in- 
 travital conditions can be imagined, especially in the field of 
 bacteriemia and "low-grade sepsis." 
 
 Southard, E. E. Report of the Mentality of a Subject fasting 
 at the Nutrition Laboratory of the Carnegie Institution of 
 Washington, Boston, Mass., from April 14 to May 15, 
 1912. (Privately printed.) 
 
 Remarks. 
 In brief, therefore, (1) there are no evidences of committable 
 insanity in the subject; (2) some alienists might think the sub- 
 ject a psychopathic personality, but (3) the subject is probably 
 an eccentric and not a psychopathic person. There are certain 
 traces of psychic exhibitionism in the case. No erotic origin for 
 this phenomenon was discovered, and it may better be taken on 
 a more naive basis as an exaggeration of a frequent phenom- 
 enon. The egoism was rather of a childish character. All 
 signs pointed rather to vanity than to ambition. The subject 
 belongs to a group of reformers and self-constituted saviors, and 
 the ultimate decision as- to his character must depend upon 
 developments of psychiatric theory as to the intellectual, emo- 
 tional and volitional significance of such reform tendencies. 
 The odds at present favor an emotional basis for these tend- 
 encies. 
 
 1912-1913. 
 
 Southard, E. E. On the Somatic Sources of Somatic Delusions. 
 Journal of Abnormal Psychology, Boston, 1912-13, VII, 326- 
 339. 
 
 Summary. 
 The writer has sought a series of cases of delusion-formation 
 in which the false beliefs were such as to impute structural dis- 
 order to various organs (somatic or visceral delusions). Since 
 
90 
 
 no collection of correlations, however striking, is conclusive in 
 the face of hosts of other non-correlations assumed to exist, resort 
 was had to a statistical method. In a series of 1,000 autopsied 
 cases, some 38 cases having characteristic somatic delusions, 
 and not showing obvious brain lesions at autopsy, were found. Of 
 these 38, 8 were found which were fairly free, at least concerning 
 the correlations at issue, from complications with delusions of 
 other types (personal or social). 
 
 In these 8 cases thus impartially drawn a statistical correla- 
 tion can be safely stated to exist between such "somatopsychic" 
 or severe "hypochondriacal" cases and serious somatic disease. 
 It seems certain that these serious somatic conditions colored 
 the lives of the patients. 
 
 In one group of cases (Cases I, II, III, possibly VIII) the 
 psychic rendering of the somatic states is rather critical and 
 temporary, and follows a process somewhat comprehensible to 
 the normal mind. (Type: "Shot by a fellow with a seven- 
 shooter," in a spot found to correspond with a patch of dry 
 pleurisy.) 
 
 In others (Cases IV, V) the psychic rendering is less natural 
 and is more a genuine transformation of the sensorial data into 
 ideas quite new. (Type: "Bees in the skull" found in the case- 
 with cranial osteomalacia.) 
 
 In others (Cases VI and VII) the problem is raised whether 
 severe hypochondria, with ideas concerning dead entrails and the 
 like, may not often indicate such severe somatic disease as 
 tuberculosis. The psychic rendering here is of a more general 
 (apperceptive (?)) sort. 
 
 Hereditary predispositions, acquired dispositions, and manifold 
 unexplained correlations must be clearly admitted. The concept 
 of the crystallization of delusions around sensorial data of an 
 abnormal sort must be entertained for some cases at least. It 
 would not be safe to neglect these somatic data any more than 
 it would be well to neglect the patient's turn of mind, his 
 critical (though perhaps forgotten) emotional past experiences, 
 or his ancestry. It might prove that the results of careful 
 physical examination would have much to do with the diagnosis, 
 or even the prophylaxis, of certain delusional conditions. 
 
91 
 
 1913. 
 
 Southard, E. E. A Series of Normal-looking Brains in Psycho- 
 pathic Subjects. Worcester State Hospital Papers, Con- 
 tribution No. 11 (1912-13). Also in American Journal of 
 Insanity, Baltimore, 1913, LXIX, 689-704. 
 
 Conclusions. 
 
 1. The main object of this communication is to stimulate 
 interest in normal or normal-looking brains in psychopathic sub- 
 jects, so that the question whether insanity is, or is not, always 
 a matter of structural brain disease may approach settlement. 
 
 2. Normal-looking brains have now been found in a large 
 fraction of senile dementia cases in two autopsy series, so that 
 the "functionality" of these cases stands on as good a footing 
 as that of various more generally recognized "diseases of mental 
 function." 
 
 3. The issue in dementia prsecox is now clearly defined, since 
 one series (Worcester) might be interpreted to affirm the func- 
 tionality, and the other (Danvers) to affirm the structurally 
 ("organic nature"), of the disease in question. 
 
 4. Incidentally the question has arisen whether dementia 
 prsecox may not, on the ground of viability, be divided into 
 dementia prcecox brevis (with early death, say under two years 
 from onset; katatonic form often here found) and dementia 
 prcecox longa (in which the subject dies, as a rule, more than 
 eight years after onset, of a variety of causes; katatonic form 
 less frequent). 
 
 5. Use has been made of a principle that apparent normality 
 of brains may be consistent with fine microscopic changes, 
 possibly of a reversible nature, and that we shall hardly from 
 gross appearances be able to assert abnormality of brains unless 
 at least three months (pre-indurative period) have elapsed from 
 the onset of some cell-destructive process. 
 
 6. Use has been made of a principle to the effect that various 
 nerve cells which are in all respects intrinsically normal may be 
 essentially sharing in processes extrinsically abnormal. 
 
 7. The hypothesis is raised that the whole cortex, or even the 
 whole nervous system, might be intrinsically normal but extrinsi- 
 cally abnormal in its reactions to a given chemical, physical or 
 other condition. 
 
92 
 
 8. It is possible that the solution of the problem of the func- 
 tionality of various diseases might be to consider the structures 
 involved as intrinsically normal whereas extrinsically abnormal — 
 the normal operation of various cells leading to injurious effects 
 in the organism as a whole. 
 
 9. It seems clear that the general statement "insanity is brain 
 disease" is well-nigh meaningless unless the particular structures 
 thought to be involved are specified, since it is clear that science 
 has not discovered even the right place to look in certain diseases 
 (no more in mental disease than in certain forms of, say, dia- 
 betes). 
 
 Southard, E. E., and Stearns, A. W. How far is the Environ- 
 ment responsible for Delusions? Being Danvers State 
 Hospital Contribution No. 38, 1913. Journal of Abnormal 
 Psychology, Boston, 1913, VIII, 117-130. 
 
 Conclusions. 
 
 By choosing cases (from a group of 1,000 cases of mental 
 disease autopsied at the Danvers State Hospital) on these 
 grounds — (a) that the brains were normal or normal-looking, 
 and (b) that the delusions recorded were purely or almost purely 
 environmental (allopsychic) in scope — we have arrived at a small 
 group of 13 cases suitable for analysis. In addition to these 13 
 cases there were 18 others (31 in all) which had been listed as 
 almost purely allopsychic in scope; but of these 18, 8 had to be 
 excluded as probably autopsychic (intrapersonal) in essence, 3 
 as imbecile, 4 as complicated by temperamental faults, and 3 as 
 influenced by cranial or meningeal disease. 
 
 Of the 13 more truly allopsychic cases, 6 showed close correla- 
 tion between previous history and contents of delusions, but the 
 others failed to show such correlation. 
 
 The problem at once arises whether concealed or unknown 
 personal factors may not have had much to do with these seem- 
 ingly pure allopsychic cases. 
 
 Whether delusions often spread inwards (egocentripetally) or 
 habitually outwards (egocentrifugally) becomes a problem to be 
 studied along these same statistical lines. 
 
 The paucity of pulmonary lesions in this group and the great 
 frequency of cardiac and renal lesions suggest further problems 
 of a more difficult nature. 
 
93 
 
 Southard, E. E. The Outlook for Work at the Psychopathic 
 Hospital, Boston, 1913. Being Psychopathic Hospital Con- 
 tribution, 1913.14. Boston Medical and Surgical Journal, 
 1913, CLXIX, 427, 428. 
 
 Southard, E. E. Mental Disease of Somatic but Extra-nervous 
 Origin (Somatic Psychoses). White and Jelliffe's Modern 
 Treatise of Nervous and Mental Disease, Philadelphia and 
 New York, 1913, I, 518-528. 
 
 Southard, E. E. Contributions from the Psychopathic Hospital, 
 
 • Boston, Mass: Introductory Note. Being Contribution 
 
 from the Psychopathic Hospital, Boston, Mass., No. 1 
 
 (1913.1.) Boston Medical and Surgical Journal, 1913, 
 
 CLXIX, 109-116. 
 
 Summary. 
 
 The contributions of a psychopathic hospital like the new 
 Boston institution are likely to emanate from the laboratory and 
 to be of somatic trend. Their source will, however, be the pa- 
 tients themselves, since many psychiatric problems (e.g., those of 
 speech) are hardly workable in lower animals. These clinical 
 problems are bound to be of a wide range on account of the rep- 
 resentativeness of the clinical material, — the drainage-product, 
 namely, of a metropolitan district. German models are avail- 
 able, and articulation with the State system of government car- 
 ries with it sundry advantages. 
 
 The juxtaposition of the medical and social points of view 
 must direct our progress. Local influences (Massachusetts Gen- 
 eral Hospital, Boston Dispensary) are of especial advantage. 
 
 We are not so happy in possessing as yet few competitors; 
 nothjng like the number of psychiatric observers (and of clinics 
 for such observers) can soon be hoped for in America as are to be 
 found in German-speaking countries. 
 
 Juxtaposition of scientific establishments for medical research 
 characterizes the recent Boston developments in which the medi- 
 cal schools, various privately endowed institutions and the Com- 
 monwealth have shared. Various examples are cited in the text 
 of men working in adjacent institutions, whose work should be a 
 stimulus to ours. 
 
 The traditions of Massachusetts in psychiatry are, however, by 
 
94 
 
 no means negligible. Examples are offered in the text of men 
 who have set the more recent traditions. 
 
 A rough statistical analysis of contributions by these more re- 
 cent Massachusetts worthies, and of contributions by workers 
 contributing to three separate sets of State hospital Festschrift 
 papers, serves to demonstrate that about one-half of all these 
 contributions have dealt with matters of nerve structure. 
 
 The paucity of sociological and psychological contributions is 
 clearly in evidence. To secure a more even development of 
 psychiatry, these latter should be stimulated, though naturally 
 our somatic studies should not be permitted to lag. . 
 
 Ltjcas, W. P., and Southard, E. E. Contributions to the 
 Neurology of the Child. III. Further Observations upon 
 Nervous and Mental Sequelae of Encephalitis in Children. 
 Boston Medical and Surgical Journal, 1913, CLXIX, 341- 
 345. 
 
 Results. 
 The facts elicited are surely striking, and are significant in the 
 following ways : — 
 
 1. They illustrate the importance of what might be called 
 sequence studies. 
 
 2. A further study has brought to light one more case of 
 epilepsy, making 10 per cent of our present total, a figure not 
 inconsistent with general statistical expectation. 
 
 3. On the same general statistical grounds we might have pre- 
 dicted that our number of mentally backward children would 
 increase as the number investigated grew. In this group we now 
 have five children, two of whom are feeble-minded without any 
 signs of epilepsy, and three are cases of marked mental retarda- 
 tion or backwardness. (Not reaching the grade of feeble-minded- 
 ness — imbecility of English writers.) This gives 28.5 per cent 
 of the living children who show marked mental defects. 
 
 4. There are four (or 15 per cent) of these cases that show less 
 marked residual effects from their encephalitis, (a) either by 
 excessive "nervousness" or (b) because they show a much 
 shorter reaction period to fatigue. 
 
 5. Two (or 7.1 per cent) still show motor sequela; (strabismus). 
 
 6. There are 28.5 per cent who have died. 
 
 7. Only six (or 21.5 per cent) of the children show no signs of 
 their previous attack, and are apparently normal in every way. 
 
 8. Tabulation of these results is as follows: — 
 
95 
 
 Epilepsy, Nos. 7, 8, 13 or 10.7 per cent, or 7.1 per cent not counting 13. 
 Feeble-minded, Nos. 5, 20 or 7.1 per cent. 
 Backward, Nos. 6, 4, 28 or 10.7 per cent. 
 Nervous or easily tired, Nos. 15, 17, 31, 24 or 14.6 per cent. 
 Strabismus, Nos. 1, 16 or 7.1 per cent. 
 Normal, Nos. 9, 3, 18, 19, 22, 23 or 21.5 per cent. 
 Dead, Nos. 2, 10, 11, 14, 25, 26, 27, 29 or 28.5 per cent, or 25 per cent 
 without No. 2. 
 
 28.5 per cent show marked mental defect. 
 50 per cent show some stigmata. 
 21.5 per cent are normal. 
 28 per cent died. 
 
 9. These results impel further investigation of these cases and 
 of any other ones we may have occasion to follow from time to 
 time. Our first endeavor has been to learn the dimensions of 
 this problem (compare Lucas' work on sequelae of syphilis 1 ) 
 rather than to study any portion of it intensively. We now plan 
 to make intensive studies on the cases we have so far followed, 
 and to individualize these more general conclusions. 
 
 Southard, E. E. Second Note on the Geographical Distribu- 
 tion of Mental Disease in Massachusetts, 1901-10. The 
 Insanity Rates of the Smaller Cities. Read before the 
 Demographic Section of the Fifteenth Congress of Hygiene 
 and Demography, "Washington, D. C, September, 1912 (to 
 be published also as a part of the Transactions of the Con- 
 gress). The work is a sequel of work on " The Insanity 
 Rates of Massachusetts Towns," read before The Eugenics 
 Section of the American Breeders' Association at its Eighth 
 -Annual Meeting, Washington, D. C, December, 1911, and 
 published as " Note on the Geographical Distribution of In- 
 sanity in Massachusetts, 1901-10," Boston Medical and Sur- 
 gical Journal, March 28, 1912. Boston Medical and Surgical 
 Journal, 1913, CLXIX, 302-306. Also in Transactions, 
 Congress of Hygiene and Demography, 1912, VI, 217-226. 
 
 Conclusions. 
 1. As from the towns, so also from the cities is there a marked 
 variation in the number of insane contributed to the State insti- 
 tutions. 
 
 1 Contributions to the Neurology of the Child. II. Note on the Mortality, and the Propor- 
 tion of Backward Children, in a Series of Congenital Syphilis followed subsequent to Hospital 
 Treatment ; from the Out-Patient Department of the Children's Hospital and the Department 
 of Pediatrics, Harvard Medical School, by William Palmer Lucas, M.D. 
 
96 
 
 2. The range of variation is far smaller for the cities (3.5 for 
 Chicopee and Pittsfield to 9.8 from Chelsea per 1,000 inhabitants 
 in a period of ten years) than for the towns (0 in the case of 12 
 towns to 16.4 or higher in other towns). 
 
 3. The treasury of the Commonwealth would be favorably or 
 unfavorably affected by political geography as follows: Most 
 favorable to the treasury would be: (1), certain rural conditions 
 where the apparent Utopia of no commitments prevails; next, 
 (2), the conditions of certain cities (e.g. Chicopee and Pittsfield) 
 would be apparently most favorable, unless it can be demon- 
 strated that special commitment habits there prevail, favorable 
 to the purse directly, but indirectly unfortunate for the com- 
 munity; (3) more likely to approach the community's ideal are 
 the conditions of the suburbs of Boston, which seem to produce 
 even less insane than (4) the towns in general, which are ex- 
 ceeded a little by (5) the non-metropolitan towns of the State at 
 large; (6) the cities of the metropolitan district outside Boston 
 are less productive of commitments than (7) the average for the 
 Commonwealth as a whole; or (8), that for all cities; (9), the 
 metropolitan district as a whole; (10), the metropolitan cities, 
 including Boston; (11), Boston; (12), Chelsea; (13), certain 
 rural conditions. 
 
 4. Accordingly, it is safe to say that "rural degeneracy" is 
 focal, but not universal, in Massachusetts, and that, on the 
 whole, the towns are better off than the cities as commitment 
 producers. 
 
 5. Certain cities can be picked out as proper subjects for in- 
 tensive study: (a) low-rate cities, Chicopee and Pittsfield, must 
 be compared, as well as (&) Lawrence and Waltham, yielding the 
 Commonwealth's average rate; (c) all seven cities having a rate 
 lower than the general town rate should be studied; (d), Salem 
 might be of interest as having the average rate of all cities; 
 (e), Holyoke, that of all towns; (/), there are surprising con- 
 trasts in the output of various seaports. 
 
 6. The attempt to utilize the census enumerations of (a) social 
 defectives and (6) physical defectives as correlative with the 
 official commitment rates is fairly successful, and yields a degree 
 of confidence in the census enumerators (1905) which is com- 
 forting. 
 
 7. The number of physical defectives found living May 1, 
 1905, used as exemplifying conditions in the decade, is found to 
 vary up and down with the insanity rate in the different groups 
 
97 
 
 of cities; the number of social defectives appears to remain more 
 nearly constant. 
 
 8. Comparison of the towns with the cities seems to show that, 
 while cities are committing more insane than towns, they harbor 
 fewer social and physical defectives than the towns. This may 
 perhaps mean that cities have more effective means than towns 
 of getting rid of all sorts of defectives. If this be the case, then 
 we may permit outselves renewed confidence in the census sta- 
 tistics. 
 
 9. Another suggestive correlation is that between the towns in 
 general and the seven low-rate cities. The seven cities distin- 
 guished by low commitment rates are also distinguished by low 
 rates of surviving social and physical defectives, and the latter 
 rates are lower than those of cities in general. 
 
 Southard, E. E. Medical Contributions of the State Board of 
 Insanity of Massachusetts: Introductory Note. Contribu- 
 tion of the State Board of Insanity of Massachusetts No. 1 
 (1913.1). Also in Boston Medical and Surgical Journal, 
 1913, CLXIX, 537-540. 
 
 Summary and Remarks. 
 
 A general picture is offered of the medical scientific activities 
 of the State Board of Insanity of Massachusetts. The duty of 
 investigation and publication as prescribed by law, and the 
 special duties of the pathologist to the board, are summarized. 
 
 A general summary of the various pieces of investigation before 
 and after the special appropriation was made is given. It is 
 estimated that over twenty-five workers have contributed to 
 various aspects of the different investigations. The investiga- 
 tions are listed under fourteen heads, of which eight relate to 
 work done subsequent to the special appropriation. 
 
 It is impossible that studies of this particular type and range 
 shall be carried out without special funds, such as the New York 
 Lunacy Commission and the Massachusetts Board of Insanity 
 provide. It is hoped that other States will be prevailed on to 
 establish a similar policy. The amount of money necessary for 
 such investigations is negligible as compared with the money 
 spent on maintenance; 'the results, however insignificant they 
 may appear at a given moment, are bound to be some day of 
 importance. 
 
98 
 
 It is planned in future to publish various medical contributions 
 from the State Board of Insanity in various appropriate journals 
 with serial numbers so that readers may readily refer back to 
 earlier contributions. 
 
 Southard, E. E., and Canavan, Myrtelle M. Bacterial In- 
 vasion of Blood and Cerebrospinal Fluid by Way of Lymph 
 Nodes, Findings in Lymph Nodes draining the Pelvis. Journal 
 of American Medical Association, Chicago, 1913, LXI, 1526- 
 1528. 
 
 Summary and Remarks. 
 
 1. The continuation of our former works shows that the cere- 
 brospinal fluid (72 per cent) still leads the heart's blood (68 per 
 cent) in percentage of positive cultures (routine aerobic methods, 
 post-mortem material). 
 
 2. Pelvic lymph nodes (like mesenteric nodes in our former 
 work) lead both blood and spinal fluid (75 per cent). 
 
 3. This is possibly due to the great percentage of pelvic lesions 
 in the present series (20 out of 25 cases; 15 of the 20 showing 
 organisms in pelvic lymph nodes). 
 
 4. It is still uncertain whether these findings indicate ante- 
 mortem or post-mortem invasions. Of course an acute or 
 chronic lesion may conceivably help the penetration of organisms 
 from without. 
 
 5. If (as seems likely) the invasions are intravital or agonal, 
 then it would appear that the pelvic lymph nodes are accustomed 
 to harboring many bacteria (compare the mesenteric lymph 
 nodes in an epidemic of dysentery). 
 
 6. Whether this habit of receiving more organisms than other 
 nodes induces any superiority on the part of these nodes in 
 respect to their power of digestion we cannot say. If so, a 
 rationale for Fowler's drainage position (upper part of abdomen 
 maintained higher than lower part) might be imagined. Such 
 a rationale would be superior to saying that the pelvic perito- 
 neum is a better filter than others, or is differently constructed 
 from peritoneum elsewhere. 
 
 7. The pelvis, often subject to acute and chronic disease in 
 the insane, appears to supply its lymph nodes with very numer- 
 ous bacteria (both motile and non-motile and of many groups). 
 Some of these are saprophytes, some doubtless pathogens; they 
 are often found in the cerebrospinal fluid post mortem, even 
 
99 
 
 when absent (destroyed (?)) in the blood. The pelvis compares, 
 under the random conditions studied, with the intestinal tract 
 in its habit of supplying bacteria to regionary lymph nodes; 
 and perhaps the pelvis surpasses the intestinal tract, since the 
 latter's lymph nodes happened to be studied during an epidemic 
 of intestinal disease which provided an excess of secondary 
 invaders. 
 
 8. The hypothesis of a route of meningeal invasion by way 
 of the blood receives added support from this work, although 
 the possibility of more direct invasion must be considered. 
 
 Southard, E. E. On Institutional Requirements for Acute 
 Alcoholic Mental Disease in the Metropolitan District of 
 Massachusetts in the Light of Experiences at the Psycho- 
 pathic Hospital. Being Contribution from the Psycho- 
 pathic Hospital, Boston, Mass., No. 34 (1913.34). Boston 
 Medical and Surgical Journal, 1913, CLXIX, 937-942. 
 
 Conclusions. 
 
 Alcoholic mental disease forms at present about one-ninth of 
 the Psychopathic Hospital's work (217 in 1,829 admissions during 
 sixteen months). Over 50 cases of delirium tremens have been 
 admitted against the law governing these matters, either on the 
 ground of common humanity or because of errors in the very 
 difficult differential diagnosis between delirium tremens and the 
 more protracted disease alcoholic hallucinosis (which latter is 
 regarded as suitable for the Psychopathic Hospital). A number 
 of devices have been adopted at the hospital to minimize this 
 error in diagnosis and to increase our knowledge of the two 
 conditions (distinctive between "short" and "long" cases 
 (Stearns), work of clinical historian, social service, and eugenics 
 worker, the Myerson-Eversole pupil reaction, etc.). 
 
 The mortality of alcoholic cases at the Psychopathic Hospital 
 has been extremely low (about 5 per cent). The mortality in 
 delirium tremens and alcoholic hallucinosis is virtually nil (0 
 per cent). A high mortality attended our Korsakow cases (about 
 35 per cent); this curious fact demands a special investigation. 
 
 These results are superior to those of general hospitals, and 
 this superiority we attribute to our methods of treatment, chief 
 among which we place hydrotherapy. 
 
 The moral and economic value of saving these cases needs no 
 
100 
 
 emphasis. The acutely insane are now accorded in most com- 
 munities better treatment than are drunkards and cases of de- 
 lirium tremens, despite the fact that the latter are economically 
 more promising in the light of after-care results. 
 
 A hospital for acute alcoholic mental disease is recommended 
 for the metropolitan district as a first step to the proper care 
 of these cases throughout the State. Such a hospital should, in 
 addition to its high medical standards (non-restraint, non- 
 drugging), uphold the highest social standards by applying in 
 its out-patient department the now well-established principles 
 of after-care for alcoholics. 
 
 Southard, E. E. The Psychopathic Hospital Idea. Being 
 Contribution from the Psychopathic Hospital, 1913.26. 
 Journal of American Medical Association, Chicago, 1913, 
 LXI, 1972-74. 
 
 Southard, E. E., and Tepfer, A. S. The Possible Correlation 
 between Delusions and Cortex Lesions in General Paresis. 
 Journal of Abnormal Psychology, Boston, 1913-14, VIII, 
 259-275. 
 
 Conclusions. 
 
 1. The present study of types of paranoia in general paresis, 
 coupled with a former study of the sources of somatic delusions 
 in a series of subjects with relatively normal brains, suggests that 
 somatic delusions lie somewhat apart from other types (auto- 
 psychic, allopsychic) in that there may usually be found for 
 somatic delusions a peripheral basis (organic lesions of soma, 
 lesion of receptor paths, lesion of central receptive apparatus 
 of cortex). 
 
 2. Accordingly, the diagnostician will proceed with unusual 
 care to the discerning of such underlying lesions, although the 
 above studies abundantly indicate that years may elapse before 
 such lesions are manifest, e.g., at autopsy. 
 
 3. The characteristic delusions of general paresis (found in 
 57 per cent of a routine series) are autopsychic. 
 
 4. The distribution of gross cortex-lesions in autopsychic and 
 non-autopsychic cases gives some color to the hypothesis that 
 autopsychic delusions must be correlated with frontal lobe 
 lesions. 
 
101 
 
 Southard, E. E. Psychopathology and Neuropathology: The 
 Psychopathic Hospital as Research and Teaching Center. 
 Being Contribution from the Psychopathic Hospital, Boston, 
 Mass., No. 2 (1913.2). Read at the Conference of the 
 National Committee on Mental Hygiene at the College of 
 the City of New York, Nov. 13, 1912. Proceedings, Mental 
 Hygiene Conference and Exhibit, New York, 1912, 137- 
 146. Also in Boston Medical and Surgical Journal, 1913, 
 CLXIX, 151-154. 
 
 Abstract. 
 Theoretical and practical objects of the mental hygiene move- 
 ment. That movement more than elaboration of the obvious. 
 Some training in fundamental medical sciences desirable for all 
 educated persons. Supervision by schools for social workers of 
 lay workers in the medical field. Lowering the age of graduation 
 in medicine desirable to leave time for a little research before 
 money-making. Improvement advocated in the correlation of 
 studies of the nervous system in medical schools. Every medical 
 faculty should have at least three members fundamentally in- 
 terested in the nervous system. Practical work in psychiatry. 
 Proper medical school arrangements for psychiatry greatly de- 
 pendent on the existence of a psychopathic hospital. No one 
 model possible or desirable. The new Boston arrangements. 
 Branches of activity of the Psychopathic Hospital in Boston. 
 Some practical conclusions already arrived at since opening the 
 hospital in June, 1912. Novel conclusions: importance of pedia- 
 trics in relation to psychopathic hospital work (e.g., Lucas' Boston 
 Dispensary Clinic for Adolescents), possibility of prophylactic 
 work in cases on older hospital records as having had nervous 
 disease. Research should be, not merely permitted, but fostered. 
 
 Southard, E. E. What Parts of the Brain does Introspection 
 reach? (Abstract.) Psychological Bulletin, 1914, XI, 66, 67. 
 
 Southard, E. E., and Bond, E. D. Clinical and Anatomical 
 Analysis of 25 Cases of Mental Disease arising in the Fifth 
 Decade, with Remarks on the Melancholia Question and 
 Further Observations on the Distribution of Cortical Pig- 
 ments. Being Danvers State Hospital Contribution No. 
 40. American Journal of Insanity, Baltimore, 1913-14, 
 LXX, 779-828. Also in Proceedings, American Medico- 
 Psychological Association, 1913, 265-314. 
 
102 
 
 Summary and Conclusions. 
 1 We have reviewed a group of 25 cases of mental disease 
 (Danvers State Hospital material), so selected as to offer a fair 
 sample of mental diseases arising in the fifth decade of life. 
 
 2. Our principle of selection excluded all cases which were 
 obviously not characteristic of the fifth decade (paresis, alcoholic 
 mental disease, and the like); the group of non-characteristic 
 cases thus excluded was extremely large (approaching 80 per 
 cent of all cases arising in the decade), and the preventable dis- 
 eases alone amounted to over 60 per cent. 
 
 3. We remained with a group of 25 cases (10 males and 15 
 females) which present certain common aspects. These cases 
 may be negatively defined as not due to syphilis, alcohol, cerebral 
 arteriosclerosis, brain atrophy, or other factors yielding coarse 
 brain disorder; as not possessing pronounced schizophrenic fea- 
 tures; as not uniform in course or outcome; as not likely to 
 show either elation or expansive delusions. They may be posi- 
 tively defined as almost, if not quite, constantly subject to delu- 
 sions at some stage in each case; as yielding manic-depressive 
 traits in the large majority of cases; as prone to depressive fea- 
 tures; as possessing a strong hereditary taint (74 per cent of 
 properly studied cases); as not infrequently suggesting disorder 
 of glands of internal secretion. 
 
 4. The delusional features, present in all cases (save one of 
 myxedema), were not characteristically of any particular form; 
 the delusions were somatic in 14 cases; dealt with various altera- 
 tions of personality in 14 cases (combined with somatic delusions 
 in 8 instances); and (superficially at least) dealt with the social 
 environment in 13 cases (6 times combined with other forms). 
 
 5. As to somatic delusions, it is further of note that a physical 
 basis could be recognized for many of them in diseases of the 
 viscera; and that, on the whole, these visceral counterparts of 
 the delusions were more serious than the patients' complaints 
 themselves. 
 
 6. Delusions of negation (5 instances) and of unreality (4 
 cases) do not bulk so large statistically as they are apt to in 
 descriptions of so-called involution-melancholia. 
 
 7. The group, taken as a whole, is far more suggestive of 
 manic-depressive insanity than of dementia prsecox or of any 
 other form of mental disease. 
 
 8. On the whole, depression is the most common manic-depres- 
 
103 
 
 sive feature of these cases; but the constant occurrence of vari- 
 ous delusions alongside the depressive emotions makes the latter 
 seem far from "causeless," certainly not so causeless looking as 
 the depressions of manic-depressive insanity. 
 
 9. It cannot be dogmatically asserted, but, on the whole, these 
 patients seem more dominated by various ideas and by various 
 more or less false beliefs than are the manic-depressives of earlier 
 decades, and are perhaps more victims of intellectual than of 
 emotional or volitional disorder. However, this may be more 
 appearance than reality, and further work may again pull the 
 emotions, and particularly the depressive emotions, into the 
 genetic foreground. 
 
 10. As to the designation "involution-melancholia" for these 
 cases, it may be surmised that the term was adopted by alienists 
 having unpleasant delusions at least as much in mind as unpleas- 
 ant mere emotions. Perhaps it is unwise to seek to overthrow 
 the classical term before more intensive work has been done on 
 the actual relation of the intellect to the emotions in this group. 
 How far, then, it may be asked, is the melancholia of involution 
 merely systematic and responsive to intellectual conditions? 
 
 11. Since Freud has claimed a sexual basis for paranoia, and 
 even perhaps for paranoic states falling short of paranoia, it is 
 fair to inquire how far the present group has a sexual basis. 
 Three of the 15 female cases in our series harbored rather system- 
 atic delusions of persecution, and all three systems had a sexual 
 tinge. This fact, allocated with the not infrequent tendency to 
 disorder of glands of internal secretion in certain cases, ought to 
 provide a fruitful field for psychoanalytic hypotheses. 
 
 12. Hallucinations, as a rule auditory, were observed in some- 
 thing like 60 to 70 per cent of the cases. There are a priori 
 reasons (Wernicke) for relating these with the unpleasant delu- 
 sions characteristic of the group; but whether the false beliefs 
 irradiate over to incite the hallucinations, or whether the hal- 
 lucinosis is a prime factor in producing the false beliefs, must 
 remain an open question. Statistically we should be forced to. 
 favor the former process. 
 
 13. The post-mortem data throw some light on the negative 
 definition of our group (see paragraph 3 supra). There appears 
 to be little or no evidence that the metabolic disorder, if there 
 be such underlying this group, tends to brain wasting. 
 
 14. Our study of the distribution of certain chemically ill- 
 defined lipoids (or pigments, as we have called them) shows that 
 
104 
 
 age plays some part in the amount of deposits, perhaps more in 
 the neuroglia cells than in the nerve cells, and least of all in the 
 perivascular phagocytes. 
 
 15. All cases living three years or more after onset of symp- 
 toms show more or less marked accumulations of pigment in 
 neuroglia cells. The same cases show a greater variability in the 
 nerve-cell accumulations. Occasionally such a three-year or over- 
 three-year case will show a negligible amount of pigment in 
 perivascular phagocytes. 
 
 16. These pigment-findings are in substantial agreement with 
 those of Southard-Mitchell, 1908: — 
 
 (a) "Perivascular cell pigmentation almost uniform in differ- 
 ent areas of the same case." The present series presents only 
 two instances of marked variability from area to area. 
 
 (b) " Neuroglia cell pigmentation . . . varies more or less di- 
 rectly with age." Our present group presents more variation 
 than did the former; there is, however, no absolutely negative 
 case over forty-six years of age. 
 
 (c) "Nerve-cell pigmentation is not a function of age." Two 
 cases of fifty years or more showed no appreciable amount of 
 pigment, and three others showed but slight amounts. The 
 variations in amount within a given brain are more striking than 
 the variations shown by the neuroglia cell pigments. 
 
 17. That these three loci for the deposition of pigment tend 
 at last to a species of saturation is indicated by the fact that the 
 even degrees of moderate or of marked pigment deposit in all 
 loci begin to appear in the later years of life (one case at forty- 
 nine years, one at fifty-six, and the rest from fifty-nine to 
 seventy-five years). 
 
 18. The fresh point of view thus obtained for the problem of 
 involution-melancholia by our study of fifth-decade insanities may 
 be stated as follows: — 
 
 Involution-melancholia has been regarded as possibly akin to 
 manic-depressive insanity, or even identical therewith, or as 
 possibly something quite different. Perhaps the majority of psy- 
 chiatrists would regard it as a disease akin to manic-depressive 
 insanity, but modified by climacteric or presenile changes, and 
 distinguished from manic-depressive insanity by the peculiar 
 tendency to depression which has given it its name. The novel 
 feature of our investigation has been to study the age-factor. 
 We have studied unselected cases arising in the fifth decade of 
 life, excluding all coarse organic cases of brain lesion. Our re- 
 
105 
 
 sultant group is, we believe, although small, otherwise ideally 
 representative of the conditions underlying mental disease at this 
 age-level. Our group includes a sufficient number of the familiar 
 cases of involution-melancholia as well as cases of delusional in- 
 sanity without melancholia. The striking fact is that the 
 melancholia cases prove also delusional. In so far as our group is 
 representative of the fifth decade, we believe that the essential 
 psychopathia involutionis is characterized by delusions; that in 
 the large majority of cases melancholia is a feature superadded 
 to the delusions; and that in a smaller majority of cases halluci- 
 nosis also occurs. The fact that melancholia may assert itself as 
 the most prominent symptom in the clinical foreground fails to 
 controvert the possible genetic importance of the delusions. As 
 to the cause of psychopathia involutionis, it is easy to invoke the 
 glands of internal secretion; and of their disorder there is actually 
 some sign in a number of cases. Whether such disorder or some 
 unknown factor determines the overpigmentation (lipoid accumu- 
 lations) in the cortex above noted, and whether these deposits 
 have a direct relation to the symptoms, must rest with the future. 
 
 Southard, E. E. The Mind Twist and Brain Spot Hypotheses 
 in Psychopathology and Neuropathology. Being Contri- 
 bution from the Psychopathic Hospital, No. 42 (1914.8). 
 Psychological Bulletin, Princeton, N. J., and Lancaster, Pa., 
 April, 1914, XI, 117-130. 
 
 Summary. 
 
 I am sure that some of the dozen or more separate conceptions 
 to which I have asked attention in the above review will hardly 
 carry conviction in the present sketchy form. 
 
 1. The mind-twist versus brain spot hypotheses have nowhere 
 been discussed in extenso (although see articles on "The Prob- 
 lems of Teaching and Research contrasted, and a Study of the 
 Dementia Prsecox Group," etc., mentioned in text), and I am 
 not sure that the distinction will strike the reader as more than 
 a fresh sample of psychophysical parallelism. Without special 
 title to a viewpoint, I wish, however, to say that personally 
 neither parallelism nor interactionism seems to me safe ground, 
 and that some kind of identity hypothesis for all the operations 
 concerned would be better consonant with my views. One thing 
 will be clear from the above sketch, viz., that it may well be 
 possible that mental operations of the introspective kind are not 
 
106 
 
 correlatable (in any sense) with a good part of the operations of 
 the cerebral cortex. 
 
 2. The definition of consciousness as equivalent to cognition and 
 compounds of cognition leaves the non-cognitive portions of the 
 mind (will and emotions) only capable of introspection by the 
 kinesthetic and allied sensorial routes. But whether the above 
 definition is correct or not, it is at least clear that many authors 
 in the past have confused the issue by identifying mind with 
 consciousness at a stage when neither concept was capable of 
 exact statement. 
 
 3. The pathological evidences which have absorbed my personal 
 attention have led me to a re-emphasis of the Flechsig concept of 
 anterior and posterior association centers; to a natural correlation 
 of consciousness and the entire sensory portion of the mind with 
 activities of the posterior association center; and to a similar 
 correlation of non-conscious, i.e., objectivistic or behavioristic 
 portions of the mind (notably the voluntary faculties) with 
 activities of the anterior association center. The prepallium 
 (pre-Rolandic cortex) would thus be more closely related with 
 behavior (kinetic and pragmatic schemata), and the postpallium 
 (post-Rolandic and infra-Sylvian cortex) most closely related 
 with consciousness. 
 
 4. But if the prepallium is more an organ of behavior than the 
 receiving postpallial mechanism, it is expressly to be stated that 
 the capacity for novelty production, or innovating power, is not 
 to be abstracted from the prepallial neurones. Such innovating 
 power, exquisitely mental as it seems, is not necessarily conscious 
 in the sense of essentially cognizable. It is perhaps only the 
 history of our innovations and inhibitions which we register in 
 the postpallial mechanisms. Arguments in this direction are to 
 be drawn from the decisive ruin of the personality which attends 
 prepallial destructive processes in general paresis of the insane. 
 
 5. A sketch is offered to show that the non-conscious, i.e., 
 non-cognitive, side of delusion-formation is perhaps more im- 
 portant than the conscious (or contentwise) side. At least, the 
 morbid correlates of delusion-formation seem to be prepallial 
 rather than postpallial disorder as a rule. 
 
 6. The reverse seems to hold for such apparently motor or 
 behavior phenomena as epileptic and cataleptic phenomena. 
 These are possibly based more often on postpallial (sensorial (?), 
 kinaesthetic(?)) disorder than on intrinsic disorder of behavior 
 mechanisms. 
 
107 
 
 Southard, E. E. Eugenics v. Cacogenics: An Ethical Question. 
 Being Contribution from State Board of Insanity, Boston, 
 Mass., No. 21 (1914.1). Journal of Heredity, Washington, 
 D. C, September, 1914, V, 408, 414. 
 
 Summary. 
 
 1. The eugenics propaganda presents ethical difficulty in view 
 of our ignorance not merely how to breed better men, but 
 actually what improvement or improvements we seek. 
 
 2. The plant and animal breeders know what they are breed- 
 ing towards, and hence face problems of technique only; the 
 eugenist, it may be feared, does not know to what he ought to 
 breed (unless we are content with generalities like "citizenship" 
 or "brain-power"). 
 
 3. The British origin and historical setting of the eugenics 
 movement suggests that eugenics is an outcome in one sense of 
 British utilitarianism, although there are certainly no Malthusian 
 or race-suicide components in the theory. 
 
 4. The chances are that the ethical basis of eugenics lies more 
 in the evolutionistic than in any utilitarian doctrines, and that, 
 just as an ethics of self -development is superior to an ethics of 
 happiness-seeking, so an ethics of race-development is superior 
 to . an ethics of the greatest good to the greatest number (at 
 least if good be defined as anything short of full development). 
 
 5. At all events, the warning deserves utterance that no narrow 
 nationalistic or chauvinistic interpretation of the eugenic aim 
 should be allowed to prevail, as, for example, that British eugen- 
 ics is German cacogenics and vice versa. The eugenic evolution 
 should rather be to develop each nation to the death-point of 
 national prejudice and to the maximal vitality of co-operation. 
 
 6. To clarify this ethical situation, certain distinctions need to 
 be drawn. Both in the matter of eugenics and in that of caco- 
 genics it is proper to distinguish a relative from an absolute 
 form. 
 
 7. Thus the breeder of draught-horses might consider speed- 
 producing factors as interfering with his plans, as relatively 
 cacogenic, whereas he might well acknowledge that another 
 breeder would find such factors relatively eugenic and draught- 
 horse factors relatively cacogenic. Similarly, should the white 
 race go down in its heredity, Caucasian cacogenics might prove 
 Semitic or Ethiopian eugenics, but always in the relative sense 
 of these terms. 
 
108 
 
 8. It would accordingly be wiser to consider the problem of 
 eugenics in the absolute sense within the species. Cacogenic 
 factors in human progress would not be merely factors which for 
 arbitrary reasons are considered proper to exclude, as, for 
 example, short men, with prognathous jaws, etc.: for here the 
 cacogenics would be merely relative. 
 
 9. What we must study to avoid are the absolutely cacogenic 
 factors, such as pathology in its widest sense might discover. 
 Examples of such absolutely cacogenic factors are: — 
 
 (a) Possible senescence not in somatic cells only, but in the 
 germ-plasm itself. 
 
 (6) Possible prepotently toxic powers in a gamete, such that 
 all zygotes in which such gamete was a component would pro- 
 duce morbid individuals out of all theoretical proportions. 
 
 (c) Possible inheritance of qualities acquired, not by the 
 somatic cells, but by the germ-plasm (e.g., through alcoholism, 
 syphilis). 
 
 10. This contrast between relative cacogenics and absolute 
 cacogenics reminds one of the contrast between the pathology 
 of measurements and anomalies and the pathology of survival- 
 values for cells, organs and the organism. 
 
 11. It may well be that the pathology of survival-values is 
 theoretically reducible to a metric basis, and that these survival- 
 values can be put on a " more-or-less " rather than on an "all- 
 or-nothing" basis. There is, nevertheless, an important sense 
 in which the pathology of anomalies is distinct from that of life 
 and death. 
 
 12. Accordingly, I propose that the logical technique of 
 pathology be applied to the problems of absolute cacogenics, 
 such problems as those mentioned in paragraph 9 above, to the 
 end that more may be understood as to the essential pathology 
 of the germ-plasm. 
 
 Southaed, E. E. Statistical Notes on a Series of 6,000 Wasser- 
 mann Tests for Syphilis performed in the Harvard Neuro- 
 pathological Testing Laboratory, 1913. Boston Medical and 
 Surgical Journal, 1914, CLXX, 947-950. 
 
 Summary. 
 1. On account of the varying standards and criteria which 
 have held or will in future hold in the matter of Wassermann 
 tests for syphilis, it has been thought wise to summarize the 
 
109 
 
 materials, controls and special precautions used in the Harvard 
 Testing Laboratory. 
 
 2. General doubts are often raised as to the reliability of 
 Wassermann's test on account of the "great number" of "doubt- 
 ful" reactions. This "great number" resolves in our large series 
 to 4 per cent of the blood sera and 2 per cent of the cerebro- 
 spinal fluids. 
 
 3. On statistical grounds we find the "doubtfuls" resolve 
 much more frequently into "negatives" than into "positives." 
 
 4. Twenty-three per cent of all sera examined were positive, 
 and since the cases are in many instances picked as likely to be 
 positive, this percentage is doubtless much higher than the 
 community's total percentage. 
 
 5. Thirty-three per cent of all cerebrospinal fluids examined 
 were positive. The principle of selection of these cases was such 
 (positive serum or symptoms of "organic" nervous or mental 
 disease) that the result is of practical value, stateable as fol- 
 lows: The chances of a syphilitic origin for a case of "organic- 
 looking" nervous or mental disease are not more than 1 in 3. 
 
 6. The Massachusetts Reformatory for Women yields 44 per 
 cent, a partial index of the infected nature, though not neces- 
 sarily of the «infectivity, of prostitutes and other delinquent 
 women. 
 
 7. The Danvers State Hospital (for the insane) yields between 
 19 and 22 per cent positive sera in its routine intake of cases 
 from Essex County. 
 
 8. The Worcester Asylum, a transfer institution (to which are 
 transferred chiefly Mcm-paretic cases), yields less than 3 per cent 
 positive. If this percentage should be maintained in future work, 
 one might infer that, from the group of persons in the com- 
 munity with insane tendencies and infected by syphilis, cases are 
 drained off into the frankly paretic group, in such wise that a 
 population of asylum transfers will be likely to show a low syphilis 
 index. But this conclusion can be only tentative on account of 
 many other issues. 
 
 9. The Psychopathic Hospital index (15 per cent) is perhaps 
 somewhat closer to the general community index than the others 
 just mentioned on account of the large number of cases "not 
 insane" that are tested, but it is evident that 15 per cent would 
 be too high an index to assign to the syphilis of the general popu- 
 lation. 
 
 10. Aside from its capacity to solve problems of individual 
 
110 
 
 diagnosis, the Wassermann method is obviously of such value to 
 the community that a community Wassermann service might well 
 be undertaken by a State agency such as the Board of Insanity or 
 the Board of Health. 
 
 Southard, E. E. Feeble-mindedness as a Leading Social 
 Problem. Being Contribution from the Psychopathic 
 Hospital, Boston, Mass., No. 38 (1914.4). Boston Medical 
 and Surgical Journal, May 21, 1914, CLXX, 781-784. 
 
 Summary. 
 I will sum up and conclude as follows: — 
 
 1. The status of the feeble-minded in Massachusetts is such 
 as to offer a large and immediate practical problem. 
 
 2. The availability of Binet-Simon and other intellectual tests 
 makes desirable the establishment of numerous dispensary centers 
 for preliminary diagnosis, so that cases suitable for well-tried 
 educational methods in our State schools may be winnowed out. 
 
 3. The criminalistic group has been singled out, hardly so far 
 as a problem of the present, but as a problem of the future, de- 
 pendent for solution on psychological data not yet available. 
 
 4. Estimates of the numerical size of the problem are available, 
 and a promising preliminary survey is being made by the Board 
 of Insanity. 
 
 5. Social sense of the importance of the problem has been 
 aroused, though not, it may be hoped, to the point of impatience 
 with the degree of progress humanly possible. 
 
 6. The interest of specialists in children's diseases has also 
 been aroused, and the eventual results of certain children's 
 diseases are being shown in the concrete case. 
 
 7. Workers in eugenics are being enlisted to study the heredi- 
 tary factor in some of these so-called "acquired" cases, and, it 
 is hoped, will solve the problem of the interplay of heredity and 
 somatic factors in the pathology of feeble-mindedness. 
 
 8. Statistical inquiries seem to justify the idea of a chiaro- 
 scuro of distribution, which means that society is not just gen- 
 erally degenerating, and that the places to begin preventive work 
 can be chosen scientifically. 
 
 9. Statistics tend to indicate that the problem is rather a 
 medical than an economic one, or, perhaps better, more medical 
 than economic, standing a bit one side perhaps from crime, some 
 part of which is economic. 
 
Ill 
 
 10. The interplay of hereditary and somatic factors promises 
 to show lines of prevention both eugenic and environmental. 
 
 11. We can educate communities in eugenics and we can con- 
 ceivably transplant, by a proper family-care system, feeble- 
 minded persons from neighborhoods where they would unite with 
 others of their kind to regions where they would either not marry 
 or would marry normal persons, thus diluting the strain (feeble- 
 minded males are probably less dangerous in the community 
 than feeble-minded females, which latter should be segregated by 
 preference in institutions). 
 
 12. Socialism of the Fourier-Marx type will have to reckon 
 with this problem; it would not appear that communism has any 
 ready solution for the problem of those who, being feeble-minded, 
 are by nature neither free nor equal. On the other hand, some 
 form of socialism of the St. Simon type, or what may be termed 
 state socialism, is the most practicable form to cope with this 
 problem. Indeed the practical solution of these problems of 
 feeble-mindedness and allied defects is fast leading us to some- 
 thing of the sort, whether we choose to call it socialism or not. 
 Yet how many vvould-be socialists face the congenital or acquired 
 inequalities of men with frankness and clear understanding? 
 
 Southard, E. E. Considerations bearing on the Seat of Con- 
 sciousness. (Abstract.) Journal of Nervous and Mental 
 Disease, New York, 1914, XLI, 581. 
 
 Abstract only. 
 The reader attempts to correlate consciousness with the 
 posterior association-center of Flechsig, and possibly rather more 
 intimately with that of the right cerebral hemisphere. The 
 reader views consciousness as a much narrower term than mind, 
 and, if the term mind is to include knowing, feeling and willing, 
 finds consciousness rather cognitive than affective or volitional, 
 and believes that will and emotions appear to consciousness 
 rather in a cognitive (kinesthetic) aspect than in any more pro- 
 found or elementary manner. To put the matter concretely, the 
 reader questions whether it is necessary to suppose ideas of words 
 correlated in any sense whatever with operations of Broca's area. 
 Broca's area contains, rather, the necessary kinetic schemata of 
 words. Generalizing therefrom, the reader wonders whether any 
 ideas either occupy or are in any sense correlated with activities 
 of the anterior association-center, which contains, rather, the 
 
112 
 
 various kinetic and pragmatic schemata that underlie voluntary 
 action and conduct. Data from comparative anatomy and from 
 casualty wards are advanced in support of this conception. 
 
 Southard, E. E. Conclusions from Work on the Paratyphoid 
 Epidemic at the Boston State Hospital, 1910. Boston Medi- 
 cal and Surgical Journal, 1914, CLXXI, 556-559. 
 
 General Conclusions. 
 
 The epidemic of mild paratyphoid fever at Boston State Hos- 
 pital in 1910 seems beyond question due to Bacillus paraty- 
 phosus, alpha (findings of Richards). 1 
 
 Apparently the source of the epidemic was infected meat, or 
 else a patient with paratyphoid infection may have spread the 
 epidemic through meat. The clinical features of the epidemic of 
 greatest interest are presented in parallel columns. Mention 
 may be here made of the fact that initial fever was practically 
 constant. Anorexia, diarrhea, abdominal pain, general malaise 
 and vomiting were not so frequent in this paratyphoid epidemic 
 as they usually are in typhoid fever. Of special modes of onset 
 which might be confusing in diagnosis, bronchitis may be men- 
 tioned. In the course of the disease stiff joints occurred in 19 of 
 30 cases of paratyphoid fever, whereas in typhoid fever, arthritis 
 is rare. Four of the patients suffered from muscle pains in the 
 back of the neck. Malaria was suspected in one case from the 
 nature of the acute symptoms. 
 
 A case is presented which died some years after the epidemic 
 and showed thickening of the ileum, possibly representative of 
 former intestinal disease, but whose cultures, including that of 
 the gall bladder, failed to show bacillus paratyphosus. 
 
 The clinical picture shows points of interest in the temperature 
 curves. A case will occasionally have a beginning temperature 
 suggestive of typhoid fever, but this is not the rule. The inter- 
 current bronchitis fails to affect the temperature reaction, so that 
 it may possibly be supposed that it is a portion of the disease 
 rather than a truly intercurrent phenomenon. But it must be 
 remembered that insane patients show some differences in fever 
 reactions to various infections from the reactions shown by sane 
 persons. 
 
 Eight cases in 30 showed a peculiar drop of temperature to 
 
 1 E. T. F. Richards: Bacteriology of Epidemic of Paratyphoid Fever, Journal Lancet, St. 
 Paul, 1913. 
 
113 
 
 subnormal in the second or third week — as a rule, between the 
 tenth and fourteenth day. This temperature drop is accom- 
 panied by a drop in the pulse and by an access of the most 
 severe subjective symptoms felt at any time in the disease. 
 
 The blood cell pictures show that there is no hypoleucocytosis 
 or loss or drop in eosinophiles in paratyphoid fever (of the type 
 here described), since the counts remain within the normal range; 
 this point may be of some value in differentiation of paratyphoid 
 fever from typhoid fever. 
 
 It was incidentally learned that the blood cell picture after 
 antityphoid vaccination also failed to show hypoleucocytosis, 
 but instead tends to show a slight initial rise in leucocytes. 
 
 The antityphoid fever vaccinations, carried out early in the 
 epidemic as a possible protective measure, gave the opportunity 
 for a few observations on the relation of paratyphoid fever to 
 antityphoid vaccinations, and it would appear that there may be 
 a moderate degree of crossed protection (typhoid vaccine against 
 paratyphoid fever), since non-vaccinated persons were far more 
 subject to paratyphoid fever than were persons vaccinated against 
 typhoid. The rule was, however, not absolute. 
 
 Southard, E. E. The Association of Various Hyperkinetic 
 Symptoms with Partial Lesions of the Optic Thalamus. 
 Journal of Nervous and Mental Disease, New York, 1914, 
 XLI, 617-639. 
 
 Summary. 
 To sum up, the writer has made an orientation study of the 
 symptomatology of a group of 25 cases of chronic diffuse optic 
 thalamus lesion, and observed 96 per cent to show one or more 
 symptoms of the hyperkinetic group (exaltation, irritability, psy- 
 chomotor excitement, homicidal tendencies, destructiveness) and 
 but 40 per cent to show depressive symptoms (including suicidal 
 tendencies and apprehensiveness). To compare with these 
 figures the writer studied the symptomatology of 261 cases hav- 
 ing normal or normal-looking brains, and therein found only 64 
 per cent showing hyperkinetic symptoms and 52 per cent show- 
 ing depressive and allied symptoms. The one exception to the 
 thalamic correlation with hyperkinesis is hardly a fair exception, 
 being a stuporous general paretic. 
 
 In evaluating these surprising results, it must be remembered 
 that coarse destructive lesions, destroying through-routes for 
 sensory impulses, have been omitted from consideration, and that 
 
114 
 
 two additional cases of chronic diffuse lesions of the thalamus 
 failed to yield hyperkinesis apparently because of injury to the 
 thalamocortical system above them. 
 
 The hyperkinetic symptoms are on theoretical grounds pos- 
 sibly due to withdrawal of corticothalamic "inhibitory" or 
 "switch-setting" impulses, although another way in which the 
 thalamic mechanism could be simplified is by atrophy or aplasia 
 of certain cerebellar connections. This question is accordingly 
 ripe for histopathological study. 
 
 The writer does not assume that hyperkinesis is always or 
 often produced in the way indicated, but regards the work as 
 pointing once more to the study of tissue-simplification with 
 selective loss of neurones as contributing to the explanation of 
 symptoms. Thus, if exaggerated knee-jerks are found corre- 
 lated with simplification of spinal cord mechanisms, so more com- 
 plicated forms of hyperkinesis may be found due to simplifica- 
 tions of more complicated structures. 
 
 Southard, E. E. Analysis of Recoveries at the Psychopathic 
 Hospital, Boston: I. One Hundred Cases, 1912-13, con- 
 sidered especially from the Standpoint of Nursing. Being 
 Contribution from the Psychopathic Hospital, Boston, 
 Mass., No. 48 (1914.14). Boston Medical and Surgical 
 Journal, Sept. 24, 1914, CLXXI, 478-483. 
 
 Remarks. 
 
 Future analyses may be made more thorough, and the elements 
 of recovery may stand out more clearly in detail. Suffice it to 
 say that a superficial analysis like the present amply proves 
 several points. 
 
 First. — The component of nursing cannot be omitted from 
 these recoveries, brief as was the time of the hospital stay of the 
 majority of cases. This is proved by the incidence of disorder 
 of heat-regulation (fever, hypothermia) in at least 37 per cent 
 of the cases. 
 
 Second. — The special value of nursing, and particularly of 
 hydrotherapy, stands out from the results of the treatment of 
 alcoholic psychoses, which though they form only about one- 
 ninth of our problem of first care, represent almost nine-tenths 
 of our early therapeutic results. 
 
 Third. — The recoveries in the so-called "recoverable" forms 
 of insanity take too long to be represented in any numbers in 
 
115 
 
 this first hundred of recoveries, and it may be suspected that the 
 average hospital stay of three to four weeks is not sufficient for 
 recoveries in groups like manic-depressive insanity. 
 
 Fourth. — The effect of psychotherapy as applied in the 
 Psychopathic Hospital is not a rapid effect. 
 
 Fifth. — The percentage of syphilis in the recovered cases is 
 exactly that of the total intake of the hospital, so that this 
 factor cannot be said to influence treatment unfavorably (two 
 questionable syphilitic cases are more fully discussed and reference 
 made to Kraepelin's analysis of allied conditions). 
 
 Sixth. — Some index of the activities of our after-care service 
 is afforded by the fact that nearly half of the patients either 
 resorted voluntarily or (in some cases) were brought to the out- 
 patient department at one or more periods subsequent to the 
 discharge. 
 
 Seventh. — The need is apparent of nurses who shall build 
 their psychopathic training on a sound basis of general hospital 
 work (letter quoted, to the committee of superintendents, dealing 
 with the general aspects of the nursing problem for the insane). 
 
 Southard, E. E. On the Topographical Distribution of Cortex 
 Lesions and Anomalies in Dementia Prsecox, with Some 
 Account of their Functional Significance. Being Contribu- 
 tion from the Massachusetts State Board of Insanity No. 
 25 (1914.5), and Danvers State Hospital Contribution No. 
 53. The substance of this contribution was presented at a 
 meeting of the American Neurological Association held at 
 the Triennial Congress of Physicians and Surgeons, Wash- 
 . ington, D. C, May, 1913. American Journal of Insanity, 
 . Baltimore, 1914-15, LXXI, 383-403. 
 
 Conclusions. 
 
 1. The writer has followed up his earlier work on the dementia 
 prsecox group (1910) with a more systematic anatomoclinical 
 study of 25 cases, having a view to (a) definite conclusions as 
 to the structurally ("organic nature") of the disease, and (b) 
 correlation of certain major symptom groups (delusions, cata- 
 tonic symptom groups, auditory hallucinosis) with disease of 
 particular brain regions. 
 
 2. As to (a), the structurality of dementia prcecox, the writer 
 feels that the disease must be conceded to be in some sense 
 structural, since at least 90 per cent of all cases examined (50 
 
116 
 
 cases, data of 1910 and 1914) give evidence of general or focal 
 brain atrophy or aplasia when examined post mortem, even with- 
 out the use of the microscope. 
 
 3. Moreover, with the use of the microscope, the problem of 
 the normal-looking remainder can perhaps be solved, since the 
 only two normal-looking brains in the 1914 series of 25 yielded 
 abundant appearances of cell-destruction and satellitosis in the 
 cerebral cortex, which had not yet had time to be registered in 
 the gross (cases of three weeks' and two months' duration, re- 
 spectively). 
 
 4. The method of anatomical analysis in the new series is a 
 more systematic one than has been hitherto employed, involving 
 careful gross description of the fresh brain; careful preservation 
 (by suspension from basal vessels) in formaldehyde solution; 
 systematic photography to scale of the superior, inferior (cere- 
 bellum removed), lateral and mesial aspects before and after 
 stripping the pia mater; study of all aspects of the brain as spread 
 side by side in photographic form; further study of the preserved 
 brains in the light of the photographic study; and eventual cyto- 
 logical or fiber studies of paired structures showing possible 
 atrophy or aplasia. 
 
 5. The neuropathologist making such a brain analysis shortly 
 discovers that there is often more to be learned from the gross 
 than from the microscopic appearances, since, of two gyri, the one 
 measurably smaller than the other (and therefore probably 
 agenesic, aplastic or atrophic), the microscopic appearances may 
 often be hard to diagnosticate, as the normal-looking gyrus at the 
 time of death may be just undergoing a satellitosis actually indi- 
 cating more disease than its shrunken fellow. 
 
 6. Nevertheless, the gross analysis gives one perfectly convinc- 
 ing evidence of some kind of lesions, leaving to other methods of 
 study the decision as to the congenital or acquired nature of these 
 lesions. Some 14 of the 25 cases may be regarded as in some 
 sense maldevelopmental, so as to arouse the suspicion that the 
 acquired atrophy was grafted on top of a congenital agenesia or 
 aplasia; but, in the opinion of the writer, aplasia is indicated 
 rather than agenesia. The potential victim of dementia prsecox 
 is probably born with the normal stock of brain cells, although 
 their arrangement and development are at times early interfered 
 with. 
 
 7. The atrophies and aplasias, when focal, show a tendency to 
 occur in the left cerebral hemisphere. The coarse atrophy is 
 
117 
 
 usually of only moderate degree, and often does not appreciably 
 alter the brain weight, at least outside the limits of expected 
 variation. In fact, the heart, the liver, the kidneys and the 
 spleen tend to show greater loss in weight than does the brain. 
 
 8. More remarkable than the atrophy and aplasia of the cortex 
 is the high proportion of cases of internal hydrocephalus (at least 
 9 cases) uncovered by the systematic photographic study of 
 frontal sections. 
 
 9. There is no evidence that this internal hydrocephalus is due 
 to generalized brain atrophy. It is possible that it begins more 
 posteriorly. It is probable that it does not mechanically so much 
 affect the frontal lobes. It is associated with cases of long dura- 
 tion, although not with all cases of long duration, and was never 
 found in cases of brief duration. Clinically, the hydrocephalic 
 cases are uncommonly catatonic, and the cases of marked general- 
 ized hydrocephalus were as a rule victims of hallucinations. De- 
 lusions, except fantastic delusions, were not prominent in this 
 group. The clinical courses of these hydrocephalic cases were 
 more than usually active and mutual, and were often interrupted 
 by remissions. 
 
 10. The hydrocephalic brains were not in other respects par- 
 ticularly open to the suspicion of congenital disease; and, without 
 adequate proofs, the writer is inclined to consider the hydro- 
 cephalus to be often an acquired hydrocephalus. 
 
 11. An ardent supporter of congenital features might claim 
 that 19 of the 25 brains showed some sort of maldevelopmental 
 defect. One impartial witness thought that 14 showed such. 
 And even if all 9 cases of hydrocephalus be taken as acquired, we 
 remain with 11 cases bearing pretty certain evidence of malde- 
 velopmental defect. On the other hand, all but 6 cases showed 
 signs of acquired lesion, and these 6 showed various microscopic 
 changes of doubtful meaning, but certainly acquired. 
 
 12. One remains with the general impression that gross altera- 
 tions are almost constant, and microscopic changes absolutely 
 constant, and that the high proportion of gross appearances sug- 
 gesting aplasia means that structural (visible or invisible) changes 
 of a maldevelopmental nature lie at the bottom of the disease 
 process. But this suspicion of underlying maldevelopment is 
 only a suspicion, although a strong one, and the first factor for 
 the theory of pathogenesis to explain is the gross and microscopic 
 changes as they present themselves in the full-fledged case. 
 
 13. Aside from left-sidedness of lesions and internal hydro- 
 
118 
 
 cephalus, very striking is the preference of these changes to 
 occupy the association-centers of Flechsig. For this there is 
 probably good a priori reason in the structure, late evolutionary 
 development, and consequent relatively high lability of these 
 regions. The interest of these findings is still greater in the func- 
 tional connection (see below). 
 
 14. In concluding this summary of the anatomical side of the 
 study, the writer cannot forbear adding that he supposes many 
 neurologists, hearing of "lesions/' will at once imagine extirpa- 
 tory lesions of a Swiss-cheese appearance or areas like those of 
 tuberous sclerosis. At the risk of being charged with naivete, the 
 writer would again here insist that the lesions described, though 
 never beyond the range of a skilful anatomist, are of a mild 
 atrophic nature or in the nature of aplasias, requiring care and 
 deliberation in their description and explanation, and often hard 
 to grasp except where photographs of all sides of the brain may 
 be compared at once and reference then made to the brains them- 
 selves. These lesions do not effect globar lacunse in the cortical 
 neuronic systems, but they are of a more finely selective char- 
 acter. Under the microscope it may be difficult to say, without 
 elaborate micrometry, that one area is worse off than another; 
 but convincing evidence of the gross convolutional extent of the 
 process is got by the naked eye and by the finger. 
 
 15. The writer regards this work as putting the burden of proof 
 on those who claim the essential functionality of dementia prsecox, 
 and is at some pains to couch objections to one formulation of 
 these changes as "incidental," and to another as "agenesic." 
 Nevertheless, the writer would not necessarily deny the value of 
 those formulations which look on these cases as cases of faulty 
 adaptation to environment. 
 
 16. As to (b), the functional correlations of this study, the re- 
 sults may be summed up by saying that strong correlations have 
 been found to support the writer's former claims that (1) delu- 
 sions are as a rule based on frontal disease, and (2) catatonic 
 symptoms on parietal-lobe disease. An equally strong correlation 
 (3) has now been found between auditory hallucinosis and tem- 
 poral-lobe disease. 
 
 17. The writer's previous work had suggested a correlation 
 between frontal-lobe disease and delusion-formation. This cor- 
 relation is not so decided in the present series, since, although 
 perhaps only 1 of the 25 cases failed to exhibit delusions, 7 of 
 the remaining 24 failed to show frontal-lobe lesions. However, 
 
119 
 
 2 of these 7, though grossly negative, were microscopically posi- 
 tive enough. 
 
 18. The findings indicate, accordingly, that there is a group of 
 delusional cases such that even long duration does not determine 
 a frontal emphasis of lesions. Five cases represent this excep- 
 tional condition; 3 of these 5 are probably best interpreted as 
 cases of hyperphantasia in which, both a priori and by observa- 
 tion, frontal lesions are not characteristic. 
 
 19. On the whole, the correlation between delusions and focal 
 brain atrophy (or aplasia capped by atrophy?) is very strong, 
 particularly if we distinguish (1) the more frequent form of delu- 
 sions with frontal-lobe correlations from (2) a less frequent form 
 with parietal-lobe correlations. 
 
 20. The non-frontal group of delusion-formations the writer 
 wishes to group provisionally under the term hyperphantasia, 
 emphasizing the overimagination or perverted imagination of 
 these cases, the frequent lack of any appropriate conduct-disorder 
 in the patients harboring such delusions, and the a priori likeli- 
 hood that these cases should turn out to have posterior-associa- 
 tion-center disease rather than disease of the anterior association- 
 center. This anatomical correlation is, in fact, the one observed. 
 
 21. The writer's previous work had suggested a possible corre- 
 lation between catatonic phenomena and parietal (including post- 
 central) disease. Ten of 14 definitely catatonic cases yielded 
 parietal or other post-Rolandic lesions; 2 were grossly negative, 
 but microscopically altered; and indications of correlation ap- 
 peared also in the remaining 2. Five of 7 clinically somewhat 
 doubtfully catatonic cases yielded similar correlations. Four 
 clinically non-catatonic cases yielded no parietal correlations. (It 
 is worth while insisting that "catatonia" is here used to refer to 
 a symptom, not to an entity or clinical group.) 
 
 22. Special interest attaches to cerea flexibilitas as a clearly 
 definable form of catatonic symptom. Four of 5 cases yielded 
 gross parietal lesions. The fifth case was one of the entirely nega- 
 tive cases in the gross, but showed very marked postcentral 
 satellitosis microscopically. Two of these cases showed the gross 
 emphasis of lesions in the postcentral gyri, thereby hinting at an 
 explanation of cerea flexibilitas along the lines of a reaction to 
 altered kinesthesia or an altered reaction to normal kinesthesia 
 (depending upon such true analysis of intragyral cortex-function 
 as the future may bestow). 
 
 23: A priori one might expect a correlation between the char- 
 
120 
 
 acteristic auditory hallucinosis found in many cases of dementia 
 prsecox and temporal-lobe lesions. In point of fact, 9 of 12 
 hallucinated cases yielded temporal-lobe atrophy or aplasia; and 
 actually only 1 of the 3 others is a good exception to the rule 
 (from the clinical standpoint), to say nothing of the fact that 
 this case had ample microscopic changes in the temporal lobe. 
 
 24. Of the 13 wow-hallucinating (auditory) cases, only 3, or at 
 most 4, could be said to have temporal-lobe lesions suggesting 
 the possibility of hallucinosis. Here we may appeal to the in- 
 adequacy of clinical work, or, better, to the non-suitability of 
 the lesions, since no one would assert that we yet have any idea 
 of the precise and intimate temporal-lobe conditions which permit 
 hallucinations. 
 
 25. In these functional connections the more recent formula- 
 tions of Kraepelin and of Bleuler have been reviewed, although 
 the entire work was done without the benefit of their analyses. 
 The present formulation appears consistent enough with either. 
 It would seem that Kraepelin regards a correlation between audi- 
 tory hallucinosis and temporal-lobe disease as already highly 
 probable from the literature. He also goes so far as to incrimi- 
 nate the "central" region for motor disorders. But the present 
 suggestions as to the possible kinesthetic relations of catatonia 
 and the special (frontal and parietal) correlations with delusion- 
 formation are not suggested by Kraepelin from the literature 
 available. 
 
 26. It is interesting to note that further study by the Munich 
 workers seems to have drawn attention away from the infrastellate 
 cortical changes sketched by Alzheimer for catatonia in 1897 to 
 various suprastellate changes. The microscopic work done in the 
 present study in connection with certain grossly negative cases 
 indicates that the early phases of the process may very often look 
 as if infrastellate change was to be the most striking product of 
 the disease. This is perhaps due to a richer original supply of 
 glia cells in these infrastellate layers. Later, when the process 
 is less acute, it may often be found that suprastellate cell losses 
 are much more in evidence than any striking infrastellate change. 
 
 27. As for the general position which this work would assume 
 toward the functional conclusions of Bleuler, it would seem that a 
 histopathological basis for "dissociations" or "schizophrenia" 
 could be somewhat readily provided by the lesions found, since 
 these are for long periods mild enough and sufficiently confined 
 to the finer cortical apparatus to provide for the exquisite mental 
 
121 
 
 changes of most cases. The main neuronic S}'stems are often 
 permanently preserved, leaving an irregularly and slightly simpli- 
 fied corticd apparatus, in which a few cell changes would nat- 
 urally throw out of co-ordination a great deal of still intact 
 apparatus. But the whole process often remains so mild as to 
 permit re-establishment of relatively normal functional relations 
 on a slightly simplified basis, the whole to be disturbed once 
 more on the occasion of the death or disease of a few more cells. 
 Very striking is the fact that the cells not attacked are, so far as 
 we can see, normal enough. 
 
 28. This work is rather a study of genesis than of etiology, in 
 the sense of modern medical distinctions between these branches 
 of inquiry. It is a modest inquiry into factors, and does not rise 
 to the height of ascribing causes. The writer will refer merely 
 to some paragraphs in the text as to a possible ontological posi- 
 tion concerning structure and function which the future may take. 
 The deplorable thing is that some structuralists throw out of 
 court all functional data and some (rather more!) functionalists 
 tend to underrate the possible contributions of anatomy to this 
 field. Luckily, science nowadays cannot long proceed merely 
 a la mode. 
 
 29. In particular, to sum up, I would call especial attention to 
 the following points: (1) the constancy of mild general or focal 
 atrophies in cases lasting long enough to yield these; (2) the 
 tendency to an exhibition of lesions somewhat more markedly in 
 the left hemisphere; (3) the preference of the lesions for the 
 "association-centers" of Flechsig; (4) the high correlation of 
 auditory hallucinosis and temporal-lobe lesions, as also (5) of 
 catatonia and parietal lesions (cerea flexibilities, especially post- 
 central), and (6) of the more frequent form of delusions and 
 frontal-lobe disease; (7) the possible existence of a hyperphan- 
 tasia group with parietal correlations, and of (8) a large internal 
 hydrocephalus group with catatonic and hallucinotic correlations 
 rather than delusional. A few more points can be got from the 
 description of the plates. 
 
122 
 
 Southard, E. E. Notes on Public Institutional Work in Mental 
 Prophylaxis, with Particular Reference to the Voluntary 
 and "Temporary Care" Admissions and the "Not Insane" 
 Discharges at the Psychopathic Hospital, Boston, 1912-13. 
 Being Contribution from the State Board of Insanity, No. 
 22 (1914.2). Journal of American Medical Association, 
 Chicago, Nov. 28, 1914, LXIII, 1898-1903. 
 
 Summary. 
 
 1. In the prophylactic division of mental hygiene the matter 
 of voluntary admissions to hospitals for the insane holds a pri- 
 mary place. Their number is increased by the plan of supporting 
 such at the public charge just as committed cases are supported, 
 and is still further increased, and even doubled, by the provision 
 of a modern psychopathic hospital (increase from 8 to 16 per 
 cent of the total of voluntary and committed cases, experience 
 at Boston Psychopathic Hospital). 
 
 2. A second prophylactic measure is the provision of proper 
 temporary care for persons suspected of mental disease, as ac- 
 cording to a unique Massachusetts temporary care law (first 
 operative in 1911; see text). This provision has been eagerly 
 employed in Massachusetts, more than doubling the number each 
 year since enactment. The Psychopathic Hospital is receiving 
 about two-thirds of all those thus received in Massachusetts, 
 1913. 
 
 3. Many important prophylactic questions relate to those 
 thought to be insane but not proved to be. In this psychiatric 
 borderland also lie many questions between insanity and feeble- 
 mindedness. A large "not insane" group, namely, 570 cases 
 among the first 2,500 discharges from the Psychopathic Hospital, 
 has been reviewed to discern the general features of this psychi- 
 atric borderland of diagnosis. 
 
 4. Consideration is omitted of 372 additional cases regarded as 
 recovered or improved after attacks of mental disease, although 
 in one sense these cases are open to prophylactic measures, since 
 the occasional review of these cases by a follow-up system must 
 tend to help society, and may help the individual. 
 
 5. Of the 570 not insane cases, 179 were cases of feeble- 
 mindedness of various grades, largely of the higher grades and 
 including a large number of the so-called defective delinquents 
 .(more than fifty). In this connection it often becomes necessary 
 to fight a bureaucratic tendency among social workers, who tend 
 
123 
 
 to proceed on the erroneous assumption that an insane or a 
 feeble-minded person belongs by definition in some public or 
 semipublic institution. 
 
 6. The numerically next largest group is that of psychoneu- 
 rotics (100), who are largely female (71), especially the hysterics 
 (39 female in 45). Consideration is given to the idea of a public 
 sanatorium or preventorium for such persons with far larger 
 provisions for females than for males. It is thought that these 
 cases, forming at least a twenty-fifth (probably more) of all 
 mental cases in the community, and at least a fourth (perhaps 
 somewhat more) of all not insane mental cases, might perhaps 
 warrant, if combined with the convalescents, the establishment 
 of a public sanatorium to be run on economical lines in the 
 country. 
 
 7. It is largely the great expense (from $20 to $25 per week) of 
 caring for these cases in a centrally placed psychopathic hospital 
 or psychiatric clinic which determines the idea of a rural public 
 sanatorium; for psychotherapy (in whatever form may be de- 
 termined to be valuable), rest treatment, work treatment and 
 calisthenics, to say nothing of dietary and other general measures, 
 can be as well, though more expensively, carried out in the urban 
 psychopathic hospital. 
 
 8. Of the 570 not insane discharges, 165 were not classified as 
 showing any particular form of mental or other defect, although 
 it must be emphasized that each of these came for psychodiag- 
 nostic reasons, and was admitted under a special form of law. 
 One even was a case regularly committed under judicial proce- 
 dure, but later determined to be not insane, and nine others came 
 under judicial authority by virtue of certain other laws not com- 
 monly used. 
 
 9. Of these 165 not insane discharges, 90 had been admitted 
 under the temporary-care law, unique in Massachusetts, referred 
 to in paragraph 2 (except in fifteen instances in which a some- 
 what similar law, operating for the city of Boston alone, was 
 employed). With respect, to these persons it must be emphasized 
 that their problems would not have been so easily solved under 
 any other procedure. Examples of such problems are question 
 of paraphrenia systematica, question of hysteria, question of 
 defective delinquent, question of epilepsy, etc. 
 
 10. Of the 165 not insane discharges, 65 either resorted volun- 
 tarily to the hospital or were pursuaded to become voluntary 
 
124 
 
 patients. It is evident that, in an increasing number of instances, 
 persons realize or can be made to realize the possible psycho- 
 pathic nature of their difficulties and come almost eagerly even 
 to a public institution. 
 
 11. About 13 per cent (18 in 136) of these persons who were 
 discharged as without active symptoms of mental or other 
 disease yielded positive Wassermann reactions in their serums. 
 The interpretation of this fact is doubtful. The percentage in 
 the males was 10 (7 in 65), in females 16 (11 in 71). 
 
 12. Two-thirds of the patients aged six to fifteen were boys 
 (21 boys, 10 girls), but of those aged sixteen to twenty-five, 
 there were more than four times as many women as men (10 
 men, 45 women). From twenty-six to forty, the sexes are about 
 evenly distributed (17 men, 19 women). Then males preponde- 
 rate (28 men, 14 women). Thus, women may be thought to get 
 into suspicious psychopathic circumstances which later resolve, 
 much more often in the period of adolescence; males somewhat 
 more often in late boyhood and in postadolescent years. Therein 
 lodges a problem in prognosis which if settled would greatly aid 
 the alienist, particularly, in making certain social decisions. 
 
 13. It is clear that the influences which are bringing the not 
 insane to the Psychopathic Hospital in Boston are bringing them 
 there at comparatively early ages, and often (especially the 
 females) in adolescence. The community's interest in the ques- 
 tion of feeble-mindedness and the social worker's often justifiable 
 desire to institutionalize her wards are powerful factors in this 
 resort for diagnosis to a State institution. The physicians in the 
 community are almost to a man, I believe, pleased with the 
 increasing facility with which, under the laws mentioned above, 
 some of their most difficult problems are solved. Time was 
 when almost the only recourse in determining absolutely whether 
 a patient was insane was to adjudge him insane and release him 
 afterward if a mistake had been made. To overcome this diffi- 
 culty, various devices have been adopted in the more highly 
 civilized of our States. The Massachusetts arrangements are of 
 particular interest to those who may not have been able as yet to 
 civilize their own States in these directions. 
 
125 
 
 Southard, E. E. Progress of the Psychopathic Hospital on the 
 Prophylactic Side of Mental Hygiene. Being Contribution 
 from the Psychopathic Hospital, Boston, Mass., No. 52 
 (1914.18). Boston Medical and Surgical Journal, Dec. 3, 
 1914, CLXXI, 847-850. 
 
 Summary. 
 I will sum up briefly by saying that the prophylactic division 
 of mental hygiene can safely claim to be far more than a letter- 
 head or a propaganda, and that, whatever its legal and public 
 institutional sides, the prophylactic division of mental hygiene 
 has as concrete measures: — 
 
 1. The stimulation of proper temporary care of persons suffer- 
 ing from mental derangement under the conditions of general 
 hospital and private practice. 
 
 2. The stimulation of voluntary admissions to existing and 
 future hospitals for the insane. 
 
 3. The establishment of psychopathic hospitals in proper 
 centers, having proper medical and social arrangements for the 
 highest forms of intramural and extramural individual and com- 
 munity service. If you are tempted to state that the term 
 "psychopathic" somewhat resembles that blessed name "Meso- 
 potamia" in its drawing powers, as Mr. Frank B. Sanborn once 
 insisted, yet I venture to hope that its extension to include both 
 the legally insane and the great variety of other mental cases, 
 including psychoneurotics, mentally deficients, and criminalistic 
 and possibly other types of mental disorder, will tend to abolish 
 the use of the term "insane" by physicians, except under court 
 conditions. The term "insane" is rightfully considered a legal 
 and not a medical term. One of the greatest features of a mental 
 hygiene propaganda will be to convince and to persuade the 
 world of this fact. 
 
 Southard, E. E., and Canavan, Myrtelle M. Normal- 
 looking Brains in Psychopathic Subjects: Second Note 
 (Westborough State Hospital Material). Journal of Nervous 
 and Mental Disease, New York, 1914, XLI, 775-782. 
 
 Conclusions. 
 1. The writers have tested former issues concerning the func- 
 tionality of mental disease (derived from a comparison of 
 Worcester autopsy material and that from Dan vers) by a study of 
 
126 
 
 Westborough material in which neither a bias towards function- 
 ality nor a bias toward structurality ("organic nature") was 
 likely. 
 
 2. The Worcester proportion of normal-looking brains in a 
 series of psychopathic subjects was about 1 in 3, the Danvers 
 proportion, about 1 in 4; the Westborough proportion proves to 
 be about 1 in 7. 
 
 3. The Westborough standards tend to overthrow the idea of 
 the essential functionality of various senile cases, an idea that 
 was suggested both by the Danvers and the Worcester series of 
 autopsies. 
 
 4. As to the moot question of dementia prsecox, the West- 
 borough results stand nearer the Danvers results, exhibiting a 
 scant majority of gross-lesion cases as against the long, entirely 
 negative series at Worcester, and the high percentages of gross 
 lesion found at Danvers. 
 
 5. In a previous study use was made of a principle that ex- 
 tensive microscopic changes may be wholly consistent with a 
 grossly normal brain appearance up to a period not yet accu- 
 rately established (say three months). In point of fact, 11 per 
 cent of the Worcester series (26 cases) and 16 per cent of the 
 Westborough series (12 cases) had a total duration of symp- 
 toms of three months or less. 
 
 6. Practically, it is often a year or more before visible and 
 tangible changes in the brain of an undoubted character set in, 
 and 15 per cent of the Worcester series (36 cases) and 33 per 
 cent of the Westborough series (24 cases) had durations of a 
 year or less. 
 
 7. Perhaps it is too much to ask the anatomist at the autopsy 
 table to diagnosticate the results of the finer diffuse destructive 
 changes (non-globar, not affecting the projection system) which 
 have lasted but a year or less. 
 
 8. Practically we look for recoveries up to three years, more 
 or less; 53 per cent of the Worcester series (132 cases) and 58 
 per cent of the Westborough series (42) had lasted but three 
 years or less. Such cases may well show (and many of them 
 have shown, though it is not our design to describe them) micro- 
 scopic changes of an important reversible or non-destructive 
 character. 
 
 9. Research should accordingly be bent upon those long-stand- 
 ing cases which nevertheless show no gross effects of their dis- 
 ease in the brain. The microscope may discover in this group 
 
127 
 
 either (a) evidences of reversible brain-cell changes such that 
 they never produce any gross effects (physical or chemical 
 changes not interfering with cell nuclei or other vegetative 
 mechanisms), or (b) no evidences of morbid brain changes what- 
 ever, but merely such appearances as are consistent with the 
 brain's reacting normally to influences ab extra. 
 
 10. These orientation studies show how seldom are all the con- 
 ditions right for testing such an hypothesis as that of the intrinsic 
 normality of brain mechanisms whose reactions are taking effect 
 in extrinsic abnormality, i.e., the hypothesis that mental disease 
 may be entirely functional so far as the brain is concerned. 
 
 11. Accordingly, we seem still father away from a strict proof 
 that "the whole cortex, or even the whole nervous system, might 
 be intrinsically normal but extrinsically abnormal in its reactions 
 to a given chemical, physical or other condition." 
 
 Southard, E. E., and Bond, E. D. Clinical and Anatomical 
 Analysis of 11 Cases of Mental Disease arising in the 
 Second Decade, with Special Reference to a Certain Type 
 of Cortical Hyperpigmentation in Manic-depressive In- 
 sanity. (Danvers State Hospital Series No. 38.) (Proceed- 
 ings, American Medico-Psychological Association, 1914, 
 223-235. 
 
 Conclusions. 
 
 1. This work is another instalment of work designed to throw 
 light on the age factor in the production of mental disease, and 
 has the same features of random selection, employing only 
 autopsied cases, from a long series, as did previous work from the 
 Danvers State Hospital laboratory on cases having onset in the 
 sixth and seventh decades (1908) and in the fifth decade (1913). 
 
 2. There turned out to be surprisingly few cases for the an- 
 alysis; somewhat less than 2 per cent of a long series of autopsied 
 cases (18 in 938) proved to be cases having onset of mental 
 disease between ten and twenty years. 
 
 3. The age distribution in the 11 cases which proved suitable 
 for full clinical and anatomical correlations is striking; of these 
 11, 8 had onset between seventeen and twenty years, and 5 of 
 these 8 at seventeen years; the age distribution, so far as it 
 goes, suggests disorder at puberty as somehow related with the 
 onset of the first attack. 
 
 4. Omitting one female epileptic which demented, we find the 
 cases equally distributed between manic-depressive insanity and 
 
128 
 
 dementia praecox. The manic-depressive 5 were composed of 4 
 females (1 of rather doubtful diagnosis) and 1 male. The de- 
 mentia praecox 5 were composed of 3 females and 2 males. Four 
 of the 5 dementia praecox cases were subject to tuberculosis; 1 
 of the manic-depressives was tuberculous. 
 
 5. The lipoid disorder, of which we attempted to get an index 
 by a study of the distribution of certain substances stainable by 
 the Heidenhain iron-hematoxylin method, was far more in evi- 
 dence in the manic-depressive series than in the dementia praecox 
 series. 
 
 6. The three cases with most marked pigmentation (in this 
 specialized sense) were: (a) the epileptic dement above men- 
 tioned, onset at thirteen, attacks till death at fifty-nine; (b) a 
 manic-depressive, depressed at seventeen, thirty-one and thirty- 
 two, maniacal at forty-nine, dead of intercurrent disease at forty- 
 nine; and (c) a manic-depressive, very numerous attacks of de- 
 pression, first at eighteen to twenty, 7 known attacks between 
 fifty-eight and death at sixty-eight. The other three manic- 
 depressive cases showed marked (although less marked) pigmen- 
 tation focally in {<£), the doubtful case above mentioned (in 
 which, indeed, the pigment is rather an index of local metabolic 
 disorder in an inflamed convolution), and (e, /), cases dying at 
 twenty-five and thirty-one, respectively. 
 
 7. The dementia praecox cases either showed no pigment, as in 
 (g), death at seventeen after nine months of symptoms; (h), 
 death at forty-five, after thirty years of symptoms; (i), death at 
 thirty-two, twenty years after onset, or a slight amount, as in 
 (j), death at twenty-nine after nine years of symptoms, and (k), 
 death at twenty-two after five years of symptoms (pigment in 
 occasional pyramids). 
 
 8. If these findings should be taken at their face value, it might 
 be inferred that manic-depressive insanity is more likely to prove 
 a disease involving brain-cell metabolism than is dementia 
 praecox. In dementia praecox there is more evidence that certain 
 cells have been destroyed outright; but cells which escape de- 
 struction are not likely to look in any respect abnormal. In 
 manic-depressive insanity there is not such good evidence of cell 
 destruction; on the other hand, these cases seem to show that 
 overloading with a certain kind of pigment is more characteristic 
 of the brain cells of manic-depressives than of precocious dements. 
 
 9. The manic-depressive cases of this series seem to have shown 
 more depression than mania. What the relation of this may be 
 
129 
 
 to the histology of these cases is doubtful, but it would seem 
 desirable to examine cases of long-continued mania and long- 
 continued depression with the same technique. 
 
 10. Previous work from this laboratory on age correlations with 
 pigment deposits has suggested that especially the neuroglia cells 
 are likely to show progressively more and more pigment with 
 advancing age; the present work, regardless of the special entity 
 correlations just discussed, seems to show that youthful cases do 
 not show much neuroglia-cell pigment, and therefore this work 
 is to that extent consistent with former results. 
 
 11. As to the possible causes of the pigment deposits in various 
 types of cell, perhaps nothing better than the mystic term " meta- 
 bolic" can be risked. Still, there are two cases in which there 
 were decidedly local accumulations of somewhat similar-looking 
 substances due to or closely associated with acute inflammatory 
 processes (see Cases 1 and 10, dying at seventeen and twenty- 
 two years, respectively). In these cases, to a large extent en- 
 tirely free from pigmentation, either the pressure or the toxines 
 of the inflammation had produced the same appearances focally 
 that are shown by other non-inflammatory cases diffusely. The 
 deposits are, then, possibly favored by certain factors working 
 ab extra with respect to the cells in question. 
 
 Southard, E. E., and Stearns, A. W. The Margin of Error in 
 Psychopathic Hospital Diagnosis. Being Contribution from 
 the Psychopathic Hospital, Boston, Mass., No. 61 (1914.27). 
 Boston Medical and Surgical Journal, 1914, CLXXI, 895- 
 900; 1013. 
 
 Summary. 
 The writers discuss the difference between insanity and mental 
 disease. Studies of similar scope at Danvers (general paresis, 
 senile dementia, psychoses in general) and at Worcester (general 
 paresis) are mentioned, and a table is offered showing the high 
 accuracy which the diagnosis of general paresis had obtained even 
 before the Wassermann reaction was available. They remark 
 upon the frequency of "unclassified' - ' cases at Danvers Hospital, 
 and show a similar frequency at the Psychopathic Hospital, 
 Boston. 
 
 It is shown that about 1 in 5 cases gets no diagnosis at the 
 Psychopathic, and that of those cases that do achieve a diagnosis 
 1 in 4 has its diagnosis altered upon removal to a State hospital. 
 Not all of those removed receive a definite diagnosis. There is, 
 
130 
 
 in fact, a residuum of about 6 per cent that have as yet re- 
 mained unclassified. 
 
 Some analysis is made of the figures for five hospitals receiving 
 the majority of the Psychopathic Hospital patients. Possible 
 bias in diagnosis is considered, but largely discarded. The most 
 difficult field of diagnosis is shown to be that of dementia prsecox 
 and manic-depressive psychosis. It is thought that the excited 
 or agitated patients of these groups form the largest and best 
 subject of diagnostic and theoretical investigation. Examples of 
 interesting alterations of diagnosis are offered, including a case in 
 which the terminal phase of an alcoholic hallucinosis, together 
 with incoherence (perhaps due to attention-disorder) and 
 maniacal symptoms, was the basis of a diagnosis of dementia 
 prsecox, whereas the true diagnosis was very probably manic- 
 depressive psychosis combined with alcoholic psychosis. 
 
 Southard, E. E. Applications of the Pragmatic Method to 
 Psychiatry. Journal of Laboratory and Clinical Medicine, 
 St. Louis, 1919, V, 139-145. 
 
 Summary. 
 
 1. Psychiatry should more and more adopt the "Laboratory 
 habit of mind," become more and more pragmatic, and bring 
 itself in line with the rest of medicine. 
 
 2. Seven applications of the pragmatic method to psychiatry 
 are offered : — 
 
 (a) It makes a difference to the patient whether he is seen by 
 a psychiatrist or by a clinical neurologist. There is thus for the 
 moment a real difference between psychiatry and clinical neu- 
 rology, though the future may destroy that difference and produce 
 " neuropsychiatry. " 
 
 (6) It makes a difference to the patient whether we take 
 "insanity" as a unit or as a collection of entities. The prag- 
 matic rule decides in favor of a pluralistic view of mental diseases. 
 
 (c) The principle of orderly exclusion in the diagnosis of com- 
 plicated cases is of pragmatic value. 
 
 (d) Especially is this true of the diagnostic field of neuro- 
 syphilis, where it is important to maintain the wow-paretic hypo- 
 thesis as long as possible in the interest of the patient's therapy. 
 
 (e) Opinions might differ as to the advisability of entertaining 
 the hypothesis of focal brain disease before or after the hy- 
 pothesis of somatic (non -neural) disease in a given case. The 
 
131 
 
 pragmatic rule might decide one way for general hospital clinics 
 and the other way for mental clinics. 
 
 (/) Schizophrenia should be eliminated before cyclothymia on 
 the pragmatic basis, for a group of schizophrenic symptoms is 
 much more decisive for dementia prsecox than a group of cyclo- 
 thymic symptoms is decisive for manic-depressive psychosis. 
 
 (g) The pragmatic method decides that in the face of complete 
 ignorance of its true nature, involution-melancholia is better 
 placed in the cyclothymic (manic-depressive) group than in the 
 senile-senescent group, if it is to be placed in either group. 
 
 Southaed, E. E. Anatomical Findings in the Brains of Manic- 
 depressive Subjects. This paper is No. 99 (1915.2), Con- 
 tributions of the Massachusetts Board of Insanity, and No. 
 54, Danvers - State Hospital Contributions. Some of the 
 conclusions were presented at the meeting of the New 
 England Society of Psychiatry at Rutland, Mass., in 
 September, 1909. An abstract was presented at the seven- 
 tieth annual meeting of the American Medico-Psychological 
 Association at Baltimore, May 26-29, 1914. Proceedings, 
 American Medico-Psychological Association, Baltimore, 1914, 
 XXI, 237-274. 
 
 Conclusions. 
 
 1. Kraepelin states that the anatomy of manic-depressive sub- 
 jects is negative. Various authors have described focal lesions 
 with which to account for the occasional dementia which text- 
 books mention. Evidence as to the existence of brain stigmata 
 is equivocal. Orton has recently found satellitosis perhaps rather 
 more in manic-depressive than in dementia-preecox subjects. 
 
 2. The fundamental and even practically important question 
 of brain-anatomy in manic-depressive subjects has been here 
 taken up precisely with the same ideas and with similar material 
 as in the writer's first study of dementia-prsecox brains, namely, 
 with the topographic idea far more prominent than it has been 
 made by most workers in the field of what used to be called 
 "functional psychoses." 
 
 3. The first question which occurs to a critic of my 86 per cent 
 of anomalies, scleroses and atrophies in dementia prsecox is: 
 What percentage of similar conditions would "not-insane" sub- 
 jects show, and what would be shown in the disease manic- 
 depressive insanity? The present paper deals with the latter 
 inquiry and throws indirect light upon the former. 
 
132 
 
 4. As ever, much depends upon what one terms manic-depres- 
 sive psychosis. In the text I have given relatively full accounts 
 of most cases excluded from my initial list, which comprised 
 every case which had received the diagnosis (at times on de- 
 cidedly insufficient grounds) in a certain period at Danvers Hos- 
 pital. Many of my exclusions tend to swell the dementia-prsecox 
 group, and these cases may be studied with my dementia-prsecox 
 material of 1910. To avoid confusion I have excluded cases of 
 involution-melancholia. 
 
 5. As against my 86 per cent lesions in dementia prsecox, I 
 regard 13 per cent as a fair percentage for manic-depressive 
 insanity (4 in 31). A little less rigorous clinical analysis would 
 leave the percentage at 18 per cent (6 focal-lesion cases in 33). 
 In a total random material (after certain obvious exclusions) of 
 38 cases, it would not be possible, I believe, for the most ardent 
 anatomist to find more than 11 cases of focal lesions (29 per 
 cent). But this last percentage is assuredly too high, since three 
 cases in the group are pretty clearly cases of dementia praecox. 
 Thus 8 in 35 (23 per cent) is a figure which some analysts might 
 prefer, though personally I believe it too high. 
 
 6. Roughly speaking, then, we may think of the manic-depres- 
 sive group as exhibiting brain stigmata or focal lesions {not arterio- 
 sclerotic) in about 1 brain in every 5, whereas dementia-pr&cox 
 brains show such conditions in about 4 out of every 5 brains. 
 
 7. This finding must be of some significance, whatever the 
 criteria, and whatever particular functional correlations one 
 might infer. The finding does not prove or indicate that the 
 manic-depressive brain is normal, but it does show that the 
 cellular lesions, if any are to be found, must be of a peculiar and 
 probably a reversible nature. And, whereas eager histological 
 researches in the brain are much to the point, perhaps the canny 
 observer will regard the non-nervous organs of the body, or those 
 supplied by the autonomic system, as even more inviting to study 
 in the manic-depressive group. 
 
 8. No special histological study is here presented, although 
 some orienting slides have been available in the great majority 
 of cases, from which Orton's conclusions about satellitosis can 
 be in a measure confirmed. Indications of a special line of attack 
 have been presented by Bond in a paper with the writer, and 
 some conclusions bearing on this point have been drawn in the 
 writer's thalamus paper. 
 
 9. A study of the literature yielded a few special questions 
 
133 
 
 which I have endeavored to answer, largely on the basis of the 
 material without focal lesions, since I regard these four-fifths of 
 my material as far less open to diagnostic suspicion than the 
 one-fifth possessing lesions. 
 
 10. The question of the relation of certain instances of eventual 
 dementia to arteriosclerotic brain lesions is provisionally answered 
 in the negative; but the question requires further study. 
 
 11. Heredity does not show itself in most manic-depressives 
 in the form of brain stigmata; but the extremely high index of 
 insane heredity in near relatives is remarkable. I am inclined 
 provisionally to regard manic-depressive insanity as constantly or 
 almost constantly hereditary, not in the sense of similar heredity 
 (this has not been adequately studied), but in the sense that 
 some kind of insanity is almost always, if not always, to be found 
 in near relatives. Without such evidence, I am clinically not now 
 disposed to make the diagnosis "manic-depressive," although it 
 is clear that the rule will not work in the other direction. For 
 the moment I am challenging my records to produce an unexcep- 
 tionable case of manic-depressive psychosis which does not show 
 family taint of insanity. 
 
 12. Upon these provisional hypotheses are we to assume that 
 the normal-looking brains of manic-depressives are really normal, 
 i.e., intrinsically, and merely purveying the impulses which a 
 sick body is producing? Or shall we assume a chemical or 
 physicochemical instability of the entire nervous system, such 
 that, although the brain is intrinsically abnormal, the abnormality 
 does not show as yet? Hereditary taint is consistent enough 
 with either assumption, since the germ-plasm might with equal 
 readiness mark the nervous and the non-nervous parts of the body 
 with those invisible marks that produce "functional psychoses." 
 
 Southard, E. E. On the Direction of Research as to the 
 Analysis of Cortical Stigmata and Focal Lesions in Certain 
 Psychoses. Being Contribution of the State Board of In- 
 sanity, No. 42 (1915.8). Transactions, Association of 
 American Physicians, Philadelphia, 1914, XXIX, 651-673. 
 
 Summary and Conclusions. 
 
 In the above communication I have endeavored to bring out 
 
 what I regard as an important line of structural research in 
 
 mental disease. The general point of view on which I stand 
 
 may be regarded as somatic, although the topic which is most 
 
134 
 
 important for psychiatry is undoubtedly the functional psychoses 
 (especially dementia prsecox and manic-depressive psychosis). 
 In dementia prsecox I find four-fifths of the cases showing at 
 autopsy certain appearances which may be regarded as anomalies 
 or lesions in some sense. Possibly they should be regarded as 
 weak places in the brain structure in which there may be later 
 every evidence of progressive disease. The percentage of cases 
 of dementia prsecox showing these lesions is 80 per cent or higher. 
 The percentage in the brains of non-psychopathic subjects has 
 never been properly established, but in the so-called functional 
 mental disease, manic-depressive psychosis, I find similar anom- 
 alies or lesions in about 20 per cent of all cases. 
 
 Accordingly, I hold that dementia prsecox is a disease in which 
 cortical stigmata are much more often found than in certain 
 other forms of mental disease, and probably decidedly more often 
 than in the normal citizens of the world. 
 
 The direction which research should take as to these findings is 
 important. My point of view here is again a structural one. I 
 present some photographs from two cases which indicate what I 
 think will prove a rich line of research. There are two main lines 
 of consideration. 
 
 First. — We may study the appearances in those tissues which 
 are regarded as the sensory arrival-platforms of the cerebral-cortex 
 (for example, the calcarine type of occipital cortex) and contrast 
 the findings in the sensory arrival-platforms with findings in the 
 elaborative tissues which are adjacent thereto (for example, the 
 .common occipital type of cortex in the occipital region just men- 
 tioned). It is currently thought that we can safely call the cal- 
 carine type the visuo-sensory type, and the common occipital 
 type the visuo-psychic part of the cerebral-cortex. When we are 
 able to get under the same cover-glass materials fixed, prepared 
 and stained in the identical manner and observable in the same 
 thickness, we are undoubtedly able to attach much consequence 
 to the results of microscopic examination. 
 
 Second. — We are able in certain cases to use the bilaterality 
 of structures in the brain to help us in our interpretations. I 
 present photographs in another case which illustrate the line 
 which research may well take. One post-central gyrus in this 
 case was about half the thickness of the other. 
 
 The interpretation of the cell richness, the possible cell losses 
 and the nature and degree of neuroglia cell reaction is not as easy 
 as might appear at first sight. Particularly important is the ques- 
 
135 
 
 tion of the form of neuroglia cell proliferation which is variously 
 termed neuronophagia and satellitosis. 
 
 In the present argument I point out that the visuo-psychic 
 tissues of a certain case showed satellitosis, whereas the imme- 
 diate adjacent visuo-sensory tissues failed to do so. On the other 
 hand, I find that the narrow and apparently decidedly anom- 
 alous postcentral gyrus of another case fails to show satellitosis, 
 but that its fellow on the other side, showing no gross lesion, 
 shows frank evidences of satellitosis when examined microscopi- 
 cally. The point, perhaps, is that the narrow gyrus has com- 
 pleted its pathological evolution and has passed the phase of 
 satellitosis; but our results here must remain problematical until 
 we know more as to the intimate nature of satellitosis. 
 
 My total argument for a certain optimism in structural re- 
 search in psychiatry is accordingly founded, not upon the inter- 
 esting clinical correlations of the two cases (A, striking scenic 
 visual hallucinosis, satellitosis of common occipital cortex, B, 
 catatonic phenomena and anomalies of the postcentral gyri), but 
 rather upon the more general consideration that we now have, 
 owing to the efforts of the modern cortex topographers, the basis 
 for differential histopathological analysis of adjacent cortical 
 tissues of different functional significance, and the benefit of 
 examining tissues of co-ordinate nature on the two sides. The 
 careful attention of the histopathologist in the nervous system 
 should accordingly be given to all those planes in which arrival- 
 platform tissue comes into contact with higher elaborative tissues 
 in the sense of the modern cortex topographers; and the findings 
 in any gyrus should be controlled by study of the corresponding 
 gyrus of the other hemisphere. 
 
 Southard, E. E., and Canavan, Myrtelle M. On the Nature 
 and Importance of Kidney Lesions in Psychopathic Sub- 
 jects: A Study of 100 Cases autopsied at the Boston State 
 Hospital. Being Contribution of the State Board of Insanity,, 
 No. 23 (1914.3). Journal of Medical Research, Boston,, 
 1914-15, XXXI, 285-299. (New series, Vol. XXVI). 
 
 Conclusions. 
 1. These general results substantiate those of a more super- 
 ficial inquiry in a larger number of cases (see introductory note) 
 as well as those of the late W. L. Worcester on the same kind of 
 material (1899). 
 
136 
 
 2. The inquiry here reported deals with a more systematic 
 histological examination of kidneys in the insane than has been 
 reported for many years, embodying a tabulation of findings in 
 the gross and microscopically in the different recognizable struc- 
 tures of the kidney. 
 
 3. The analysis permits saying that normal kidneys must be 
 of the greatest rarity in the insane at autopsy, for in the present 
 series of 100 no instance of normal kidneys was found. 
 
 4. It is less possible to say that these renal conditions were of 
 moment to the individuals who bore them, since some of the 
 lesions are very possibly extinct, and others cannot safely be in- 
 terpreted in the present state of pathology. 
 
 5. Their interest from the therapeutic and dietetic standpoint 
 is considerable, since there were at least 39 instances of acute 
 renal disease, and 11 of these complicated by a background of 
 chronic lesions. 
 
 6. Aside from these 39 acute (or acute and chronic) conditions, 
 there were 55 instances of chronic lesions (or 66, if we include 
 the 11 cases with both acute and chronic lesions). 
 
 7. There were in point of fact but 5 cases in which the kidneys 
 were regarded as normal to the naked eye. 
 
 8. Clinically, among 65 cases examined, albuminuria was found 
 in 25 (or 38 per cent), and cylindruria in 18 (or 28 per cent). 
 Also the specific gravity went below 1015 at times in 18 cases (or 
 28 per cent). No special statistical significance need be attached 
 to these latter figures. 
 
 9. Clinically, also, there were 10 instances of oedema, probably 
 either caused or favored by the renal condition (4 of these 10 
 cases showed cardiac disease also). 
 
 10. Clinical records show 19 instances of seizures or convul- 
 sions of some sort ; but it is not clear how many of these can be 
 regarded as renal. 
 
 11. Clinical records also indicate that 23 of the 100 cases were 
 regarded in life as more or less severe cardiac cases. 
 
 12. Of the females examined, 26 (or 52 per cent) had borne one 
 or more children. 
 
 13. Thirty-two of the 100 cases were emaciated at death. 
 
 14. The most prominent gross lesion in the series was chronic 
 interstitial nephritis, which occurred in 42 cases. 
 
 15. Microscopically, chronic interstitial nephritis was found 
 not only in these 42 cases, but also in 24 other cases (a total per- 
 centage of 66). 
 
137 
 
 16. There were 33 cases in which chronic interstitial nephritis 
 was not only marked in the gross, but was the only significant 
 kidney finding microscopically also. 
 
 17. Microscopically, much attention was paid to the occurrence 
 and distribution of plasma cells in the kidney substance, since 
 these might well be regarded as indicating a more active (or less 
 extinct) sort of lesion than simple fibrosis. 
 
 18. Plasma cells were never found in such quantity as to sug- 
 gest acute interstitial nephritis, but plasma cells were found in 
 42 per cent of the series. 
 
 19. Thirty-eight of these 42 plasma cell cases showed the 
 plasma cells distributed chiefly about the glomeruli. This dis- 
 tribution naturally suggests special conditions (toxic?) in the 
 periglo.merular region, and in point of fact there was very fre- 
 quently a glomerular lesion associated with this exudation. 
 
 20. A broader or different distribution of plasma cells was far 
 less common, and the small groups of such unusual distribution 
 are presented in the text. 
 
 21. Eleven cases out of 26 under fifty years of age yielded 
 plasma cells, i.e., exactly the same percentage as did the total 
 series. 
 
 22. The occurrence of plasma cells in the kidneys of general 
 paretics is worthy of note by reason of their constant occurrence 
 in the brains. Seventeen of 30 paretics in this series showed 
 plasma cells in the kidney, or 56 per cent. It is possible that 
 they are of focal occurrence in the kidney (though nothing 
 specially to indicate this was found), and that more systematic 
 work would swell the percentage. Sixteen of the 17 paretics 
 showed the plasma cells in the periglomerular region, while 1 
 showed them in a subcapsular zone. 
 
 23. Seven of the whole series of 30 paretics had seizures; 5 
 of these seizure cases showed periglomerular plasma cells, 1 
 showed no chronic lesion except general fibrosis, and 1 was a 
 case of acute parenchymatous nephritis without chronic lesion 
 (12.13). But 3 of these 7 cases showed casts, and these only in 
 one tubule type (descending loop of Henle). 
 
 24.. Curiously enough, 12 other non-paretic cases which had 
 seizures or convulsions of various sorts failed to show plasma cells 
 in the kidneys, but in 8 instances did show casts, although always 
 confined to a single tubule type (six times in the tubule type of 
 election, the descending loop of Henle). 
 .25. Seventy -three cases showed casts in one or more types of 
 
138 
 
 tubule; 50 cases in one type of tubule only (40, descending loop 
 of Henle); 14 in two tubule types; 7 in three tubule types; and 
 2 in four tubule types. 
 
 26. Sixty-three of the 73 cast-bearing cases showed the casts 
 in the descending loop of Henle, which seems entitled by conse- 
 quence to be called the tubule of election for cast deposit or re- 
 tention. 
 
 27. There was a curious time distribution of those cases which 
 showed casts in the less common locus of the proximal convoluted 
 tubule. Ten of these 12 cases died within a period of four 
 months, November to February, 1912-13. One may suspect 
 special dietary or bacterial conditions for this fact. 
 
 28. Glomerular tuft changes of a serious nature occurred in 51 
 cases, and there were indications of disease in 13 others (besides 
 two acute lesions). Changes in the glomerular capsule were far 
 less in number, being of a serious nature in but 17 cases (slight or 
 infrequent in 10 others). Cast deposits occurred in 8 cases under 
 fifty years of age without evidence of glomerular change. 
 
 29. Some facts are noted concerning the possible relations of 
 acute renal lesions to infective foci in the urinary apparatus or 
 in the body at large. 
 
 30. The study seems to show a significantly high proportion of 
 chronic and acute lesions of the kidney in psychopathic subjects; 
 such conditions should engage the attention of dietitians in insane 
 hospitals. 
 
 Canavan, Myrtelle M., and Southard, E. E. The Signifi- 
 cance of Bacteria cultivated from the Human Cadaver: 
 A Second Series of 100 Cases of Mental Disease, with 
 Blood and Cerebrospinal Fluid Cultures and Clinical and 
 Histological Correlations. Being Contribution of the 
 State Board of Insanity No. 24 (1914.4). Journal of 
 Medical Research, Boston, 1914-15, XXXI, 339-365. 
 (New series, Vol. XXVI.) 
 
 Summary and Conclusions. 
 
 (Note. — The conclusions have been numbered to correspond 
 with the conclusions of Gay and Southard, 1910.) 
 
 1. In a study similar in scope to that of Gay and Southard, 
 1910, the writers present the results of a second series of 100 
 bacterial cultivations from the heart's blood and the cerebro- 
 
139 
 
 spinal fluid post mortem in cases of mental disease. The new 
 series is from the Boston, instead of the Danvers, State Hospital. 
 
 2. The bacteria were cultivated upon agar plates inoculated 
 with 1.5 cubic centimeters heart's blood, and others with 1.5 
 cubic centimeters cerebrospinal fluid. The cerebrospinal fluid was 
 removed from the third ventricle through the infundibulum, 
 severed at its origin. 
 
 3. Forty-four per cent of the blood cultures remained sterile 
 (Gradwohl, 22 per cent; Gay and Southard, 41 per cent; Otten, 
 42 per cent; Simmonds, 48 per cent). 
 
 4. Twenty-four per cent of the cerebrospinal fluid cultures 
 remained sterile (Tomlinson, 28 per cent; Gay and Southard, 28 
 per cent). 
 
 5. Under somewhat different laboratory conditions the Boston 
 laboratory (bodies often not ice-cooled and always held at a 
 somewhat higher temperature than at Danvers) thus paradoxi- 
 cally yields more steriles than the Danvers laboratory in the 
 blood (44:41), but less in the cerebrospinal fluid (24:28). 
 
 6. It is interesting, however, that the Boston- series shows 
 fewer cerebrospinal positives in the earlier than in the later 
 periods post mortem, — a tendency quite the reverse to that of 
 the Danvers series, where the icing (often freezing) of the cada- 
 vers may well have inhibited the growth of bacteria post mortem. 
 
 7. On the other hand, the heart's blood results are not readily 
 interpretable on the above or any other basis, unless we invoke 
 special bactericidal properties in the sera of different cases. 
 
 8. With the lapse of time post mortem, accordingly, the cere- 
 brospinal fluid certainly seems to show the effect of its non- 
 bacteriolytic properties (see conclusions 7-9 of Gay and South- 
 ard's article quoted above), at a comparatively early date, in the 
 increased frequency of its positives when temperature permits 
 (Boston) as against no increased frequency (or reduction?) when 
 temperature is unfavorable (Danvers). 
 
 9. The heart's blood with its (for some time) persistent bac- 
 teriolytic substances does not seem to show notable variation in 
 its incidence of positives as time post mortem elapses under 
 either Boston or Danvers conditions. 
 
 10. As to particular bacterial forms, cocci prevail in both 
 series, and in both series there were more cultivations of cocci 
 from the cerebrospinal fluid than from the blood. 
 
 11. At Danvers no diphtheroid organisms were picked up in 
 bodies of paretics (pace Ford Robertson, 1906); at Boston there 
 
140 
 
 was one such instance from the blood and fluid of a case. This 
 as well as other considerations concerning secondary invasions in 
 general paresis will be taken up in a separate communication. 
 
 12. Cultivations from twenty-six general paretics are listed; 
 cocci no longer especially prevail in the positive cases (contra 
 Dan vers). 
 
 13. No conclusion as to the possible relation of bacterial in- 
 vaders to fatty changes can be drawn from the sterile cases, since 
 all the cases but one were too old to be free from the suspicion 
 of age-changes in the production of lipoid alterations; there was, 
 however, one case, twenty-three years of age, probably quite 
 sterile throughout, and this case showed no lipoid alterations in 
 any part studied. 
 
 14. On the other hand, there were twenty cases in which no 
 fatty changes were found histologically, and of these no case 
 showed Bacillus coli communis, and cocci prevail as in the 
 Danvers series. Thus, whether we assume various lipoid altera- 
 tions to go on ante mortem or post mortem, and under the in- 
 fluence of bacteria or not under such influence, it would appear 
 that cocci can hardly be charged with effecting such lipoid 
 changes. 
 
 15. Forty-six cases are listed, having had symptoms less than 
 four days in duration, as against 31 in the Danvers series; 18 
 per cent of the new series, examined by fat-staining methods, 
 proved negative as against 29 per cent histologically negative in 
 the Danvers series; and the 18 per cent thus both clinically and 
 histologically negative in the Boston series contrast with 14 per 
 cent histologically negative in the total Boston series, — a varia- 
 tion in the same direction as in the Danvers series (29 per cent: 
 10 per cent), only less striking. 
 
 16. In 8 cases chosen as showing most marked fatty changes 
 there were no instances of colibacillosis (one case only of anaero- 
 genes bacillemia); in fact, 5 cases were negative in the cerebro- 
 spinal fluid, and 6 negative in blood. 
 
 17. One of the highly (Marchi) degenerated cases (among the 
 8 just mentioned) yielded Cladothrix invulnerabilis in the 
 cerebrospinal fluid; a second case with the same finding also 
 showed degeneration, though of less marked degree; two of the 
 highly degenerated cases (of the 8 supra) yielded Bacillus muri- 
 septicus; another case showed degenerations, but less marked. 
 
 18. There were 9 cases of generalized softening of brain tissues 
 in the Boston series as opposed to 13 in the Danvers series; more- 
 
141 
 
 over, three of these Boston cases were autopsied from three to 
 eight and one-half days post mortem (at a time when ferment 
 action may be presumed to be under way). No case showed 
 Bacillus coli communis; the bacteria found were in two instances 
 reputed pathogens (Bacterium varicosum and Micrococcus sali- 
 varius). In three other cases the organisms were either liquefiers 
 of various media (Bacillus subtilis, Micrococcus alvi) or ab- 
 stractors of water (Cladothrix invulnerabilis). In only one case 
 was the bacteriology negative (a case of ulcerative colitis). 
 
 19. Only indirect evidence concerning the effect of Bacillus coli 
 communis or its toxines on nerve fiber degeneration is here 
 afforded; however, the organisms which are associated with the 
 soft brains in the Boston series are in most cases also liquefiers of 
 various laboratory media. 
 
 Epicritical Conclusions. — The conclusions of the new study in 
 general coincide with those of Gay and Southard, but present 
 some novel points (especially conclusions 6, 8, 14, 16, 18), and 
 these points may be briefly considered as follows: — 
 
 20. It is suggested by a comparison of the two series that the 
 more immediate and thorough cooling (or even icing) of the 
 Danvers cadavers has served to inhibit the growth of bacteria in 
 the cerebrospinal fluid, since the lapse of time post mortem is 
 attended in the Boston series by increasing frequency of positives 
 in the cerebrospinal fluid. 
 
 21. The blood findings show no such effects as those just men- 
 tioned for the cerebrospinal fluid; perhaps the curve is spoiled by 
 the presence or absence in special cases of bactericidal sub- 
 stances in the blood. 
 
 22. Whatever may be said of the possible ante-mortem or 
 post-mortem effects of other organisms in producing lipoid 
 changes in the nervous system, the cocci as a group may be ab- 
 solved from this charge; if the cocci act at all ante mortem, it 
 must be rather in the direction of irritative than of destructive 
 effects. 
 
 23. The absence of colibacillosis in the Boston series is striking; 
 a few other organisms, either pathogenic or somewhat destructive 
 to the laboratory media used for their cultivation, enter to take 
 the place of Bacillus coli communis in the "soft brain" cases. 
 
142 
 
 1915. 
 
 Southard, E. E., and Canavan, Myrtelle M. A Study of 
 Normal-looking Brains in Psychopathic Subjects: Third 
 Note (Boston State Hospital). Being Contribution of the 
 State Board of Insanity, No. 35 (1915.1). Boston Medical 
 and Surgical Journal, 1915, CLXXII, 124-131. 
 
 Conclusions. 
 
 1. The present is a fragment from more extensive studies 
 tending to settle the question how far mental disease is consistent 
 with normality of brain; and as in previous work from the 
 Worcester State Hospital, so this work from the Boston State 
 Hospital has chosen to begin with normal-looking brains, since 
 these are more likely to be essentially normal than those brains 
 which yield obvious lesions. 
 
 2. On comparison with the Worcester percentage of normal- 
 looking brains, viz., about 1 in 3, and the Danvers percentage, 
 viz., about 1 in 4, the present Boston percentage is much lower, 
 viz , about 1 in 8. 
 
 3. We do not deny that some of the lesions found in the 
 abnormal brains may have had little or nothing to do with the 
 mental disease which their bearers showed; the point of our 
 research lodges in the endeavor to discover essentially normal 
 brains in subjects of mental disease. There are 20 in 153 
 examined by uniform methods which gave promise of being 
 microscopically as well as macroscopically normal. 
 
 4. One normal-looking brain yielded a chronic-looking exu- 
 date, Case I (12.55) which was a case of general paresis of brief 
 duration (less than five months), clinically certain, showed 
 nerve cell and fibre changes, gliosis and perivascular mononu- 
 cleosis (including plasma cells) of fairly even degree throughout 
 sections examined. The gross examination yielded opaque points 
 of thickening in the pia mater over the vertex. The dura had 
 begun to thicken and the calvarial diploe had begun to disappear. 
 The brain had not lost more than 100 grams in weight (Tigges' 
 formula). 
 
 5. One case yielded evidences of acute perivascular exudate 
 post-pneumonic encephalitis, but the mental picture cannot be 
 regarded as due to the exudate. 
 
 6. The suspicion is often uttered that cases not infrequently 
 show fine vascular disease not evident in the gross. No such 
 
143 
 
 case has appeared, but there was one (X, 11.42) which, despite 
 coarse changes in the basal vessels, was included in the normal- 
 looking series and microscopically showed slightly marked fine 
 vascular changes with equally marked cortical changes (no in- 
 farcts, but generalized and focal losses). This case was a female 
 of eighty whose brain weighed 1,125 grams, i.e., 5 grams above 
 the calculated weight according to body length. It is possible 
 that the brain was slightly edematous — vacuoles among nerve 
 cells (eighteen hours post mortem, tuberculous peritonitis). The 
 brain was included in the normal-looking series, although on the 
 autopsy table the diagnosis of "general cerebral gliosis" was 
 made (confirmed by the excess of cells in the plexiform layer in 
 virtually every region examined). It may be inquired why a 
 case with basal vascular disease should not be forthwith excluded 
 on the ground that fine changes will be certain to be found; but 
 they are not sure to be found, as XIV, 12.11, proved (since in 
 this case there were gross arterial changes and few or no fine 
 vascular changes). 
 
 7. We have accordingly reduced our 20 normal-looking cases to 
 18, which still give some promise of proving normal on microscopic 
 examination. One of these 18 was a case of epilepsy, V, 11.26, 
 with dementia; and since the epilepsy began in infancy, it is doubt- 
 ful whether it should be included in this study. Microscopically, 
 in any event, there were numerous evidences of cell losses. 
 
 8. If we exclude this case of epilepsy from the normal-looking 
 numerator of the fraction, we should also possibly exclude 5 
 other epileptics (or in all 6) from the denominator, yielding a 
 percentage of 11.5, i.e., 17 in 147 cases, excluding all epileptics 
 and two cases, I and X, in which the microscope revealed changes 
 which should theoretically yield gross lesions. 
 
 9. In a study of the percentage of normal-looking brains it 
 would be wise, also, to exclude clear cases of imbecility, of which 
 there were 2 in the series, neither of which yielded a normal- 
 looking brain; this makes a percentage of 11.7 per cent normal- 
 looking brains in a series of 145. 
 
 10. In the analysis of this residue of 17 normal-looking brain 
 cases we must first consider the question of atrophy or aplasia. 
 Eleven cases yielded brain weights above normal, employing 
 Tigges' formula (i.e., 8 X body length in cm. = probable brain 
 weight). Six remaining brains weighed less than normal accord- 
 ing to this formula. Of these 6, one (Case IV, 11.11) yielded 
 a brain weight of 1,010 grams, calculated weight, 1,208 grams, 
 
144 
 
 which should probably make this case fall into the atrophic 
 brain group. The reflex picture and certain other clinical features 
 gave rise to the diagnosis taboparesis. The total duration was 
 but one month and four days. The absent knee jerks proved 
 due either to axonal anterior horn cell reactions or to peripheral 
 neuritis (abundant Marchi degenerations), and it is probable that 
 we are dealing with a Korsakoff' s psychosis (history of previous 
 attacks of alcoholic mental disease not obtained, but possible). 
 Abundant evidence of cell loss with satellitosis was found in 
 many areas microscopically. 
 
 11. Another case (XV, 12.29) yielded a brain weighing 1,050 
 grams, i.e., a calculated loss of 150 grams. This case showed 
 various evidences of atrophy in other organs also, and microscop- 
 ically a remarkably diffuse cell loss in the cortex. Clinically 
 the case was one of involution-melancholia, fifty-nine years of 
 age, of twenty months and fourteen days. 
 
 12. Case XIII, 11.5, with a calculated brain weight loss of 
 120 grams, was a female of seventy-three years, with total dura- 
 tion of about eight years. The microscopic evidences of cell 
 loss were such that this case also must probably be placed in the 
 atrophic group; in point of fact, her brain atrophy was probably 
 obscured by increase of weight eight and one-half days post 
 mortem (brain not palpably soft on account of gliosis). 
 
 13. Case XIX, 10.9, with a calculated brain weight loss of 
 100 grams, showed a small heart (145 grams) and a small liver 
 (1,000 grams). This case probably does not belong in the 
 atrophic group, since microscopically there was small evidence 
 of cell loss. This case of paranoid dementia prsecox will be 
 considered below. Case XVI, 11.36, and Case XII, 13.41, with 
 calculated brain weight losses of 76 and 54 grams, respectively, 
 can also hardly be classed as showing important degrees of brain 
 atrophy (see below). 
 
 14. One case (VII, 11.31) must be excluded from the present 
 analysis, because total brain sections are in process of making 
 (case of syringomyelia). 
 
 15. There remains a group of 12 cases, excluding I, XIV, V 
 from the original 19, i.e., I as general paretic, XIV as arterio- 
 sclerotic dement, V as epileptic, IV, XV and XIII as having 
 atrophic brains, VI as syringomyelia (analysis unfinished). We 
 accordingly remain with 1 normal-looking brain in 12. 
 
 16. The residue of normal-looking brains, with the above 8 
 omissions, consists of the following 12: — 
 
145 
 
 Case. 
 
 II (13.44) . 
 
 III (13.6) . 
 
 VIII (12.37) 
 
 IX (13.16) . 
 
 XI (12.7) . 
 
 XII (13.41) . 
 XIV (12.11) 
 
 XVI (11.36) 
 
 XVII (13.29) 
 
 XVIII (13.7) 
 
 XIX (10.9) . 
 
 XX (12.47) . 
 
 Sex. 
 
 F. 
 M. 
 F. 
 M. 
 M. 
 F. 
 M. 
 F. 
 F. 
 F. 
 F. 
 F. 
 
 Age. 
 
 44 
 44 
 71 
 77 
 43 
 60 
 84 
 30 
 53 
 64 
 56 
 27 
 
 Onset. 
 
 44 
 43 
 71 
 
 75 
 42 
 50 
 67 
 29 
 41 
 20 
 42 
 25 
 
 Duration. 
 
 y/z mos. 
 
 V/% mos. 
 
 8 mos. 
 
 22 mos. 
 
 3 mos. 
 
 10% yrs. 
 
 14 yrs. 
 
 20 mos. 
 
 13^ yrs. 
 
 2 -M^ yrs. 
 
 14 yrs. 
 
 28 yrs. 
 
 Diagnosis. 
 
 Central neuritis. 
 
 General paresis ? Korsakoff. 
 
 Senile psychosis. 
 
 Senile psychosis; cerebral arte- 
 riosclerosis. 
 Exhaustion psychosis. 
 
 Unclassified (paranoia). 
 
 Involution-melancholia. 
 
 Manic-depressive psychosis. 
 
 Manic-depressive psychosis. 
 
 Unclassified manic depressive. 
 
 Paranoia or dementia prsecox. 
 
 Dementia prsecox (catatonia). 
 
 17. Attention is first directed to four cases of mental disease 
 over ten years in duration; these are XIX, XIV, XII and 
 XVII. 
 
 18. This group of cases in which gross registration of lesions 
 might have been expected was subjected to orienting microscopic 
 examination: — 
 
 Case XIX, 10.9, shows strikingly few evidences of cell loss, 
 but careful search discovered foci of cell loss in the right second 
 temporal gyrus. This case, though of slow evolution and diagnos- 
 ticated paranoia, is thought to have had hallucinations of hearing 
 as well as of sight. The delusions were largely of jealousy and 
 otherwise sexual. One attack of so-called "cerebral congestion" 
 at forty. 
 
 Case XIV, 12.11, involution-melancholia, eighty-four years at 
 death, exhibited considerable cell loss in outer layers without 
 marked satellitosis. Marked cell loss in calcarine region. 
 
 Case XII, 13.41, unclassified paranoic case, died at sixty, 
 showed fairly numerous cell losses. 
 
 Case XVII, 13.29, manic-depressive psychosis, died at fifty- 
 three, showed numerous cell losses, especially in upper layers. 
 
 19. According to a principle mentioned in the Worcester analy- 
 sis, it would be unlikely that induration should register itself in 
 brains undergoing gliosis in less than three months. There were 
 three cases (II, III, XI) of which II was the case of possible 
 central neuritis with marked acute cell changes ample to explain 
 roughly the brief mental disease; III showed numerous acute cell 
 
146 
 
 changes, probably quite consistent with the mental picture 
 (Korsakoff's psychosis); and XI showed cell losses, perhaps of 
 long standing (although there were overt symptoms for three 
 months only), together with acute cell changes. 
 
 20. The group of intermediate duration, three months to three 
 years, comprises 5 cases, — XVI, VIII, XX, XVIII, IX. Of 
 these, VIII, aged seventy-one, and IX, aged seventy-seven, 
 attract attention on the score of age. Both showed cell losses: 
 in the former, focal with perivascular gliosis; in the latter, 
 marked diffuse losses. Of the three remaining, two are manic- 
 depressive cases (XVI, 11.36, and XVIII, 13.7), and one (XX), 
 catatonic dementia prsecox. All three showed moderate degrees 
 of cell loss. 
 
 21. Accordingly, it is plain that the search for functional 
 psychoses which shall be above all neuropathological reproach is 
 an exceedingly elusive task, and possibly never to be rewarded. 
 In a forthcoming communication we shall deal with the detailed 
 microscopic picture in five of the cases of this series (XII, XVI, 
 XVIII, XIX, XX), since these five appear to be the least likely 
 of all our series of 153 cases to show important microscopic 
 lesions. 
 
 Southard, E. E. Some Relations of Mania to the Sensorium. 
 (Abstract.) Psychological Bulletin, Lancaster, Pa., and 
 Princeton, N. J., 1915, XII, 73. 
 
 Remarks. 
 Mania, as conceived by modern workers, tends always to entail 
 what Wernicke has called hyperkinesis. It might be natural to 
 seek for the sources of hyperkinesis in the kinetic brain mecha- 
 nisms. In point of fact, however, various better-known condi- 
 tions of hyperkinesis, such as epilepsy and chorea, are often found 
 related with lesions in various parts of the sensorium, and may 
 even require a certain integrity of the kinetic apparatus. A brief 
 review is given of the writer's work, showing the relations of 
 hyperkinetic symptoms to certain lesions of the optic thalamus. 
 New work is adduced concerning the association of mania with 
 irritative lesions of the hinder part of the cerebral cortex (senso- 
 rium). Some other arguments are presented for the sensorial 
 origin of hyperkinetic symptoms, and for the peculiar value of 
 the intaking nervous mechanisms for the so-called behavior- 
 psychology. 
 
147 
 
 Southard, E. E., and Canavan, Myrtelle M. Notes on the 
 Relations of Somatic (Non-Neural) Neoplasms to Mental 
 Disease. (From the Psychopathic Hospital Laboratory of 
 the State Board of Insanity (1915.11.)) Interstate Medical 
 Journal, St. Louis, 1915, XXII, 738-751. 
 
 Summary and Conclusions. * 
 
 The writers present a sketchy review of the present relations of 
 tumor research to psychiatry, pointing out the special value of 
 teratological conclusions and brain tumor work to psychiatry. 
 The writers wish all brain tumor cases carefully examined by 
 psychiatrists to be published for the purpose of corroborating or 
 modifying the conclusions of Schuster as to correlations between 
 tumors in various brain parts and mental symptoms. Reference 
 is made to recent work on symptomatic psychoses and to various 
 other pieces of work showing the close relation of oncology to psy- 
 chiatry as found in the volumes of Zeitschrift fur Krebsforschung. 
 
 The writers believe that less than 3 per cent of routine autopsy 
 material of State hospitals for the insane will show tumors of 
 the brain. The figures for non-neural tumors stand at 3.9 per 
 cent; allowing for errors and omissions of diagnosis, 4 per cent 
 may be given as a roughly approximate index of the number of 
 non-neural tumors in insane hospital autopsies. It is clear, ac- 
 cordingly, that brain tumors are of some importance in the causa- 
 tion or liberation of mental symptoms. Special lists are made of 
 20 gastric carcinomata, 6 intestinal, 10 uterine and 6 mammary 
 occurring in the Boston and Danvers series. A study of mental 
 symptoms displayed by cases possessing or developing non-neural 
 neoplasms has been made, from which it is clear that certain 
 symptoms stand higher and lower than they do in mental dis- 
 eases at large. For example, incoherence stands high in these 
 cases, emphasizing the frequency of delirium in the group. De- 
 pression, on the other hand, which has frequently been stated to 
 be a major symptom in cases of intestinal disease, stands low in 
 the cancer list, although it stands exceedingly high in a list of 
 symptoms derived from 17,000 living and dead cases (Danvers 
 State Hospital). The symptom sicchasia (refusal of food), com- 
 paratively low in the 17,000 miscellaneous cases, stands out 
 prominently in carcinoma cases. Insomnia is surprisingly low in 
 the psychopathic cancer group. Pain is not at all frequent in 
 these cases. Cancer cases seem to have shown a marked exhi- 
 bition of delusions with respect to food and with respect to mem- 
 
148 
 
 bers of the family. The ideational reactions to the world of these 
 cancer cases are, on the whole, of an unpleasant nature, despite 
 the comparative infrequency of depression. 
 
 The writers present 7 cases in which it might be thought that 
 the cancers had close relation to the development of mental 
 symptoms. Two of these are from the Psychopathic Hospital, 
 Boston, one of which (Case VI) is most suggestive; but even 
 in Case VI there were brain lesions of an acute nature, which 
 may have complicated the picture. The second Psychopathic 
 Hospital case (Case VII) was one in which the pancreatic 
 carcinoma with its metastases may perhaps decidedly have 
 influenced the symptoms in the fatal attack, but the casa can 
 be demonstrated to have been decidedly psychotic at the 
 outset. 
 
 The remaining 5 cases (Cases I to V) are from the Danvers and 
 Boston series. The correlations in Case I are fairly close in point 
 of time and in simultaneous occurrence of physical signs of gastric 
 cancer. The correlations in Case II are somewhat suggestive, 
 and the hypochondriacal delusions ("stomach full") are striking. 
 Two cases of esophageal carcinoma appear to illustrate the 
 general tendency of carcinoma, or infection derived therefrom, 
 to produce delirium or phenomena of the "exhaustion" group 
 of the psj^chiatrists. Case V was a case of toxic delirium, ap- 
 parently somewhat closely related to developments in a sarcoma 
 of the jaw. The correlation is very possibly between infection 
 from ulcer and mental symptoms. 
 
 Out of 68 cases of non-neural tumor found in the Boston and 
 Danvers series, some 16 might be thought to show possible 
 oncogenesis of the mental symptoms. A study of these 16 cases 
 quickly shows that the 5 enumerated above were the only ones 
 in which the correlation was at all convincing. The cases in 
 question show phenomena possibly related to infection of ulcera- 
 tive cancer surfaces, with some instances of a delusional coloring 
 related to the tumors. 
 
 On the whole, accordingly, there cannot at present be erected a 
 very persuasive argument for the oncogenesis of mental disease, 
 but certain mental symptoms may possibly be altered by car- 
 cinoma. In one instance (Case VI), a Psychopathic Hospital 
 case, the predominance of neurological symptoms in the vagus 
 region of supply directed attention to the probability of the 
 gastric carcinoma found at autopsy. 
 
149 
 
 Southard, E. E. General Psychopathology. Psychological 
 Bulletin, Princeton, N. J., and Lancaster, Pa., 1915, XII, 
 245-273. 
 
 Southard, E. E. Data concerning Delusions of Personality, 
 with Note on the Association of Bright's Disease and Un- 
 pleasant Delusions. Presented in abstract at the sixth 
 annual meeting of the American Psychopathological Asso- 
 ciation, held in New York City, May 5, 1915. Being Con- 
 tribution of the State Board of Insanity No. 47 (1915.13). 
 The material was derived from the pathological laboratory 
 of the Danvers State Hospital, Hathorne, Mass., and the 
 clinical notes were collected by Dr. A. Warren Stearns, 
 to whom I wish to express my indebtedness, but to whom 
 no one should ascribe the somewhat speculative character of 
 the present conclusions. Journal of Abnormal Psychology, 
 Boston, 1915, X, 241-262. 
 
 Summary and Conclusions. 
 
 The paper deals with delusions of a personal (autopsychic) 
 nature, and is one of a series based upon certain statistics of Dan- 
 vers State Hospital cases (previous work published on somatic, 
 environmental (allopsychic) delusions and those characteristic of 
 general paresis). The previous work had suggested that somatic 
 delusions are perhaps more of the nature of illusions in the sense 
 that somatic bases for somatic false beliefs are as a rule found. 
 On the other hand, delusions respecting the environment (allo- 
 psychic delusions) had appeared to be more related to essential 
 disorder of personality than to actual environmental factors. 
 
 The fact that cases of paresis with delusions were found to 
 have their lesions in the frontal lobe, whereas non-delusional 
 cases showed no such marked lesions, is of interest in the light of 
 the present paper, because three cases of senile psychosis were 
 found to have delusions of grandeur and, although they are 
 demonstrably not paretic, they also show mild frontal lobe 
 changes supported by microscopic study. 
 
 The Danvers autopsied series, containing 1,000 unselected 
 cases, was found to show 306 instances with little or no gross 
 brain disease. Of these, 106 had autopsychic delusions, and of 
 these 106, 50 cases had delusions of no other sort; 15 of these 
 50 cases appeared to have been cases of general paresis in which 
 gross brain lesions were not observed at autopsy, and upon 
 
150 
 
 investigation 13 other cases were found to be, for various reasons, 
 improperly classified. The residue of 22 cases was subject to 
 analysis, and readily divides itself into two groups of 11 cases 
 each, or two groups of normal-looking brain cases having auto- 
 psychic delusions; and these only are cases which may be 
 termed the "pleasant" and "unpleasant" groups, in the sense 
 that the delusions in the first group were either pleasant or not 
 unpleasant, whereas the delusions in the second group were of 
 clearly unpleasant character. 
 
 Three of the "pleasant" delusion group were the three cases 
 of grandeur and delusions in the senium above mentioned. Three 
 others were cases of "theomania" in the sense that their delu- 
 sions concerned messages from God. It is not clear that these 
 three religious cases should be regarded as belonging in the group 
 of "pleasant" delusions on account of the sense of constraint 
 felt by the patients. 
 
 The remainder of the "pleasant group," as the delusions were 
 originally defined, turned out for the most part to show either 
 doubtful delusions or delusions involving a sense of constraint 
 rather than of pleasure. 
 
 An endeavor was made to learn the relations of pulmonary 
 phthisis to the emotional tone of the delusions. The few avail- 
 able cases in this series seem consistent with the hypothesis of 
 phthisical euphoria (IV, "happiest woman in the world, hearing 
 God's voice," VII and possibly XI). 
 
 The problems of the "pleasant" delusion group, as superficially 
 defined, turned out to be (a) the problem of a group of senile 
 psychoses with grandiose delusions and frontal lobe atrophy; (6) 
 the problem of felt passivity under divine influence; (c) the prob- 
 lem of phthisical euphoria. 
 
 The group of "unpleasant" delusions in the normal-looking 
 brain group should be diminished by one on account of its positive 
 microscopy (encephalitis). One case (XIII) is a case of mixed 
 emotions of religious type, showing phthisis pulmonalis, together 
 with abdominal tuberculosis and nephritis. One case (XV) is 
 doubtful as to delusions; the remainder are subject to renal dis- 
 ease, as a rule associated with cardiac lesions. 
 
 Two cases which were transferred from the "pleasant" to the 
 "unpleasant" group on account of constraint feelings were also 
 renal cases, — VII and IX. The only exception to the universal- 
 ity of renal lesions in this group is the case in which religious 
 delusions were probably based upon hallucinations, for which hal- 
 
151 
 
 lucmations an isolated brain lesion was fourrd, very probably cor- 
 rectable with the hallucinosis. 
 
 Virtually all of the 11 cases determined to belong in the "un- 
 pleasant" group are cases with severe renal disease as studied at 
 autopsy. 
 
 Whether the unpleasant emotional tone in these cases of delu- 
 sion formation is in any sense nephrogenic, and whether particu- 
 lar types of renal disease have to do with the unpleasant emotion, 
 must remain doubtful. A still more doubtful claim may be made 
 concerning the relation of euphoria to phthisis. The renal corre- 
 lation is much more striking as well as statistically better based. 
 A further communication will attack the problem from the side 
 of the kidneys in a larger series of cases. 
 
 Southard, E. E. Dilatation of Cerebral Ventricles in Various 
 Functional Psychoses. (Abstract.) Journal of Nervous 
 and Mental Disease, New York, 1915, XLII, 741-743. 
 
 Remarks. 
 Case of dementia prrecox, manic-depressive insanity and in- 
 volutional-melancholia studied photographically. The dilatation 
 of the ventricles often more marked in posterior parts. Correla- 
 tion of dilatation with excitement. 
 
 Southard, E. E. The Feeble-minded as Subjects of Research 
 in Efficiency. 1 Proceedings, National Conference Charities 
 and Corrections, Chicago, 1915, XLII, 315-319. 
 
 Thom, D. A., and Southard, E. E. An Anatomical Search for 
 Idiopathic Epilepsy: Being a First Note on Idiopathic 
 Epilepsy at Monson State Hospital. Being Contribution 
 from the State Board of Insanity No. 46 (1915.12). Review 
 of Neurology and Psychiatry, Edinburgh, 1915, XIII, 
 471-486. Also (Abstract) in Journal of Nervous and. 
 Mental Disease, 1918, XLVII, 57, 58. 
 
 Summary and Conclusions. 
 1. Seventy-six of 205 brains of institutional, but otherwise 
 unselected, epileptic subjects, i.e., 37 per cent, yielded brains 
 without substantial lesions visible to the naked eye upon super- 
 ficial examination or dissection. 
 
 Not published in State Board of Insanity Contribution (1915.23). 
 
152 
 
 2. This percentage of "normal-looking" brains is rather higher 
 than has hitherto been found in institutional, psychopathic, now- 
 epileptic subjects, although the dissections in the epileptic group 
 have probably not been so extensive as in the psychopathic group. 
 
 3. A study has been made of 76 epileptics with normal-looking 
 brains, with the hope of securing a number of "idiopathic" cases 
 for special examination. 
 
 4. In order to secure a group of pure epilepsy, 68 cases had 
 to be excluded as being complicated with feeble-mindedness, 
 acquired dementia, or other psychotic symptoms, leaving 8 ap- 
 parently non-psychotic epileptics for study. Of these 8, 1 had 
 facial palsy, 1 had organic-looking symptoms, and 2 had chronic 
 leptomeningitis. Dismissing the 2 cases of chronic leptomenin- 
 gitis we have 6 cases from which a truly idiopathic brain, from a 
 histological point of view, may be isolated, and it is upon these 
 6 brains that further study must be made. 
 
 5. The whole series affords an opportunity for general conclu- 
 sions on certain classical questions of epileptology, for example: — 
 
 Age at Onset {Table II). — (a) Seventy-two cases out of a total 
 of 76 with normal-looking brains where the age at time of first 
 convulsions was known. Eighteen {25 per cent) began between 
 eleven and fifteen years, a period quite significant for the disturb- 
 ance of the nervous system, already predisposed to psychochem- 
 ical changes. Of the 118 cases with abnormal brains (with history 
 of onset established), only 9.3 per cent had their onset during this 
 same period, {b) The abnormal series show that the percentage 
 of cases (11 per cent) where the age at onset was under one year 
 was twice as high (5.5 per cent) as the normal series (suggesting 
 birth injuries and congenital defects). All those cases where 
 the epilepsy began after the fortieth year were about equally 
 divided between the normal and abnormal group. 
 
 Duration of Epilepsy {Table III). — The cases where the dura- 
 tion was of thirty-five years or more were divided as follows: 
 18.4 per cent abnormal group; 5.3 per cent normal group. 
 Those with shorter durations were about equally divided between 
 the two groups. 
 
 Age at Death {Table IV). — Average age of patient at time of 
 death, in normal group, 38.9 years; abnormal group, 41.44 years. 
 
 Heredity {Table V). — Heredity present in 24 per cent normal 
 cases, 20 per cent abnormal cases, being about equally divided 
 in either group into the same and allied types of heredity. 
 
 Mental Status {Table VI). — Only 10 per cent of the cases in 
 
153 
 
 either group that did not present mental symptoms, dementia 
 being more frequent in the normal group (46 per cent), while 
 feeble-mindedness predominated in the abnormal group (53 per 
 cent). 
 
 Number of Convulsions {Table VII). — Cases with minimum 
 number of convulsions, one or less a month belonged largely to 
 abnormal series, while the cases where the convulsions occurred once 
 a day or more frequently were usually found in the normal series. 
 
 Assigned Causes of Epilepsy (Table VIII). — The assigned 
 causes varied so widely, and in so many instances were unknown, 
 that the data were of little significance, excepting that head in- 
 juries were given as the cause in 9.1 per cent in the normal series 
 and in 10 per cent in the abnormal series. Alcohol, normal 
 series, 5.2 per cent; abnormal series, 1 per cent. The causes of 
 death were also so numerous that the data are of little impor- 
 tance, excepting that tuberculosis was the cause of death in about 
 10 per cent of all cases in either group. 
 
 Alcohol and Syphilis in Patients (Table IX). — Alcohol, 12.5 
 per cent normal group; 10 per cent abnormal group. Syphilis, 
 1.5 per cent normal group; 2.3 per cent abnormal group. 
 
 We feel that, contrary to the expression of the numerous 
 authors already quoted, there still remains some doubt that all 
 epilepsies are organic in nature, and it has been the purpose of 
 this note to introduce a more logical method of anatomical 
 search for idiopathic epilepsy than has hitherto been applied to 
 the problem. 
 
 Southard, E. E. Advantages of a Pathological Classification 
 of Nerve Cells, with Remarks on Tissue Decomplicati on as 
 shown in the Cerebral and Cerebellar Cortex. 1 Being con- 
 tribution of the Massachusetts State Board of Insanity 
 No. 121 (1915.24). Transactions, Association of American 
 Physicians, Philadelphia, 1915, XXX, 531-546. Also in 
 Bulletin, Massachusetts Commission on Mental Diseases, 
 Boston, 1918, II, 75-89. 
 
 Remarks. 
 
 Enough has been said to show that neuropathological 
 research: — 
 
 1. Might do well to engage on a program of studying by 
 available methods the differential viabilities of the various nerve- 
 
 1 Xot published in State Board of Insanity Contributions (1915.24). 
 
154 
 
 cell types, thereby erecting an essentially "pathological" classi- 
 fication of nerve cells on the basis of their powers of resistance 
 or survival values. 
 
 2. Might endeavor to collect data as to the differential effects 
 of simplification or " decomplication " of nerve tissues, having in 
 mind the evolutionary or survival values of the functions which 
 different forms of decomplication would destroy or leave intact. 
 
 1915-16. 
 
 Sotjthakd, E. E., and Canavan, M. M. Focal Lesions of the 
 Cortex of the Left Angular Gyrus in Two Cases of Late 
 Catatonia. Being Scientific Contribution of the State 
 Board of Insanity No. 119 (1915.22). Read at the seventy- 
 first annual meeting of the American Medico-Psychological 
 Association, Old Point Comfort, Va., May 11-14, 1915. 
 American Journal of Insanity, Baltimore, 1915-16, LXXII, 
 553-580. Also in Proceedings, American Medico-Psycho- 
 logical Association, Baltimore, 1915, XXII, 227-254. 
 
 Conclusions. 
 
 The writers present two cases of chronic lesion of the left 
 angular gyrus which received the clinical diagnosis of dementia 
 prsecox. One case showed a cyst of softening and the other a 
 solitary tubercle. It appears that both lesions may well be of 
 suitable age to correspond with the date of onset of the symp- 
 toms. Although not in all respects typical, the diagnosis of 
 dementia prrecox seems to have been accepted by the Boston 
 State Hospital officers in charge of the cases. Decidedly atypical 
 is the age of onset of the first case, at forty-one; the second case 
 had its onset at thirty-six. 
 
 The writers are especially interested in the fact that the 
 isolated lesions in these cases are in the parietal region, a region 
 which has been stated in previous work from this laboratory 
 to be correlated with catatonic symptoms. Plates are presented 
 showing the site of the lesions. 
 
155 
 
 1916. 
 
 Southard, E. E. The causes of feeble-mindedness. Read 
 before the American Association of Clinical Criminology, at 
 Buffalo, October, 1916. Proceedings, Annual Congress, 
 American Prison Association, 1916, 186-197. 
 
 Southard, E. E. A Frequency List of Mental Symptoms found 
 in 17,000 Institutional Psychopathic Subjects (Dan vers State 
 Hospital, Massachusetts). (Abstract.) Journal of Nervous 
 and Mental Disease, New York, 1916, XLIII, 56, 57. 
 
 Southard, E. E. General Psychopathology. Psychological 
 Bulletin, Princeton, N. J., and Lancaster, Pa., 1916, XIII, 
 229-257. 
 
 Southard, E. E. Syphilis and the Psychopathic Hospital: 
 Notes on Medical and Social Progress, especially in Neuro- 
 syphilis, Boston, Mass., 1915. Being State Board of In- 
 sanity Contribution No. 131 (1915.34). Boston Medical 
 and Surgical Journal, 1916, CLXXIV, 50-53 and 81-85. 
 
 Summary. 
 The writer has endeavored in these notes to present the neuro- 
 syphilis situation as it faces us locally, and has not endeavored to 
 sum up the neurosyphilis situation in general. Still it is clear that 
 among the ten papers of the present series will be found briefly 
 mentioned most of the aspects of the neurosyphilis problem which 
 are appealing to the world at the present time. The humanity of 
 Dr. Post's remarks in Article I needs no comment. Especially 
 wise is his note that "when a social worker comes into the family of 
 the syphilitic, she must dismiss from her mind any presupposed 
 guilt." It is also important to take seriously Dr. Post's point 
 that when all the laboratory signs of syphilis of the nervous 
 system are present, and no clinical features of neurosyphilis are 
 outstanding, there must be a serious question whether the clinical 
 work is being done effectively. We need very intensive clinical 
 work in the field of neurosyphilis at the present time. We cannot 
 get on with the kind of loose work which prevails, it is to be 
 feared, in certain fields of private practice and in certain institu- 
 tions. 
 
156 
 
 The eagerness with which social workers are beginning to take 
 up the problem of the examination and prophylaxis for syphilitic 
 patients and their families, and the entirely scientific manner of 
 the approach of these social workers to their problem, are to be 
 seen clearly in the communication of Miss Wright (Article II) 
 and of Miss Jarrett (Article III), as well as in the spirit of Dr. 
 Gregg's article (IV) on "Some Economic Facts of the Problem." 
 How concrete the social worker's confrontation of the problem is 
 can be seen from the appendices to Miss Wright's article (Article 
 II), embodying the blank forms which are used in the syphilis 
 family investigation. The syphilis of railroad men and even of 
 a lighthouse man, of caterers, cooks and nursemaids, mentioned 
 by Dr. Gregg, is a mention of nothing new to the community; 
 yet we cannot be too insistent upon the familiarity of such in- 
 formation. These facts should stand out prominently in our 
 propaganda. 
 
 Article V, by Beasley and H. M. Anderson, upon the mental 
 features of the congenital cases, is a mere beginning of work in 
 this direction. How much of our truancy and juvenile court 
 problem is due to congenital syphilis cannot yet be safely esti- 
 mated, but whatever the true percentage of the luetic fraction 
 among these antisocial cases, the absolute numbers are sizable 
 enough to warrant attention. The impairment of the sense 
 organs and the elementary psychic apparatus, brought out in this 
 article as characteristic of congenital syphilitics, is of some gen- 
 eral importance. 
 
 There follow articles (VI, VII, VIII and IX) upon the diag- 
 nostic situation in neurosyphilis. Article VI, by Solomon and his 
 associates, is a continuation of his previous work, and not only 
 emphasizes the fact that the gold sol examination is essential in 
 cerebrospinal fluid examinations, but also that it is at present 
 impossible to tell the paretic from the non-paretic form of neuro- 
 syphilis. Upon this fact is based the important conclusion above 
 mentioned in the ninth section of these notes. 
 
 Article VII shows that the cell count in the cerebrospinal fluid 
 is not an index to the quality or degree of irritative and paralytic 
 changes shown in the symptoms of cases of neurosyphilis. 
 
 Article VIII brings up a rather large question, — whether the 
 laboratory signs of neurosyphilis, and, in particular, signs of ex- 
 tensive chronic inflammation of the nerve system, appear before 
 the occurrence of any characteristic mental symptoms. We have 
 been fortunate to discover a certain number of these cases which, 
 
157 
 
 of course, will often elude observation because, having no mental 
 symptoms or other symptoms of importance, such cases would 
 not naturally be subject to intensive examination. An extension 
 of family work in syphilis, and especially neurosyphilis, may un- 
 cover a great many more of these cases that we have termed 
 "latent" neurosyphilis, or somewhat fantastically, general paresis 
 sine paresi. Do these findings indicate certain unsuspected con- 
 ditions in the genesis of neurosyphilis? It is too early to make 
 such a claim. It is certain that, after all, such cases deserve 
 immediate and intensive treatment. 
 
 Article IX makes a special point concerning the gold sol 
 reaction, namely, the point that the cerebrospinal syphilitic gold 
 sol reaction is in some sense a forme fruste of the characteristic 
 paretic reaction. Should this point be maintained, the essential 
 unity of the two conditions would be still further established. 
 The true explanation of the forme fruste here described must 
 probably await developments in colloidal chemistry. 
 
 Article X, of which the present paragraph forms a part, en- 
 deavors to give a brief account of the special aspects of the 
 neurosyphilis situation which have attracted attention at the 
 Psychopathic Hospital. 
 
 Southard, E. E., and Solomon, H. C. Latent Neurosyphilis 
 and the Question of General Paresis, Sine Paresi. Being 
 State Board of Insanity Contribution No. 129 (1915.32). 
 The general conclusions of this paper were read by Dr. 
 Solomon at the April meeting of the Boston Society of 
 Psychiatry and Neurology. Boston Medical and Surgical 
 Journal, 1916, CLXXIV, 8-15. 
 
 Summary. 
 
 1. There is a group of cases showing the laboratory signs 
 characteristic of central nervous system syphilis: (a) positive 
 Wassermann reaction in the serum, (6) positive Wassermann 
 reaction in the spinal fluid, (c) pleocytosis, (d) excess of globulin 
 and (e) of albumin in the spinal fluid, (/) gold sol reaction of 
 central nervous system syphilis, and which show no sign or symp- 
 tom of neural syphilis. 
 
 2. We believe these cases represent a form of chronic cerebro- 
 spinal syphilis, probably paretic in type. 
 
 3. They have the greatest theoretical and practical significance 
 in the consideration of the life history of neural syphilis, in the 
 
158 
 
 concept of allergie, in regard to results of treatment, and finally 
 as to the evaluation of the laboratory tests. 
 
 4. Here is perhaps offered the last link to form a complete 
 chain between the symptoms of the primary stage of syphilis and 
 its final termination of life as the result of the diseases cerebro- 
 spinal syphilis or general paresis. 
 
 Southard, E. E. The Major Divisions of Mental Hygiene — 
 Public, Social, Individual. Massachusetts Society for 
 Mental Hygiene Publication No. 18, from the Boston 
 Medical and Surgical Journal, 1916, CLXXV, 404-406. 
 
 Southard, E. E. Social Research in Public Institutions. 1 
 Proceedings, National Conference, Charities and Correc- 
 tions, Chicago, 1916, 376-386. 
 
 Southard, E. E. Psychopathic Delinquents. 2 Proceedings, 
 National Conference, Charities and Corrections, Chicago, 
 1916, 529-538. 
 
 Southard, E. E. The Psychopathic Hospital's Function of 
 Early Intensive Service for Persons not Legally Insane. 3 
 Being Contribution No. 154 (1916.12) "The Psychopathic 
 Hospital's Function of Early Intensive Service for Persons 
 not Legally Insane," in Proceedings of the National Con- 
 ference of Charities and Corrections, 1916. Published in 
 the Journal of Educational Psychology, December, 1916, 
 Vol. VII. (Abstract.) Proceedings, National Conference, 
 Charities and Corrections, Chicago, 1916, 277-279. 
 
 Southard, E. E. Dissociation of Parenchymatous (Neuronic) 
 and Interstitial (Neuroglia) Changes in the Brains of Certain 
 Psychopathic Subjects, especially in Dementia Prsecox. 
 Being M. C. M. D. Contribution No. 164 (1916.22). 
 Transactions, Association of American Physicians, Phila- 
 delphia, 1916, XXXI, 293-310. Also in Bulletin of Massa- 
 chusetts Commission on Mental Diseases, Boston, 1917, I, 
 236-253. 
 
 1 Not published in Bulletin of Massachusetts Commission on Mental Diseases. (1916.10). 
 
 2 Not published in Bulletin of Massachusetts Commission on Mental Diseases. (1916.11). 
 
 3 Not published in Bulletin of Massachusetts Commission on Mental Diseases. (1916.12). 
 
159 
 
 Summary. 
 To sum up: — 
 
 1. Parenchymatous (neuronic) lesions and interstitial (neurog- 
 lia) lesions may be dissociated and combined, much as similar 
 lesions in the kidney. 
 
 2. A case of manic-depressive psychosis failed to show con- 
 vincing degrees of parenchymatous lesions. 
 
 3. Dementia preecox cases had marked parenchymatous dis- 
 order, to which gliosis was not at all proportionate. 
 
 4. It is necessary to find and study by like methods a good 
 group of non-tuberculous cases of dementia prsecox, so as to 
 exclude tuberculosis from having a share in the production of 
 these lesions. 
 
 Southard, E. E. The Comparative Convolutional Complexity 
 of Male and Female Brains. (Abstract.) Science, Lan- 
 caster, Pa., 1916. (New series, Vol. XLIII, 900.) 
 
 Remarks. 
 The material for the study consists of brain photographs (six 
 views of each brain) in the collection of the Massachusetts State 
 Board of Insanity, derived from over 500 brains in the possession 
 of various State and private institutions of Massachusetts, in- 
 cluding so-called "normal" brains and brains from a variety of 
 psychopathic subjects. The method of the study is numerical, 
 based upon counts of fissures and fissurets. The results, so far 
 as interpretable, show no great sex difference in degree of 
 fissuration. 
 
 Southard, E. E. On the Application of Grammatical Categories 
 to the Analysis of Delusions. The Philosophical Review, 
 1916, XXV, 424-455. Also in Bulletin of Massachusetts 
 Commission on Mental Diseases, Boston, 1917, I, 22-50. 
 
 Remarks. 
 The object of this paper has been to illustrate the method of 
 Royce's logical seminary at Harvard. No attempt has been 
 made to describe the method, which is comparative rather than 
 observational or statistical. When the logician superposes the 
 categories of Science A upon the material of Science B, or com- 
 pares the categories of both, he is not at all sure of important 
 
160 
 
 results. If he obtains too extensive or too numerous identities 
 by means of his comparisons, he may be compelled to decide that 
 identity of categories means actual unity of materials. Thus, in 
 the present instance, the reader may be the more ready to 
 swallow the identity of certain categories in grammar and psycho- 
 pathology, simply because he fundamentally believes in a larger 
 degree of identity of speech and thought. In the event of such 
 a nominalistic view as that, the only merit of the present essay 
 would consist in spreading a sound method over new materials 
 of the same sort; the method would not then be comparative in a 
 very rich sense of the term. But, even if speech and thought 
 are as closely allied as, e.g., Max Miiller thought them to be, 
 the fact still remains that the categories of linguistics and of 
 psychology have not been wrought into their present form by the 
 same group of men or under the same group of interests. If there 
 is a partial identity of scientific materials, there is no evidence of 
 identity of categories. The comparative method will then obtain a 
 certain scope, even if that scope is limited to trying-out of special 
 methods devised by linguists inexpert in technical psychology. 
 
 I hesitate to set forth the point; but I am left with a queer 
 impression that linguistics falls short of representing logic in 
 somewhat the same way that psychopathology falls short of repre- 
 senting psychology. I do not so much refer to the prevalence 
 of concepts like "phonetic decay," "empty words," "anomalism," 
 etc., in linguistics, although these concepts certainly suggest 
 human frailty quite outside the frame of classical logic. I do not 
 wish to construct a false epigram to the effect that linguistics is a 
 kind of pathology of logic, attractive as this epigram might be. 
 My point is that human facts are got at more readily in linguis- 
 tics and in psychopathology than in logic and in so-called normal 
 psychology. 
 
 For example, if I try to determine the logical modality of 
 something and to affix the proper epithet (necessary, impossible, 
 contingent, possible), I sink into a morass of factual doubts. 
 But, equipped with the fundamental grammatical moods (im- 
 perative, indicative, subjunctive, optative), I can dismiss my 
 doubts by describing them under one of these mood aspects, 
 regardless of objective reality, truth to me, truth to Mrs. Grundy, 
 or any situation except that depicted by the statement in ques- 
 tion. The grammatical moods deal with evidence unweighed; 
 the logical modalities require more weighing of evidence than is 
 as a rule humanly possible. Psychopathology also deals with 
 
161 
 
 evidence unweighed. Particularly is this true of that portion 
 of psychopathology which deals with false beliefs. Granted 
 that some beliefs are prima facie fantastic and to us incredible. 
 By the patient these fantastic and incredible beliefs are believed, 
 but the nature and history of these fantastic beliefs may well be 
 investigated to learn whether we are not dealing with a so-called 
 wish-fulfilment (a Freudian technical term) or with a kind of 
 degradation of what the linguist might term an optative attitude. 
 But the majority of false beliefs are not prima facie fantastic and 
 incredible. They, on the contrary, require the test of experience. 
 They represent pragmatic situations. Granting the truth of 
 certain hypotheses, we say, these beliefs might be accepted also 
 as truth. Our thesis is that these pragmatic delusions do not 
 represent a conceived wish-fulfilment, if by wish is meant a 
 fancied situation. On the other hand, these pragmatic delusions 
 appear to hang rather upon the degradation of a subjunctive 
 attitude, that is, upon taking as true a certain hypothesis. But 
 neither fantastic nor pragmatic delusions can readily be classed 
 under the logical modalities, e.g., as possible or contingent, 
 however possible and contingent they actually seem to the 
 patient. In any event, they are or will shortly turn out to be 
 impossible, logically speaking, and if the patient were to ascribe 
 * any logical modality thereto he would be likely to deal in neces- 
 sities on the one hand and impossibilities on the other. Gram- 
 matically speaking, the degraded optative belief may even set 
 into an imperative, and beliefs degraded from both the optative 
 and the subjunctive appeal to the patient as indicative, if not 
 yet imperative. 
 
 From our superficial study of the categories of grammar as 
 they revolve about the verbs, we have come upon two consider- 
 ations of value that are not entirely obvious, the psychopathic 
 analogue of the grammatical "voice," and the question of two 
 main types of delusion degraded, respectively, from "subjunc- 
 tive" and "optative" attitudes. 
 
 I believe that the "voice" distinction will forthwith appeal to 
 all psychiatrists as valid within its range. The distinction seeks 
 to express the relation between the world and the individual from 
 the individual's point of view under two forms, (a) that in which 
 the self is active, and (6) that in which the self is passive in rela- 
 tion to the environment; but in the third place (c) the relation of 
 the individual to himself is suggested, viz., under the "middle" 
 or reflexive relation. Whether the reflexive relations of the self 
 
162 
 
 break up further into a group where the "I" dominates the 
 "me" and another where the "me" overpowers the "I" (that 
 is, whether the ego is sometimes active in respect to itself and 
 sometimes passive), is a question partly of fact, but more of the 
 nature of the self and of the whole difficult topic of self-activity. 
 
 Whether the distinction between pragmatic delusions (as 
 it were, precipitated subjunctives) and fantastic delusions (as 
 it were, precipitated optatives) is valid must remain undeter- 
 mined. The distinction has at least the value of suggesting a 
 similar distinction in human character in general; both distinc- 
 tions may be derived from identical psychological facts. 
 
 If in the practical handling of a patient, or indeed of any one 
 else in a situation hard to interpret, the observer can make out 
 the "voice" of the subject's situation from the subject's point of 
 view, and can secondly determine whether the difficulty rests 
 upon trouble with hypotheses or trouble with wishes, much is 
 gained surely. 
 
 We saw also from our incidental study of person, number, and 
 gender how important might become the question of monadic, 
 diadic, triadic, or polyadic situations involving false beliefs. 
 The collection of groups of such situations for analysis is certainly 
 indicated, naturally with invariable reference to the "voice," 
 active or passive, of the patient or central figure. Fiction and 
 drama could throw some light on these matters. 
 
 In the gathering of data for analysis, it is clear also that the 
 time-relations must also be studied from the patient's point of 
 view, to the end of determining whether the particular subjunc- 
 tive precipitate has relation to some central point in the past, 
 whether the particular optative precipitate has relation to a 
 present or present perfect situation, or whether other "tenses" 
 come in question. 
 
 Southard, E. E. The Comparison of the Mental Symptoms 
 found in Cases of General Paresis with and without Coarse 
 Brain Atrophy. Being Contribution of the State Board of 
 Insanity No. 38 (1915.4). Journal of Nervous and Mental 
 Disease, 1916, XLIII, 204-216. 
 
 Summary and Conclusions. 
 The possession of a suitable statistical background (the Dan- 
 vers Case Symptom Index) has rendered worth while an orient- 
 ing study in the mental symptomatology of general paresis. A 
 
163 
 
 group of 38 general paretics whose brains were specially exam- 
 ined and described by the writer has been divided into two 
 groups according to whether there was or was not coarse evi- 
 dence of brain atrophy. The cases without brain atrophy were 
 termed "mild" and those with brain atrophy were termed 
 "severe," although these designations are only approximations 
 to accuracy; the groups are, however, in no sense "early" and 
 "prolonged." 
 
 Symptomatically the two groups show several surprising con- 
 cordances and a number of instructive divergencies. Thus am- 
 nesia, motor restlessness, disorientation, dementia and depression 
 lead both series and in that order (except that allopsychic delu- 
 sions stand fourth in the "mild" series and are far less common 
 in the "severe"). Are amnesia and dementia, therefore, in no 
 sense proportional to brain tissue loss f 
 
 Nineteen symptoms occurred in 20 per cent or over of the 
 paretic series, viz., the five just mentioned, and nine others (irri- 
 tability, defective judgment, psychomotor excitement, autopsychic 
 delusions, insomnia, aphasia, hallucinations of doubtful or un- 
 specified nature, convulsions, visual hallucinations) not always 
 in like proportion in the two series. Five other symptoms oc- 
 curred in each series, but symptoms quite sundered from one 
 another in general significance. 
 
 The "mild" cases showed a group of symptoms which might 
 be termed contra-environmental, viz., allopsychic delusions, sic- 
 chasia (refusal of food), resistiveness, violence, destructiveness. 
 
 The "severe" cases showed a group of symptoms of a quite 
 different order, affecting personality, either to a ruin of its mech- 
 anisms in confusion and incoherence, or to the mental quietus 
 involved in euphoria, exaltation or expansiveness. 
 
 Some speculations are offered in the text as to the perversion 
 of inhibition or inco-ordination of inhibition which the largely ir- 
 ritative lesions of the "mild" cases are presumably effecting in 
 the perhaps more seriously affected frontal areas. When these 
 are still more gravely affected, as to the point of atrophy, then 
 the intrapsychic disorder might well become more manifest, e.g., 
 in the distinctive symptoms of the "severe" group just men- 
 tioned. 
 
 In a series of 17,000 clinical cases (of all sorts of mental disease, 
 alive and dead, recovered and impaired) symptomatologically 
 analyzed, there were but ten symptoms occurring in 20 per cent 
 or over; these were, in order, psychomotor excitement, allopsychic 
 
164 
 
 delusions, dementia, auditory hallucinations, motor restlessness, 
 depression, autopsychic delusions, insomnia, incoherence, amnesia. 
 Each of these is represented high in general paresis (i.e., in 20 
 per cent or over), except that auditory hallucinations are in- 
 frequent in both "mild" and "severe" cases, and allopsychic 
 delusions are infrequent in "severe" cases. There may be topo- 
 graphical reasons for the paucity of auditory hallucinations in 
 general paresis. The method of production of allopsychic delu- 
 sions in general paresis should be studied, since there can be no 
 such alliance of allopsychic delusions and auditory hallucinations 
 therein as is perhaps the rule in dementia praecox. 
 
 If we consider the next nine symptoms in order in 17,000 cases 
 of mental disease at large, viz., violence, visual hallucinations, 
 irritability, defective judgment, disorientation, destructiveness, con- 
 fusion, resistiveness and somatic delusions, we find only the last, 
 viz., somatic delusions, not represented in either group in fair 
 proportion, although (as above stated) confusion is poorly rep- 
 resented in the "mild" cases and violence, destructiveness and 
 resistiveness are poorly represented in the "severe" cases. 
 
 Aphasia, hallucinations of doubtful or unspecified nature and 
 convulsions appear to be frequent symptoms in general paresis 
 that do not figure at all so largely in mental disease as a whole. 
 Besides these, sicchasia of the "mild" group, and euphoria, exal- 
 tation and expansiveness of the "severe" group, appears to stand 
 out for general paresis against mental disease as a whole. 
 
 The most positive results of this orienting study appear to be 
 the unlikelihood of euphoria and allied symptoms in the "mild" 
 or non-atrophic cases, and the unlikelihood of certain symptoms, 
 here termed contra-environmental, in the "severe" or atrophic 
 cases. Perhaps these statistical facts may lay a foundation for 
 a study of the pathogenesis of these symptoms. Meantime the 
 pathogenesis of such symptoms as amnesia and dementia cannot 
 be said to be nearer a structural resolution, as these symptoms 
 appear to be approximately as common in the "mild" as in the 
 "severe" groups. 
 
165 
 
 1917. 
 
 Southard, E. E., and Canavan, M. M. Autopsy Material of 
 Poliomyelitis Epidemic of 1916. (Abstract.) Journal of 
 Nervous and Mental Disease, 1917, XL VI, 217, 218. 
 
 Southard, E. E. On Descriptive Analysis of Manifest De- 
 lusions from the Subject's Point of View. Being 
 M. C. M. D. Contribution No. 150 (1916.8). Journal of 
 Abnormal Psychology, Boston, 1916-17, XI, 189-202. Also 
 in Bulletin of Massachusetts Commission on Mental Dis- 
 eases, Boston, 1917, I, 80-91. 
 
 Summary. 
 The writer aims at a descriptive analysis of manifest delusions 
 and false beliefs taken subjectively, i.e., from the patient's point 
 of view. He regards this as an indispensable preliminary to ex- 
 planatory synthesis of psychopathic situations, even should it 
 turn out that aliquid latens is the nucleus of such situations. 
 Practically he proposes a minimum of terms which the tyro in 
 psychiatric examination must aim to get from a lucid patient 
 entertaining or alleged to entertain false beliefs. In addition to 
 (a) the person or persons involved, (6) the number of persons 
 involved, (c) the sex of these persons, (d) the time, past, present 
 or future, in which the noxious event or condition is believed to 
 occur, the writer deals also with (e) the "voice" in which the 
 patient takes himself to be. The patient from his own point of 
 view regards himself as at odds with the environment 
 
 (1) as it were actively 
 (PATIENT > ENVIRONMENT) 
 
 or (2) as it were passively 
 
 (PATIENT < ENVIRONMENT), or again as at odds with himself, 
 either 
 
 (3) with higher (spiritual) self dominant 
 (EGO>"ME") 
 
 or (4) with lower (material) self dominant 
 (EGO<"ME"). 
 
166 
 
 The writer deals also with (/) the distinction of "mood," find- 
 ing that patients above the "imperative" level entertain either 
 irrational delusions or fantastic ones. The writer speculates that 
 irrational (pragmatic) delusions represent hypotheses taken as 
 facts (i.e., "subjunctives" degenerating into "indicatives"), and 
 that fantastic (prima facie false) beliefs represent wishes taken 
 as facts (i.e., "optatives" degenerating into "indicatives"). 
 Possibly those who transcend the imperative and indicative levels 
 in normal development split into two classes of persons, those 
 with a leaning toward hypotheses (highest development, men of 
 science) and those with a leaning toward wishes (highest devel- 
 opment, artists). In the body of the paper some account is 
 given of the comparative method by which these items of psy- 
 chiatric analysis were obtained, a fuller account of which has 
 appeared in the "Philosophical Review" in a paper written in 
 honor of Prof. Josiah Royce. 
 
 Southard, E. E. General Psychopathology. Psychological 
 Bulletin, Princeton, N. J., and Lancaster, Pa., 1917, XIV, 
 193-215. 
 
 Southard, E. E. The Correlation of Brain Anatomy, Mental 
 Tests and School or Hospital Records in a Series of Feeble- 
 minded Subjects (Waverley Anatomical Research Series). 
 (Abstract.) Journal of Nervous and Mental Disease, 
 Lancaster, Pa., 1914, XLIII, 454-457. 
 
 Remarks. 
 Dr. Southard presented an account of the first instalment of 
 work on the brains of the feeble-minded done under the auspices 
 of the Waverley School for Feeble-minded. He called attention 
 to the extraordinarily small amount of work which has been done 
 upon the anatomy of brains of feeble-mindedness, speaking of 
 the work of Bourneville, Hammarberg and the early work of 
 Wilmarth in this country. He spoke of the present as an aus- 
 picious period for work in this field on account of the great 
 achievements in cortex topography of recent years. He described 
 the systematic photography of the brains from above, below, 
 from the two sides and from the two mesial aspects, and of the 
 further photography of frontal sections. Thereupon microscopic 
 work could be done with the full advantage of correlations with 
 
167 
 
 the gross appearances, such as anomalies, atrophies and other 
 focal lesions. 
 
 Another reason for working eagerly at this topic at this time 
 was the fact that mental tests are now available, so that we can 
 compare: (a) the psychometric level of the patient, (6) the 
 functional level of the patient as exhibited clinically and educa- 
 tionally, and (c) the level of brain development. 
 
 The speaker insisted upon the importance of studying effi- 
 ciency in the material of feeble-mindedness. He considered that 
 feeble-mindedness forms the best material now available for re- 
 search in efficiency, and called attention to the fact that all the 
 modern books upon efficiency had neglected the field. Just as 
 the Montessori method was a logical descendant of the work of 
 Seguin, so new ideas in the education of the normal derive from 
 the more modern work in the education of the feeble-minded. 
 
 If correlations between the psychometric and practical capacity 
 levels of the patients on the one hand, and the trained brains on 
 the other, can be made, then possibly something new concerning 
 the nature of work in this connection, and comparison between 
 appearances in the parietal lobes and those in the frontal lobes, 
 would obviously be of importance. 
 
 Southard, E. E., and Canavan, M. M. The Stratigraphical 
 Analysis of Finer Cortex Changes in Certain Normal- 
 looking Brains in Dementia Prsecox. Being M. C. M. D. 
 Contribution No. 166 (1916.24). Journal of Nervous and 
 Mental Disease, New York, 1917, XLV, 97-129. Also in 
 Bulletin of Massachusetts Commission on Mental Diseases, 
 Boston, 1917, I, 261-293. 
 
 Summary and Conclusions. 
 
 The writers present an analysis, chiefly stratigraphical, of 
 certain lesions, notably nerve cell loss and gliosis (including 
 satellitosis) in four cases of dementia prsecox. These cases were 
 cases which showed no gross aplasia, sclerosis or atrophy in the 
 gross and yet exhibited symptoms of two years' or greater dura- 
 tion, entitling them to be considered in the dementia prsecox 
 group. 
 
 In connection with this work, a review of Kraepelin's estimate 
 of structural work in dementia prsecox brains is offered, and the 
 
168 
 
 stratigraphical data are presented in relation to Kraepelin's views 
 as to the functions of suprastellate and infrastellate layers. 
 
 Absence of suprastellate lesions in a case of the paranoic or 
 paraphrenic group was noted, but there was no special evidence 
 of schizophrenia in this case as clinically viewed; the case did 
 show infrastellate lesions in areas contiguous with one another 
 in the two flanks of the brain. It might be possible to correlate 
 the late catatonia and late hallucinosis in the case with these 
 infrastellate lesions. Other cases possibly more typical of 
 dementia prsecox exhibited lesions both in the suprastellate and 
 infrastellate regions, sometimes numerous, sometimes isolated 
 and apparently capricious in distribution. No good example of 
 lesions chiefly limited to the suprastellate layers has been found. 
 
 Gliosis and satellitosis do not follow the nerve cell losses. The 
 same holds true of shrinkage changes and axonal reactions. Nor 
 is satellitosis closely associated either with shrinkage changes 
 (which are not numerous in this series) or with axonal reactions. 
 The dissociation of parenchymatous (neuronic) and interstitial 
 (neuroglia) changes reported in a previous communication is 
 further emphasized. 
 
 Southard, E. E. The Effects of High Explosives upon the 
 Central Nervous System: A Review of Mott's Lettsomian 
 Lectures, 1916, and G. Elliot Smith's "Shell Shock and its 
 Lessons." Mental Hygiene, Concord, N. H., 1917, I, 
 397-405. 
 
 Southard, E. E. Proposals for a Sequence of Disease Groups 
 to be successively considered in the Practical Diagnosis of 
 Mental Diseases. (Abstract.) Journal of Nervous and 
 Mental Disease, New York, 1917, XLVI, 277-279. 
 
 Remarks. 
 The proposals look to a practical rather than a theoretical 
 ordering of mental disease groups. The classification is "arti- 
 ficial" rather than "natural," as John Stuart Mill used those 
 terms. The familiar issues of etiology and entifiability are not 
 here raised. Instead, the jundamentum divisionis is the practical 
 ("artificial") one of separation along lines of available tests in 
 the interest of differentiated treatment or counsel; e.g., the 
 syphilitic group stands first, neither in virtue of frequency nor 
 of theoretical simplicity, but because of the complement-fixation 
 
169 
 
 test, and the therapeutic possibilities in the syphilitic group. 
 But the method is not necessarily one of successive elimination 
 of disease groups until the correct group is reached. In the 
 majority of cases the entire gamut of a dozen or more groups 
 must be applied. For a given case may be one, e.g., of a syphi- 
 litic, feeble-minded, epileptic, alcoholic, senile with coarse brain 
 disease. A provisional sequence is composed of the syphilitic, 
 feeble-minded, epileptic, alcoholic, encephalopathic, somatopathic, 
 senescent, schizophrenic, cyclothymic, psychoneurotic, psycho- 
 pathic, special, dubious and simulant groups, and the non- 
 psychotic. 
 
 Southard, E. E. On the Focality of Microscopic Brain Lesions 
 found in Dementia Prsecox. Being M. C. M. D. Con- 
 tribution No. 201 (1917.21). Archives of Neurologie and 
 Psychiatrie, 1919, I, 172-192. Also in Transactions, Asso- 
 ciation of American Physicians, Philadelphia, 1917, XXXII, 
 435-459, and Bulletin of Massachusetts Commission on 
 Mental Diseases, Boston, 1918-19, II, 45-67. 
 
 Summary. 
 
 Thanks to the work of Elliot Smith, Bolton, Campbell, Brod- 
 mann, Ramon y Cajal and others, the neuropathologist can now 
 afford to attempt finer functional histologic correlations in the 
 field of mental diseases, thus aiding in the problems of micro- 
 localization. The antilocalizing tendencies of the Wundtians 
 and the interest in merely logical categories taken by Freudians 
 should not interfere with progress in microlocalization. Dementia 
 prsecox, for example, can be called a matter of maladaptation 
 of the patient to his environment or of the patient to himself, 
 and also a disease characterized by cortical changes. 
 
 Previous work had shown anomalies in a high proportion of 
 dementia prsecox brains, and in a correspondingly low proportion 
 of the brains of manic-depressive subjects. These anomalies may 
 well be interpreted as weak places in these dementia prascox 
 brains, and the brains in fact are apt to show scleroses and 
 atrophic processes over and above the anomalies. But certain 
 perfectly normal-looking brains in dementia prsecox also show 
 the same microscopic changes in lesser degrees than are found 
 in the anomalous sclerotic and atrophic brains. The problem of 
 the present communication has been to work out the focality of 
 these microscopic lesions in a few normal-looking brains studied 
 
170 
 
 with unusual intensiveness. In the same series of brains, work 
 of previous seasons had shown a dissociation of parenchymatous 
 (neuronic) and interstitial (neuroglia) changes, indicating a tend- 
 ency on the part of cortex pathology to resemble the pathology 
 of the kidney. But the majority of brains show mixtures of the 
 parenchymatous (neuronic) and the interstitial (neuroglia) lesions. 
 Recent work in comparative anatomy indicates the rather funda- 
 mental importance of distinguishing the functions of the upper 
 cortical layers (what may be called the supracortex) from the 
 functions of the lower cortical layers (what may be called the 
 infracortex). The finer processes of mental dissociation (schizo- 
 phrenia) ought to be correlated with lesions of the supracortex, and 
 such lesions were found in cases with evidence of schizophrenia. 
 
 On the other hand, in a case of delusions characterized by no 
 splitting (schizophrenia) whatever, but rather by a process of 
 overelaborate synthesis, there was no evidence of supracortical 
 disorder, and, in fact, no proposal can be made for any histologic 
 correlate with this process of oversynthesis. 
 
 Other processes equally characteristic of dementia praecox, but 
 logically far simpler in their make-up, such as auditory hallu- 
 cinosis and muscular hypertension (catatonia), received sugges- 
 tive correlation with processes in the lower layers of the temporal 
 and parietal regions, respectively. 
 
 As far as the tissues of these four cases go, there is little or 
 nothing inconsistent in the findings with the hypothesis that 
 ordinary (non-phantastic) delusions are correlated with frontal 
 rather than with otherwise situated lesions; but the supra- 
 cortical type of delusions found in certain long-standing para- 
 noiacs, whose fine mental processes run in a quasi-normal manner, 
 find no special correlation in any region, and the probable lines 
 on which this problem is to be solved remain obscure. 
 
 As for auditory hallucinosis, the work seems to afford the 
 expected correlation with temporal lesions. In one case, however, 
 temporal lesions of considerable severity were not attended in 
 life by hallucinations of hearing, but in this case there was also 
 a severe supracortical disease of the temporal region, and it 
 may be that for the production of hallucinations, some congress 
 is necessary between the activation of the supracortex and 
 infracortex, respectively. 
 
 In previous work on this series, the brains had indicated a post- 
 central and superior parietal correlation for catatonia whose 
 muscular hypertension was accordingly regarded as very possibly 
 
171 
 
 a kind of morbid kinesthesia. Present work suggests that the 
 anatomic correlate is not merely to the postcentral and parietal 
 regions, but still more specifically to the infracortical parts of 
 these regions. 
 
 It may be suggested that the lesions found in samples of tissue 
 in the postcentral, superior parietal, inferior parietal and superior 
 temporal regions indicate a certain systemic tendency in the 
 underlying processes, for these lesions were bilateral, and occurred, 
 as it were, in two continuous sheets of tissue on both flanks of 
 the brain in one of the best defined of our cases; these flank 
 lesions were not attended by any similar lesions of the frontal, 
 precentral, occipital and lower temporal and smell regions. The 
 nature of a process which could mildly affect nerve cells and 
 neuroglia on two sides of the brain, and also specially affect the 
 infracortical rather than the supracortical portions of these 
 affected sheets of tissue, remains a mystery. It is perhaps no 
 greater mystery than that which attends the distribution of 
 lesions in the spinal cord of pernicious anemia. It remains 
 unsettled whether these lesions are secondary in point of time to 
 a non-cell-destructive phase in the disease, or whether the lesions 
 of which these microscopic effects are indicators began pari passu 
 with the symptoms; that is, it remains a question whether we 
 are dealing with the excess wear-and-tear process of cell mech- 
 anisms morbidly employed, or whether the morbidity of neural 
 function is an exact equivalent of the neuronic and neuroglia 
 morbidity. 
 
 Southaed, E. E., and Solomon, H. C. Neurosyphilis, Modern 
 Systematic Diagnosis and Treatment presented in 137 Case 
 Histories. Boston, 1917, W. M. Leonard, 496 pp., 8°. 
 
 Southard, E. E. Alienists and Psychiatrists: Notes on Divi- 
 sions and Nomenclature of Mental Hygiene. Being 
 M. C. M. D. Contribution No. 187 (1917.7). Mental 
 Hygiene, Concord, N. H., 1917, I, 567-571. Also in Bulletin 
 of Massachusetts Commission on Mental Diseases, Boston, 
 1917-18, I, Nos. 3 and 4, 201-205. 
 
 Conclusions. 
 It is proposed that the term alienist be used of experts in the 
 forensic or medicolegal subdivision of mental hygiene, dealing 
 with insanity. 
 
172 
 
 It is proposed that the term psychiatrist be used of medical 
 experts concerned with mental diseases. 
 
 As a minor point in nomenclature, it is proposed to distinguish 
 the alienistics of a case from the psychiatry thereof. As insanity 
 stands /to mental disease, so alienistics would stand to psychiatry. 
 Alienistics would be primarily a branch of law; psychiatry a 
 branch of medicine. 
 
 Five or six subdivisions of mental hygiene are mentioned as 
 existent or developing. 
 
 Public mental hygiene has the two well-established subdivi- 
 sions, institutional and medicolegal. 
 
 Social mental hygiene has produced effective social service. It 
 is a question how far character handicap work can go; but there 
 are signs of a specialty in mental hygiene here also, using practical 
 psychiatric, social-service and social-psychological categories. 
 
 Personal or individual (medical) mental hygiene is founded on 
 the achievements of practical psychiatry, which may now be 
 regarded as a specialty independent of institutional mental 
 hygiene and of "alienistics." But metric psychiatry is gaining 
 ground, following the work of Binet, and "mental tests" promise 
 to be of value not only in "mind-lack" and "mind-loss" ques- 
 tions of practical psychiatry, but also (at least negatively) in 
 the field of character handicap work in employment and voca- 
 tional choice. 
 
 Southard, E. E., and Solomon, H. C. Notes on Gold Sol 
 Diagnostic Work in Neurosyphilis (Psychopathic Hospital, 
 Boston). Being M. C. M. D. Contribution No. 165 
 (1916.23). Bulletin of Massachusetts Commission on 
 Mental Diseases, Boston, 1917, I, Nos. 1 and 2, 254-260. 
 Also in Journal of Nervous and Mental Disease, New York, 
 1917, XLV, 230-236. 
 
 Southard, E. E. The Desirability of Medical Wardens for 
 Prisons. Being M. C. M. D. Contribution No. 192 
 (1917.12). Proceedings, National Conference of Social 
 Work, Chicago, 1917, XLIV, 589-594. 
 
 Southard, E. E. Zones of Community Effort in Mental 
 Hygiene. Being M. C. M. D. Contribution No. 193 
 (1917.13). Proceedings, National Conference of Social 
 Work, Chicago, 1917, XLIV, 405-413. 
 
173 
 
 1918. 
 
 Southard, E. E., and Canavan, M. M., M.D. An Anatomical 
 Search for , Non-tuberculous Dementia Prsecox. (Abstract.) 
 Journal of Nervous and Mental Disease, New York, 1918, 
 XL VII, 41. Also in Transactions, American Neurological 
 Association, 1917, 242. 
 
 Remarks. 
 Several autopsy collections in Massachusetts institutions have 
 been searched for dementia prsecox, and the percentages of open 
 and closed tuberculosis determined. General figures for the 
 whole series; dementia prsecox patients are more apt to die of 
 tuberculosis than are non-dementia prsecox patients. The demen- 
 tia prsecox group itself, defined by various more or less rigorous 
 criteria, has been studied more narrowly with respect to tuber- 
 culous lesions, disease type and the like. 
 
 Southard, E. E. Remarks on Advanced Training for Social 
 Workers. Radcliffe Quarterly, February, 1917, 35-38. 
 
 Southard, E. E. Remarks on the Progress of the Waverley 
 Researches in the Pathology of the Feeble-minded. Pro- 
 ceedings and Addresses of the Forty-second Annual Session 
 of the American Association for the Study of the Feeble- 
 minded, 1918, 48-59. 
 
 Southard, E. E., and Taft, Annie E. Memoirs of the 
 American Academy of Arts and Sciences, 1918, XIV. I. 
 General Aspects of the Brain Anatomy of the Feeble- 
 minded (E. E. Southard). II. Clinical, Anatomical, and 
 Brief Histological Description of Ten Cases of Feeble- 
 mindedness (Dr. Southard and Dr. Annie E. Taft). III. 
 Neuropathological Correlations with Clinical and Psycho- 
 metric Findings in Feeble-mindedness (Waverley Research 
 Series Cases I-X) (Dr. Southard and Dr. Taft). 
 
 Summary. 
 The entirely provisional conclusions of the epicritical review 
 may be briefly stated as follows : — 
 
 First. — It is not impossible that the problem of matching 
 
174 
 
 brain complexity with mental capacity may be solved by a 
 much larger series of instances than is here available; but the 
 instances of such matching as has been undertaken are somewhat 
 convincing as to the correlations of • low orders of intelligence 
 with simple brains, and of higher orders of intelligence with more 
 complex brains. Occasional exceptions to the rule may be ex- 
 plained by the finer anatomy of certain cases (Case IX); others 
 remain less easy to explain away (Case III). 
 
 Second. — The partial orienting and microscopic examination 
 yielded more instances of slight exudative lesions (including in 
 some instances rod cells) than might have been a priori, except 
 from a relatively stable institutional material like that here 
 largely drawn upon. What the share of syphilis in this group 
 of cases may really be is doubtful. There was one instance of 
 feeble-mindedness very possibly due to an early focal encepha- 
 litis entailing maldevelopment of brain. 
 
 Third. — As an example of special neurological interest attach- 
 ing to this study, some considerations about hydrocephalus 
 offered bring up the question of the relation between occasional 
 bursts of excitability and alterations of intracranial pressure 
 with the production of hydrocephalus. 
 
 Southard, E. E. Notes on Researches in Epilepsy at Monson 
 State Hospital, Massachusetts. Being Contribution No. 
 208 (1917.28), in Bulletin of Massachusetts Commission on 
 Mental Diseases, 1918, II, No. 21, 10-19. 
 
 Southard, E. E., and Canavan, M. M. Notes on the Relation 
 of Tuberculosis to Dementia Prsecox. Journal of Nervous 
 and Mental Disease, 1918, XLVIII, 193-200. 
 
 Summary. 
 On account of a recent revival of interest in the relation be- 
 tween tuberculosis and dementia prsecox, a brief statistical 
 inquiry was made, using data of the Massachusetts autopsy 
 series. It was shown that dementia prsecox, found in 8 per cent 
 of 5,040 Massachusetts autopsies, was far more apt to be termi- 
 nated by tuberculosis than manic-depressive psychosis, occurring 
 in 7 per cent of the basic series. Out of 403 cases of dementia 
 prsecox 120 died of tuberculosis, and but 43 of 339 cases of 
 
175 
 
 manic-depressive psychosis. Eighty-seven cases of dementia 
 praecox showed neither death due to tuberculosis nor any anatom- 
 ical feature whatever (even including adhesions in various parts 
 of the body), which could conceivably be related with tubercu- 
 losis. Ninety-five cases of manic-depressive psychosis were 
 equally free from tuberculosis. 
 
 The question whether these non-tuberculous cases of dementia 
 praecox were actually victims of the disease and not subject to 
 erroneous diagnosis was taken up in the statistical study from 
 the Danvers symptom catalogue, from which 36 cases dead of 
 tubercle were taken to contrast with 27 cases dying without the 
 slightest evidence of tuberculosis whatever. Some of the most 
 characteristic symptoms of dementia praecox were found equally 
 distributed in the two groups and strongly represented in both, 
 so that no major doubt can be raised as to the accuracy of the 
 diagnosis of dementia praecox in the non-tuberculous group. For 
 example, the fundamental symptoms of dementia and delusions 
 of paranoid type are found equally represented in both. Nor 
 was it found that the fundamental symptom, dementia, was more 
 frequently shown in the fatally tuberculous cases than in the 
 others. 
 
 An interesting question is raised by the distribution of hyper- 
 kinetic and catatonic symptoms. Tuberculosis appears to dis- 
 pose certain cases to catatonia and to hyperkinetic symptoms of 
 a presumably psychogenic or cortical nature. Per contra, the 
 non-tuberculous cases showed more instances of the peripheral 
 symptom — motor restlessness — than did the tuberculous cases. 
 Can it be true that tuberculosis inclines the dementia praecox 
 victim more to catatonia {central hyperkinesis) and less (perhaps 
 by processes of inhibition) to peripheral forms of hyperkinesis 
 than do the conditions that prevail in the non-tuberculous 
 group? 
 
 Another hypothesis raised by this statistical study is whether 
 tuberculosis does not cause a trend of symptoms in dementia 
 praecox over toward manic-depressive psychosis. Does not the 
 superposition of a somatic feature like tuberculosis upon the 
 encephalic or psychogenic picture of dementia praecox cause also 
 a superposition of sundry features showing an alliance with those 
 of manic-depressive psychosis? Or, put more briefly, does not 
 tuberculosis tend to make dementia praecox look more at times 
 like manic-depressive psychosis than dementia praecox is ordi- 
 narily likely to look? 
 
176 
 
 Southakd, E. E. The Kingdom of Evil: Advantages of an 
 Orderly Approach in Social Case Analysis. Proceedings, 
 National Conference of Social Work, Chicago, 1918, XLV, 
 334-340. 
 
 Southard, E. E. Suggestions in the Nomenclature of the 
 Feeble-mindednesses. Mental Hygiene, Concord, N. H., 
 1918, II, 605-610. 
 
 Southard, E. E. Shell Shock and After. (The Shattuck 
 Lecture.) Boston Medical and Surgical Journal, 1918, 
 CLXXIX, 73-93. Being Contribution No. 268 (1918.8), 
 in Bulletin of Massachusetts Commission on Mental Dis- 
 eases, III, No. 2, 1919, pp. 5-43. 
 
 Southard, E. E. Mental Hygiene and Social Work: Notes on 
 a Course in Social Psychiatry for Social Workers. Mental 
 Hygiene, Concord, N. H., 1918, II, 388-406. 
 
 Summary. 
 
 Some reflections have been put together on a course for social 
 workers on social psychiatry recently given in Boston. These 
 reflections deal largely with some distinctions between mental 
 hygiene and social service. Mental hygiene is regarded as a 
 branch of medicine, in a sense co-ordinate with the psychiatric 
 branch of social work. 
 
 At first, the distinctions between mental hygiene and psychi- 
 atric social work are very clearly and definitely drawn. Particu- 
 lar emphasis is laid upon the individualism of the point of view 
 of mental hygiene as against the groupism of social workers. But 
 in the end it is pointed out that if mental hygienists are to ob- 
 tain auxiliaries, such as every expert eventually obtains in the 
 evolution of his art, these mental hygiene aides will probably be 
 best drawn from the ranks of the social workers; they will be a 
 kind of specialized and advanced social worker. 
 
 The point is that as the mental hygienist advances from the 
 individual to the family and thence to the community, so the 
 social worker, at first aiming at the community, focalizes upon 
 the family, and finally gets a point of view concerning the indi- 
 vidual not far from that entertained by the mental hygienist. 
 
 Despite the logical differences, then, between the point of 
 
177 
 
 view of mental hygiene and that of social work (logical differ- 
 ences which it is well to bring out when endeavoring to get the 
 medical point of view to some extent over into the minds of the 
 social workers), there will be in practice little doubt that mental 
 hygienists will find some of their most valuable aides in specially 
 trained social workers. Just as the orthopedists will use nurses 
 and others skilled in physical therapy, and just as the vocation 
 workers will use persons specially trained in invalid occupation 
 and in handicraft teaching, so the mental hygienists in war time 
 will crave the aid of specially trained social service auxiliaries; 
 that is, mental hygiene aides that have been given special training. 
 
 In the Boston course, largely for advanced social workers who 
 had all had a pretty definite curriculum, stress was laid upon 
 sundry methods of analysis of social data after their collection. 
 Among these methods of analysis was one which took up the 
 question of the public, social and personal aspects of whatever 
 problem of maladjustment was in question. Another dealt with 
 the analysis of the patient's subjective attitude to his environ- 
 ment and himself, — a question of the passive voice. A third 
 dealt with a method of analyzing data from the standpoint of the 
 evils found in evidence, and for the purpose of orderly analysis 
 a tentative rough classification of the kingdom of evil was given. 
 
 In view of war contingencies, brief suggestions have been 
 made as to the desirable content of courses for psychiatric social 
 workers of value in war time and after. 
 
 Southard, E. E. Insanity versus Mental Diseases. The Duty 
 of the General Practitioner in Psychiatric Diagnosis. Ab- 
 breviated in Journal of American Medical Association, 
 1918, LXXI, 1259-1264. Published in full in the Trans- 
 actions of the Section on Nervous and Mental Diseases at 
 the Sixty-ninth Annual Session of the American Medical 
 Association, Chicago, June, 1918. Also (Abstract) in Journal 
 of Nervous and Mental Disease, 1919, XLIX, 371, 372. 
 
 Conclusions. 
 
 1. The advance of the mental hygiene movement throws more 
 responsibilities in psychiatric diagnosis on the general prac- 
 titioner. 
 
 2. The general practitioner should bring his specialistic knowl- 
 edge of psychiatry up level with his specialistic knowledge, in 
 ophthalmology and dermatology, for example. 
 
178 
 
 3. Alienists are to be distinguished from psychiatrists, and 
 forensic psychiatry ("alienistics") from practical psychiatry, in 
 certain ways (Table 1). 
 
 4. There is at present great unanimity on the part of American 
 specialists in mental disease, as indicated by the adoption of 
 common statistical forms (American Medico-Psychological Asso- 
 ciation). 
 
 5. For arriving at a diagnosis of mental disease, I suggest an 
 arbitrary order of exclusion by eleven great groups, into which 
 I have thrown the accepted entities. 
 
 6. Nomenclature divergences are much more frequent than 
 divergences on facts. 
 
 7. The use of Bleuler's term "schizophrenia" for dementia 
 prsecox, and of the term (in cognate use) "cyclothymia" for 
 manic-depressive psychosis, is advocated in the line of exactitude 
 and the ready formation of adjectives and relative terms. 
 
 8. The use of a new term "hypophrenia" for the various 
 feeble-mindednesses is advocated. 
 
 9. The ending "osis" is in general advocated for the larger 
 groups of mental diseases, parallel with the use of " acece" and 
 "oscc" for botanical orders. 
 
 10. A tentative list of "genera" under these orders is given in 
 the text. 
 
 Southard, E. E. The Training School of Psychiatric Social 
 Work at Smith College; II. A Lay Reaction to Psychiatry. 
 Mental Hygiene, Concord, N. H., 1918, II, 584, 585. 
 
 Southard, E. E. Diagnosis per Exclusionem in Ordine: General 
 and Psychiatric Remarks. Journal of Laboratory and 
 Clinical Medicine, St. Louis, 1918, IV, 31-54. Also in 
 Transactions, Association of American Physicians, Phila- 
 delphia, 1918, XXXIII, 267-301. Being Contribution 
 (1917.53) in Bulletin of Massachusetts Commission on 
 Mental Diseases, 1918, II, No. 3, 90-122. 
 
 Summary. 
 
 1. The writer apologizes for a communication on medical logic 
 
 in general when he is only a psychiatrist and but recently a. 
 
 pathologist. His excuse is the necessity for reasonably accurate 
 
 snap diagnosis in the sifting problem of the psychoses, psycho- 
 
179 
 
 neuroses and psychopathias, as they flow through the Psycho- 
 pathic Hospital clinic in Boston. 
 
 2. The medical student is found destitute of the ability to 
 define entities and symptoms. The textbooks in medicine, 
 especially the single volume textbooks, rather tend to make the 
 student believe that diagnosis is observation. In point of 
 fact, diagnosis is not observation, though it requires and indeed 
 stands or falls by accurate observation. 
 
 3. Da Costa and his successors have lauded so-called direct 
 diagnosis to the skies, and Da Costa rather decried indirect 
 diagnosis by exclusion as a tedious process. An example is cited 
 from Da Costa which shows how relatively simple the classical 
 diagnoses of general medicine are beside those of psychiatry. 
 
 4. It seemed that diagnosis by exclusion ought to be rehabili- 
 tated. An examination of recent research work in logic indicated 
 that higher and more complex methods than those of observation 
 had become necessary in science. For example, Cabot and Her- 
 bert French have attempted to profit by the statistical method, 
 which again, though it requires reasonably accurate observation, 
 is not in itself a method of observation at all. Yet Cabot's 
 statistical frequency tables possess a certain diagnostic value. 
 But the student is often misled by the brilliancies of so-called 
 observational diagnosis in a clinic. Here diagnoses are often 
 rendered on inspection by a process akin to the recognition of a 
 fruit as an orange, or an automobile trouble as "the engine is 
 skipping." This process is not diagnosis, it is a process of recog- 
 nition that may receive a simpler term gnosis. 
 
 5. The offhand snap diagnostic work at the Psychopathic 
 Hospital indicated that we were in practice relying upon the 
 successive exclusion of certain great disease groups in a certain 
 definite order. 
 
 6. A study of Royce's "Summary of Recent Researches in 
 Logic" shows how an organized combination of theory and 
 experience is the higher logic to which the more complicated 
 sciences must resort. Royce himself mentioned psychiatry as a 
 science about to climb out of the classifying era into the era of 
 logical order, that is, of the organized combination of theory and 
 experience. Such a dictum as that "disease is life under altered 
 conditions" seems now childishly simple. The idea that disease 
 is a matter of an organism plus a germ was found to be altogether 
 too simple when in the nineties of the last century the concepts 
 of immunology were developed. 
 
180 
 
 7. Those departments of medicine in which the presenting 
 symptom of Richard Cabot is of value are lucky departments. 
 Those departments of medicine in which the indices of disease, or 
 indicator symptoms of the elder writers are available, are also 
 fortunate departments in comparison with psychiatry. In 
 mental disease there are exceedingly few indicator symptoms. 
 
 8. Hence the need became apparent of a process of exclusion of 
 great groups or phenomena in a certain definite order, so that 
 nothing of large significance should evade consideration. To 
 avoid the tediousness of exclusion, complained of by Da Costa, 
 the phenomena of disease had to be logically grouped in certain 
 great groups, and the process types of diagnosis in the books may 
 be counted as six or eight, according to definition. 
 
 9. In the body of the paper, a special statement was made 
 about each of these process types: inspection (regarded as not 
 really diagnosis but as merely recognition of gnosis); expecta- 
 tion, a newly named but frequent method (far older than Mi- 
 cawber); induction, ex juvantibus, ex nocentibus (three methods 
 in which in no very rigorous way experiment is used); and these 
 three methods of diagnosis by comparison are successively dis- 
 cussed. 
 
 10. The ninth method, diagnosis per exclusionem in ordine, is 
 in one sense a minor modification of the old method of diagnosis 
 by exclusion. It is of value in departments of medicine, where 
 there are no indicator symptoms, and where the so-called pre- 
 senting symptom would merely indicate some kind of mental 
 disease. 
 
 11. The general application of the method of diagnosis per 
 exclusionem in ordine in the field of mental disease is demon- 
 strated in the eleven groups of mental diseases into which most 
 of the phenomena may be pragmatically cast. The groupings 
 are not by clinical resemblances, by anatomical attack or by 
 etiology. The distinction is a pragmatic and therapeutic one, 
 and will naturally tend to become more and more etiologic as 
 the causes are determined. But in the field of mental disease, 
 causes are so apt either to be unknown or to be multiple that 
 etiologic classification on any simple basis, such as that of the 
 infectious diseases, is practically inconceivable. 
 
 12. It is hoped that other departments of medicine (where 
 diagnosis is raised above the level of mere recognition, and where 
 there are few or no pathognomonic or indicator symptoms), will 
 find it to their advantage to set up a method of diagnosis per 
 
181 
 
 exclusionem in ordine, the great groups or orders being always 
 determined on a pragmatic basis. In the body of the paper are 
 given the general designations of the ten great groups of mental 
 diseases, with the eleventh residual group. 
 
 Southard, E. E. The Empathic Index in the Diagnosis of 
 Mental Diseases. Journal of Abnormal Psychology, Boston, 
 1918, XIII, 199-214. 
 
 Canavan, M. M., and Southard, E. E. Microlienia and Other 
 Observations on the Spleen in Psychopathic Subjects. 
 Being M. C. M. D. Contribution No. 236 (1917.56). Bulle- 
 tin of Massachusetts Commission on Mental Diseases, 
 1918, II, 136-142. 
 
 Summary. 
 
 1. Microlienia is frequent in the bodies of psychotic subjects. 
 
 2. Possibly this small spleen is an index of general hypo- 
 lymphatism in the body. At all events, it is correlated with 
 these mucous membranes and with a small amount of lymph 
 node tissue in a large number of instances. The "psychotic" 
 spleen-liver index was 112 to 1,362, as against normal, 171 to 
 1,500. 
 
 3. Chronic lesions are frequent, for example, 15 per cent of 
 lesions in the capsule; 28 per cent of lesions in the tunica 
 albuginea; 12 per cent of thickenings in the trabeculee; 67 per 
 cent of plasma cells in the pulp cords; and 86 per cent of 
 thickenings in the arterial twigs. 
 
 4. The high degree, 67 per cent, of plasma cells in the pulp 
 cords seems of importance when it is considered that some 
 authors feel that plasma cells in the spleen have pathological 
 significance. v 
 
 5. A similar study of kidney lesions in the same series, pub- 
 lished in 1914, showed but 42 per cent of plasma cells in the 
 kidney. 
 
 6. As for the malpighian bodies, considerable variations in the 
 number of rows of cells was found therein, 3 to 30. 
 
 7. Whether this hypolienia has anything to do with reactions 
 of psychotic subjects to infection must remain doubtful. 
 
 8. It would appear that further studies of the hemopoietic 
 system ought to be made in the psychoses and ought to be 
 
182 
 
 supported by accurate clinical studies of the peripheral blood 
 intra titam. 
 
 9. Eighteen spleens of general paretics were carefully studied 
 for spirochetosis; no spirochetes were found. 
 
 Southard, E. E. Discussion on Illness in Industry — Its Cost 
 and Prevention. Transactions, American Institute of 
 Mining Engineers, 1918, LIX, 678-684. 
 
 1918-19. 
 
 Southard, E. E. A Key to the Practical Grouping of Mental 
 Diseases. Being M. C. M. D. Contribution No. 196 
 (1917.16). Journal of Nervous and Mental Disease, 1918, 
 XLVII, 1-19. Also in Bulletin of Massachusetts Commis- 
 sion on Mental Diseases, Boston, 1918-19, II, No. 1, 5-24. 
 
 Summary and Conclusions. 
 
 I have here presented not so much a classification as a key to 
 the grouping of mental diseases. The key has been worked out 
 to the extent of ten well-defined groups and an eleventh residual 
 group. These groups correspond to the groups of, e.g., the 
 Rosacea? or Leguminosa? of botany, and do not correspond to the 
 genera and species of those orders. Some hint is given of the 
 generic and specific distinctions of mental disease that might 
 correspond to the genera and species of botany, provided that 
 there were any practical need for a quasi-botanical or zo-ological 
 genus-species distinction in mental diseases. 
 
 The incentive to this grouping has been practical. No en- 
 deavor was made on the library table to construct a hortus siccus 
 of mental diseases. On the contrary, this key is the product of 
 several years of work in the Psychopathic Hospital in Boston, 
 where the task of reasonably accurate diagnosis by an ever- 
 changing staff of psychiatrists in training was the desideratum. 
 I do not accordingly suggest this key as something to replace 
 the methods of the expert in arriving at a conclusion concerning 
 psychiatric diagnosis. I do offer it, however, as a guide for the 
 tyro and the psychiatrist in training. It is not an outline giving 
 an order of examination. It is a scheme for summarizing arid 
 evaluating results after the physical, mental and historical data 
 are collected. The plan is eliminative, but is subject to this 
 reservation: if one arrives in the chosen sequence of analysis at 
 
183 
 
 a plausible or even a correct group diagnosis, one is not thereby 
 absolved from continuing the process of analysis. All data bear- 
 ing on any of the groups must be considered. Diseases may be 
 "hybrid," though practically one is almost never in doubt as to 
 the group under which to subsume a case. Theoretically, one 
 may be, for example, both epileptic and alcoholic; practically 
 one is either an epileptic alcoholic or an alcoholic epileptic. The 
 guide to the grouping here is a pragmatic one, and depends upon 
 the institution or the special treatment to which the supposed 
 victim of epilepsy and alcoholism must gravitate. I must es- 
 pecially emphasize that the groups and the group names do not 
 correspond to nosological entities and entity names. The placing 
 of a case in one of these eleven groups is not psychiatric diagnosis 
 in the entitative sense. Accordingly, this grouping does not run 
 into collision with any previous endeavor to classify the genera 
 and species of mental disease, such, for example, as the genera 
 and species in the majority of classifications quoted in Hosack. 1 
 
 I would insist, further, that the group headings given are not 
 special enough to constitute sufficient diagnosis for a classifica- 
 tion of use in the statistics of institutions for the insane. The 
 plan is not so much an excursion in nosology as an essay in the 
 technique of psychiatric diagnosis for the tyro. The plan gives 
 hints for a method of arriving at an eventual diagnosis: it does 
 not prescribe the names of diseases. Again, the plan is not an 
 etiological plan, although recent advances in psychiatric etiology 
 have been such that many of the practical groups are actually 
 etiological groups. 
 
 It is possible that the sequence has been unduly telescoped. 
 It is possible that there should be a traumatic and an arterio- 
 sclerotic group. I have placed both of these groups in the en- 
 cephalopathic or coarse brain, or "neurologist's" group, feeling 
 that I do the diagnostic tyro a service by pulling the encephalo- 
 traumatic psychoses far apart from the traumatic psychoneuroses 
 on the one hand, and the arteriosclerotic psychoses far apart 
 from the senile psychoses on the other hand. 
 
 Lastly, I would insist once more that the plan is one born of 
 Psychopathic Hospital experience and bred in the first place for 
 the inexpert. It is a key to study and not an analytical classi- 
 
 1 Hosack, David, "A System of Practical Nosology: to which is prefixed A Synopsis of the 
 Systems of Sauvages, Linnaeus, Vogel, Sagar, Macbride, Cullen, Darwin, Crichton, Pinel, Parr, 
 Swediaur, Young and Good, with References to the Best Authors on each Disease," 1st edition, 
 1819, 2d edition, 1821, New York. 
 
184 
 
 fication with any pretense to finality. Elements in the sequence 
 can be destroyed and new elements inserted. Indeed, such proc- 
 esses of extrapolation and interpolation must needs occur in 
 the progress of practical diagnosis. Whatever novelty the plan 
 may have lodges in the sequential character of the analysis 
 of data already collected, and not in the completeness or ultimacy 
 of the groups. The sequential plan of analysis is of course as 
 old as the diagnostic hills. It is superior, however, to the type- 
 matching method of diagnosis in vogue with many tyros, who 
 very often come to their superiors with the plaint that the data 
 in a given case fit the book descriptions of half a dozen diseases. 
 A set sequential analysis of collected data must be superior to 
 a hit-or-miss type-matching of entities. 
 
 Southard, E. E. Recent American Classifications of Mental 
 Diseases. American Journal of Insanity, Baltimore, 1918- 
 19, LXXV, 331-349. 
 
 Summary. 
 We thus arrive at the following general considerations con- 
 cerning the recent American classifications in psychiatry: — 
 
 1. There is an extraordinary unanimity on the part of American 
 psychiatrists as to the constituents of psychiatric nosology, and 
 this despite a number of nomenclatural divergences. 
 
 2. The classification proposed by the American Medico-Psycho- 
 logical Association and adopted by the United States government 
 for practical war work is a suitable reference table for statistical 
 purposes of the major groups and clinical types of mental disease. 
 
 3. The classification may be somewhat inadequate for the pur- 
 pose of general and psychopathic hospital practice, but a slight 
 revamping might solve this difficulty. 
 
 4. The American Medico-Psychological Association's classifica- 
 tion appears to follow an etiological ordering borrowed ultimately 
 from reputable German sources, and this etiological ordering is a 
 good one if a certain etiological viewpoint is in mind. 
 
 5. The question is raised, Whether it would not be better to 
 order the groups and types of mental disease in a pragmatic 
 rather than a theoretical order, that is, in an order having 
 therapy in mind rather than an order having etiology in mind? 
 
 6. The writer proposes such a pragmatic order of certain great 
 groups or orders of mental disease, corresponding with the botani- 
 cal or zo-ological orders. 
 
185 
 
 7. The writer finds that the 22 American Medico-Psychological 
 Association's groups might well be compressed for practical pur- 
 poses of diagnosis into 11 groups. He finds that the clinical types 
 subordinated to the great groups of the American Medico-Psycho- 
 logical Association's classification correspond more or less ac- 
 curately to the genera of a botanical or zo-ological classification, 
 and proposes that in practice these sub-groups be considered in 
 order, in general accordance with the principles of botanical or 
 zo-ological taxonomies. 
 
 8. This question of how to use a classification may be defined 
 as the question of a key to the grouping of diseases. The key 
 question is entirely independent of the classification or reference- 
 table of entities and entity groups, and both the key question and 
 the classification-list question are independent of questions of 
 nomenclature and terminology. Moreover, the writer would 
 insist that the logical process of diagnosis per exclusionem in 
 ordine here developed has nothing whatever to do with the order 
 in which data can or should be collected. 
 
 1919. 
 
 Southard, E. E. Shell Shock and Other Neuropsychiatric 
 Problems presented in 589 Case Histories from the War 
 Literature, 1914-18. With a Bibliography by Norman 
 Fenton, S.B., A.M., and an Introduction by Charles K. 
 Mills, M.D., LL.D. W. M. Leonard, Boston, 1919. 
 
 Southard, E. E. The Functions of a Psychopathic Hospital. 
 Canadian Journal of Mental Hygiene, Toronto, Ont., 1919, 
 I, 4-19. 
 
 Southard, E. E. Prothymia: Note on the Moral Concept in 
 Xenophon's " Cyropedia." Contributions of Medical and 
 Biological Research, Osier, 1919, II, 786-795. Also (Ab- 
 stract) in Journal of Nervous and Mental Disease, 1919, 
 I, 63. 
 
 Conclusions. 
 
 1. The material in Xenophon's "Cyropedia" indicates the 
 probable great value of a historical study of the morale-concept, 
 — a study that might enliven the ethics of the day. 
 
 2. The itemizing of morale-measures found in the "Cyropedia" 
 
186 
 
 indicates the probable success of a behavioristic version of a 
 large part of morale as the Greeks saw it. 
 
 3. In particular, the roots of most of the words employed in 
 Xenophon's morale-description are roots having to do with move- 
 ment and speed (rather than with mere strength statistically 
 taken), and having little to do with mere feelings. 
 
 4. In particular, also, many of the words indicate the thoracic 
 seat of the motions engaged (e.g., the early localization of #17-10'?, 
 aniwius, strong feeling and passion, derived probably from Ova), 
 rush) rather than a seat in the head or in the muscular system at 
 large; i.e., morale of Xenophon's description is more a matter of 
 heart than of brawn or of head, but "heart" gets a behavioristic 
 accounting rather than one in terms of felt emotion. 
 
 5. The morale of Xenophon's day, or at least the morale of 
 his account in the " Cyropedia," is plainly far from a complete 
 story of morale in the modern sense, especially the morale de- 
 velopments in armies and nations subsequent to the French 
 Revolution. 
 
 6. The term prothymia is indicated for the morale situation as 
 depicted by Xenophon. This term has several advantages: — 
 
 (a) The root is a leading term in Xenophon's list. 
 
 (b) The root word 6v/jl6s has deep-lying hints of motion in 
 it, as well as general usage in compounds suggesting "heart" in 
 a figurative sense; and the prefix irpo has suitable intimations 
 of pushing forward in space. 
 
 (c) Modern psychiatry has come to use the theme thymia in 
 many compounds describing variants of emotion (e.g., hyper- 
 thymia, parathymia). 
 
 (d) The term prothymia is euphonious and readily suggests 
 variants, e.g., prothymic (adjective to be used of morale proce- 
 dures) and prothymics (substantive for the art of morale, or for 
 our accumulation of facts concerning morale). 
 
 Southard, E. E. The Individual versus the Family as a Unit 
 of Interest in Social Work. Mental Hygiene, Concord, 
 N. H., 1919, III, 436-444. Also in Proceedings, National 
 Conference of Social Work, 1919, LXVI, 582-587. 
 
 Southard, E. E. The Range of the General Practitioner in 
 Psychiatric Diagnosis. Journal of American Medical Asso- 
 ciation, Chicago, 1919, LXXIII, 1253-1256. 
 
187 
 
 Summary. 
 
 Psychiatry has become almost more popular with non-medical 
 mental hygienists than the medical profession. Of course, the 
 relations that are ultimately to stand between clinical neurology 
 and psychiatry are not entirely clear. But the relations between 
 psychiatry and the general practice of medicine are disturbed by 
 special difficulties, e.g., phobias on the part of the general prac- 
 titioner concerning nomenclature and concerning his own sup- 
 posed ignorance of psychiatry. 
 
 A frontal attack is proposed on the general practitioner, in 
 addition to the flank attacks considered desirable in the past, 
 for his proper postgraduate education. 
 
 Psychiatry is more a synthetic art than is clinical neurology, 
 now predominantly analytic. But, being synthetic, psychiatry 
 has much in common with general medicine. General medicine, 
 psychiatry, and (to a certain point) obstetrics treat the patient 
 as an individual, whereas the majority of the specialties treat the 
 patient (in scholastic phrase) as a dividual. 
 
 The body of the text contains material illustrative of some in- 
 adequacies of the general practitioner re psychiatry. Many of 
 these are easily reparable. 
 
 Southard, E. E. Non-dementia Non-praecox; A Note on the 
 Advantages to Mental Hygiene of extirpating a Term. 
 (Abstract.) Journal of Nervous and Mental Disease, New 
 York, 1919, I, 251, 252. 
 
 Note. 
 
 Dr. E. E. Southard spoke in regard to the unsuitableness of 
 the term "dementia praecox" furnished by Kraepelin, upon the 
 badness of which term all are agreed. Some international com- 
 mittee on psychiatric terminology should be formed to select 
 desirable psychiatrical terms. 
 
 Neither dementia nor praecox are indispensable features of 
 what is called dementia praecox. The use of the term brings un- 
 happiness to patients and much wrong results from its use. 
 Catatonia was first described in 1858. In 1896 Kraepelin used 
 the term dementia praecox to include several types of mental 
 disease. In 1913 he evolved thirteen types, containing nine 
 types of dementia praecox and four of paraphrenia, and desig- 
 nated these thirteen types as endogenous deterioration. Bleuler 
 
188 
 
 later suggested that schizophrenia should be used instead of the 
 undesirable term dementia prsecox. This conveys the idea most 
 important to this disease, the splitting of the personality, and it 
 forms a good basis for various derivations. It does not commit 
 one to any one notion of the mechanism involved nor of the 
 nature of the process. 
 
 Southard, E. E. The Activities of the War Work Committee 
 of the National Society for Mental Hygiene. (Abstract.) 
 Journal of Nervous and Mental Disease, New York, 1919, 
 XLIX, 44, 45. 
 
 Note. 
 Dr. E. E. Southard was absent from the meeting, and the 
 secretary of the society read a few notes from him on these 
 activities, in which he outlined the early organization of the War 
 Work Committee by Dr. Bailey, now Lieutenant-Colonel, and 
 Dr. Salmon, now Major, aiming at both unity of action and 
 speed in the mobilization of the neuro-psychiatric and psycho- 
 logical resources of the country. He mentioned the work of the 
 psychologists at the cantonments in the examination of the 
 soldiers and officers, and in the testing for defectives, and also 
 the work of the neuro-psychiatric units in the army. The results 
 of the examinations of the latter group had resulted by January, 
 1918, in the elimination of 8,000 men from active military duty 
 as unfits. Dr. Southard emphasized the fact that this country is 
 the first to attempt elimination of nervously unfit from the army 
 activities by examinations for evidences of such inadequacy. He 
 spoke of the great need for men trained in this field, noting that 
 over 300 men had already been commissioned in the army for 
 this work, New York and Massachusetts leading all other States 
 in the number, proportionate and absolute, of men to enlist from 
 the State institutions. He said that there was also a great need 
 of male nurses for the work, reconstruction aides, social service 
 workers, a necessity for provisions for the care of the families of 
 men entering the service, and similar problems to which the War 
 Work Committee is now devoting its energy and time. 
 
 Southard, E. E. Sigmund Freud, Pessimist. Journal of Ab- 
 normal Psychology, 1919, XIV, 197-216. Also (Abstract) 
 in Journal of Nervous and Mental Disease, New York, 
 1919, I, 162, 163. 
 
189 
 
 Southard, E. E. The Genera in Certain Great Groups or 
 Orders of Mental Disease. Archives, Neurology and Psy- 
 chiatry, 1919, I, 95-112. 
 
 Summary. 
 
 In this paper I have tried to amplify the key to the practical 
 grouping of mental diseases presented to the American Neuro- 
 logical Association in 1917. I have amplified it by proposing 
 certain genera comprised under each of the eleven major groups 
 of mental diseases. These genera have been placed in the se- 
 quence supposed to be the pragmatic sequence in which the in- 
 expert diagnostician should seek to exclude successively the 
 various genera; in short, just as the key to the practical group- 
 ing of mental diseases dealt in a certain sequence with eleven 
 major groups, so here the diagnostician is given an idea as to the 
 proper method -of considering one after another the genera com- 
 prised in each great group. No endeavor has been made to re- 
 vamp or especially modify the ideas of psychiatrists as to what 
 psychotic entities exist. Finality cannot be hoped for either 
 theoretically or practically. The principle of diagnosis per 
 exclusionem in or dine is the special principle insisted on. It is 
 applicable to any diagnostic problem after the data of observation 
 are collected. True diagnosis can only take place after sufficient 
 data are collected, and efforts to make diagnoses early in the 
 stage of collecting data are apt to result in prejudice. 
 
 The writer earnestly hopes for critique of his propositions. 
 Such critique he hopes will be separated into — 
 
 (a) Critique of the general principle of diagnosis per exclusionem 
 in or dine. 
 
 (b) Critique of the genera chosen for the different groups. 
 
 (c) Critique of nomenclature. 
 
 But judging from the world's experience in the past, it is un- 
 likely that many persons will be able to distinguish nomenclature 
 from the objects named and the method of using a classification 
 from the classification itself. Herein some nomenclatural sug- 
 gestions are made, but they have nothing to do with the main 
 line of argument. Herein a certain classification is adopted, but 
 there is absolutely no pretence to originality therein. The 
 writer's main emphasis is on the pragmatic principle of diagnosis, 
 namely, the principle of diagnosis by exclusion in order, which 
 principle will prove useful or useless without regard to the 
 classification which it endeavors to exploit or the nomenclature 
 which it uses by the way. 
 
190 
 
 Unpublished. 
 
 Southard, E. E. Artistic Experience: Its Relation to Other 
 Forms of Ecstasy. 1 
 
 Southard, E. E. General Psychopathology. Psychological 
 Bulletin, 1919, XVI, 187-199. 
 
 Southard, E. E., Canavan, M. M., and Thom, Douglas A. 
 The First Thousand Autopsies of the Pathological Service 
 of the Massachusetts Commission on Mental Diseases, 
 1914-19. Transactions, American Medico-Psychological 
 Association, 1919. (Sent to American Journal of Insanity, 
 March, 1920.) 
 
 Southard, E. E. An Attempt at an Orderly Grouping of the 
 Feeble-mindednesses (Hypophrenias) for Clinical Diagnosis. 2 
 
 Southard, E. E. Cross-sections of Mental Hygiene, 1844, 1869, 
 1894. ' Presidential Address at the Seventy-fifth Annual 
 Meeting of the American Medico-Psychological Association, 
 Philadelphia, June 18 to 20, 1919. American Journal of 
 Insanity, 1919, LXXVI, 91-111. 
 
 Address. 
 
 My task was to speak of an anniversary. I have adopted the 
 device of cross-sectioning the years, no doubt at all too brief 
 intervals in so long a history, and beyond question, choosing facts 
 in quite too random a fashion. Yet the variety and the hetero- 
 geneity of the facts and the arbitrariness of the trisection allow, 
 with all the greater certainty, a number of conclusions and com- 
 ments. These I shall set forth with a baldness quite unjustifiable 
 save by the brevity of our time. 
 
 1. The American Medico-Psychological Association, now over 
 900 members strong and representing a large majority of the 
 United States and the Canadian provinces, being the oldest 
 national medical association in continuous existence (so far as we 
 are aware) on the continent, has a history of seventy-five years, 
 cast in a time of almost unprecedented interest in the world's 
 history to date. 
 
 1 Read in Charaka Club, New York, Nov. 19, 1919. 
 
 2 Read before Association for Study of the Feeble-minded, Chicago, June 11, 1919. 
 
191 
 
 2. During these seventy-five years an extraordinary process of 
 public enlightenment concerning mental disease has gone for- 
 ward, pari passu with general progress in education and the 
 more material and engineering sides of economics. 
 
 3. Put in a phrase, this progress has been to a deeper and 
 more pragmatic hygiene in all matters pertaining to the mind. 
 Perhaps the most eminent of our earlier members was Dr. Isaac 
 Ray, the author of a work on "Mental Hygiene," in which there 
 was, from our present viewpoint, much elaboration of the ob- 
 vious, and in which there was naturally very little of the modern 
 social conception. Yet Ray himself was one of the founders of 
 the Social Science Association, and distinguished himself, as Dr. 
 Charles K. Mills this morning said, by writing an excellent work 
 on the "Jurisprudence of Insanity." 
 
 4. Just as Ray's "Mental Hygiene" was largely devoted to a 
 consideration of individual psychiatry, and took up the psy- 
 chiatry of the person as such and as affected by various con- 
 ditions of the society in which that person's life befell, so, on the 
 other hand, Ray's "Jurisprudence of Insanity" dealt with what 
 we would now call forensic psychiatry, that is, with public or 
 governmental aspects of mental disease. Accordingly, the whole 
 intermediate realm of social psychiatry proper, that is, of 
 psychiatry that deals neither with the individual person as such 
 nor with his legal or institutional relations, got no formulation 
 in the early years of our association's life. 
 
 5. As Isaac Ray typifies our membership 1844-69, so perhaps 
 Edward Cowles typifies the membership in the second quarter- 
 century of our association's existence. Cowles stood — and 
 thank God still stands — for a profounder insight into the nature 
 and causes of mental disease and defect, and no doubt to him is 
 greatly due the impetus to the establishment of laboratories in 
 our institutions. This is no place to eulogize the living. But 
 the third quarter-century, now coming to a close, could not have 
 been so greatly distinguished by the laboratories and by the 
 exercise of what has been called the laboratory habit of mind, had 
 it not been for Cowles. Nor is this a personal view of my own. 
 A dozen of the best men amongst our psychiatrists have said as 
 much to me in the last few years. 
 
 6. Perspective interferes overmuch with our estimate of a 
 typical personality for the third quarter-century. I myself believe 
 that no greater power to change our minds about the problems 
 of psychiatry has been at work in the interior of the psychiatric 
 
192 
 
 profession in America than the personality of Adolf Meyer. If he 
 will pardon me the phrase, I shall designate him as a ferment, an 
 enzyme, a catalyzer. I do not know that we could abide two 
 of him. But in our present status we must be glad there was 
 one of him. No American theorist in psychiatry of these and the 
 immediately succeeding decades but is compelled either to agree 
 or else — a thing of equal importance — most powerfully to 
 disagree with him. And who shall say that anybody is abler to 
 get truth and reality out of disagreement and error than psy- 
 chiatrists? 
 
 7. The outstanding development in the latter years, and espe- 
 cially in the last quarter-century of the association's history, has 
 been, to my mind, the development of social psychiatry, than 
 which it might be hard to name a more important feature of the 
 face of the world to-day. Social psychiatry, even were we to 
 include (what practically is not included, namely) public psy- 
 chiatry within its conception, is far from the whole of mental 
 hygiene. For mental hygiene includes also the far more difficult 
 and intriguing topic of the psychiatry of the individual, as 
 related to himself and his organs and processes. 
 
 8. Personally I hold, and I think every physician and espe- 
 cially every psychiatrist must hold, that the individual is not only 
 the unit of the physician's interest, but also (following Herbert 
 Spencer) the unit of the sociologist's interest. This we ought to 
 maintain, I think, against the supposed sociological improvement 
 introduced by Schaffle, namely, that the family is the social unit. 
 Accordingly, I hold that the foundation of social psychiatry (as 
 also of public psychiatry) is the psychiatry of the individual. 
 
 9. Now it was just at the outset of our third quarter-century 
 that Josiah Royce made his theoretical contributions to the con- 
 ception of the social consciousness (1894-95). From that at- 
 mosphere developed in the work of Richard Cabot the idea of 
 medical social work. Mark you that this idea was far more than 
 a mere addition of two ideas, namely, the idea medicine and the 
 idea social work, but was a productive combination of these ideas, 
 an actual novelty. It was then only a step to the development 
 of psychiatric social work in Massachusetts, 1912, a step stated 
 by Cabot himself (at the recent meeting of the National Con- 
 ference for Social Work) to be the greatest innovation in medical 
 social work since its foundation. 
 
 10. From Bakunin to Lenin is a half century. What has the 
 world to say of anarchism and Bolshevism? Certainly these 
 
193 
 
 are no new things. Perhaps neither Bakunin nor Lenin is a 
 topic for alienists of the old medicolegal group. These world 
 leaders are not on the minute to be interned as insane! But does 
 any man of us here believe that the psychiatric viewpoint could 
 fail to throw light on Bakunin and on Lenin? Alone amongst the 
 specialties of medicine, psychiatry has for its daily task the con- 
 sideration of the entire individual. The rest of the branches of 
 medicine, even neurology, appear to remain much too analytic in 
 their view of a man. Psychiatry alone uses the daily logical 
 apparatus of the synthesizer. 
 
 11. Is mental hygiene ready for the problem of Bakunin and 
 Lenin? Alas, No! We have our "Varieties of Religious Experi- 
 ence," but no James has arisen to depict, on the basis of the 
 extremest cases, the varieties of political experience. In fact, the 
 delineator of Lincoln or of Roosevelt as in any sense psychopathic 
 might well bring down upon his head far more partisan fury than 
 one who should discover the queerest traits and episodes in 
 religious heroes. We deal with Aqua Regia, with Damascus 
 blades, in our psychiatric laboratories and armories. " Divide to 
 conquer" is a necessary precaution. We must teach the world, 
 what we as physicians have so recently learned, namely, that to 
 be crazy is to be one of scores of things. To describe Lincoln as 
 a cyclothymic with attacks of depression, or Roosevelt as consti- 
 tutionally hyperkinetic (always supposing these to be true desig- 
 nations), should be no more impolite or less objective than to 
 think of Bakunin or Lenin as paranoic personalities. Crazy? 
 No! But, cyclothymic or paranoic, certainly! 
 
 12. Insanity is mental disease, but not all of it or rather of 
 them. Alienists are psychiatrists, but not all, or, in the long run, 
 the majority of psychiatrists. " Alienistics," as we may call the 
 doctrine of medicolegal insanity, is not the whole of psychiatry. 
 But, above all, psychiatry must be conceived to include the 
 minor psychoses, the smallest diseases and the minutest defects 
 of the mind, as well as the frank psychoses and the obvious 
 feeble-mindednesses. The psychiatry of temperament is an art 
 that might fling itself very far. Mr. Wilson, I believe, spoke 
 of some members of his cabinet as temperamental. As a cat 
 may look at a king (time and weather permitting), so I suppose 
 a psychiatrist might look at a cabinet officer, at least in one of 
 his temperamental phases. 
 
 13. W T e passed from the age of Darwin to the age of Pasteur, 
 to the age of Metchnikoff and of Ehrlich; we lived through the 
 
194 
 
 beginnings of systematic psychiatry in the period of Griesinger; 
 we witnessed the first clarifications of mental disease function in 
 the period of Charcot; and we have just concluded a war whose 
 psychiatric achievements (from the deepest theoretical side) trace 
 back to Charcot, flowering to my own mind in Babinski. In 
 iVmerica, outside institutions, there had been a dearth of great 
 theorists after Benjamin Rush. But the basic ideas of Weir 
 Mitchell were no doubt being laid down in the war time of our 
 first quarter-century only to effloresce in the second period. The 
 work of Charles K. Mills stands out for me as of the greatest 
 theoretical importance in American work in that second period. 
 I think of Donaldson as a great force in our third period, if we 
 are looking outside institutional ranks. 
 
 14. But it is clear that the American idea, mental hygiene, 
 must have grown in philosophic circles too. I think first of the 
 great Emersonian period, with its grotesque parody called Eddy- 
 ism or Christian Science. Then I think of the laying down of 
 the idea of pragmatism by Charles Peirce, the great and little 
 known central figure of American thought. And then I think of 
 the man William James, who put pragmatism across the Ameri- 
 can scene, but added thereto what I may call the 'psychiatric 
 touch, and really typifies all that is best in American thought. 
 Emerson, Peirce, James — these are three American names to 
 conjure by, and they are deeply responsible for the spiritual, 
 the logical and the practical factors in the whole of mental 
 hygiene. With their spirit, illumination and dynamism we shall 
 face the terrible analyses of the present hour — the rights and 
 interests of the individual as against society, and of society as 
 against the individual — with full confidence that synthesis will 
 follow analysis, and the task of Humpty-Dumpty solved at last. 
 
 15. Do you not agree with me that in all the pot-pourri of the 
 years this great problem of the place of the individual stands 
 out? That American thought, transilluminated as always by the 
 softened European lights, contains within itself immortal funda- 
 ments of the mental hygiene of nation, race and person? And 
 may we not rejoice, as psychiatrists, that we, if any, are to be 
 equipped by education, training and experience better than per- 
 haps any other men to see through the apparent terrors of 
 anarchism, of violence, of destructiveness, of paranoia, whether 
 these tendencies are shown in capitalists or in labor leaders, in 
 universities or in tenements, in Congress or under deserted cul- 
 verts? It is in one sense all a matter of the One and the Many. 
 
195 
 
 Psychiatrists must carry their analytic powers, their ingrained 
 optimism and their tried strength of purpose into not merely the 
 narrow circles of frank disease, but, like Seguin of old, into edu- 
 cation; like William James, into the sphere of morals; like 
 Isaac Ray, into jurisprudence; and above all, into economics 
 and industry. I salute the coming years as high years for 
 psychiatrists ! 
 
 Southard, E. E., and Pressey, S. L., Ph.D. A Review of In- 
 dustrial Accident Board Cases examined at the Psychopathic 
 Hospital. Proceedings, International Industrial Accident 
 Boards and Commissions, 1917, Washington, 1919, 159- 
 170; United States Bureau of Labor Statistics, March, 
 1919. No. 248. 
 
 Summary. 
 
 To sum up, then, I have mentioned a surprising number of 
 points of contact made of recent years by psychiatry and psy- 
 chology with industrial problems. 
 
 I have presented a special report of Dr. S. L. Pressey showing 
 the reliability of the psychological tests in industrial accident 
 cases, and Dr. Pressey has included in his report a number of 
 special instances in which the working of these tests may be 
 seen. 
 
 A few instances from our review have been given, showing 
 the decided bearing which psychiatric diagnosis may have upon 
 the findings for claimant or insurer, as the case may be, and on 
 the amount of compensation when rendered. 
 
 A number of pitfalls of the work have been enumerated. I 
 have laid the greatest stress upon psychometric ("mental test") 
 work because of its quantitative nature and its relatively recent 
 developments. In the industrial accident board group, from the 
 psychiatric point of view, I find cases of syphilis of the nervous 
 system, of feeble-mindedness, epilepsy, alcoholism, focal brain 
 disease, dementia prsecox, and manic-depressive psychosis, to 
 say nothing of the traumatic variety of neuropsychosis and the 
 number of odd cases difficult to classify. 
 
 I think there is no doubt that just as this work will benefit 
 those physicians and psychiatrists who are going to deal with 
 the shell shock wrecks of this war, so the entire work of indus- 
 trial accident boards throughout the world is going to prove of 
 most concrete value in the whole field of after-war re-education. 
 
196 
 
 Southard, E. E. The Mental Hygiene of Industry — A Move- 
 ment that Particularly Concerns Employment Managers, 
 and Industrial Management. The Engineering Foundation, 
 Reprint Series No. 1, February, 1920, LIX, 100-106. Also 
 in Mental Hygiene, 1920, IV, 43-64. 
 
 Summary and Conclusions. 
 
 1. The general object of this paper is to set forth the existence 
 and present rate of progress of a movement for the mental 
 hygiene of industry. 
 
 2. This term mental hygiene is coming into general use to cover 
 the expert activities of •psychiatrists {i.e., medical men interested 
 in the problems of mental disease, including the mildest forms 
 of temperamental deviation), •psychologists {i.e., scientific and 
 theoretical experts, who are now turning attention to methods 
 of mental testing designed to improve and replace the hit-or-miss 
 methods of the past), and various non-professional or semi- 
 professional aides (such as social workers with special experience 
 in character-handicap cases). 
 
 3. The recent improvements in employment management and 
 all activities dealing with industrial personnel show that industry 
 is ready for the new movement, and employment managers 
 everywhere are displaying the keenest interest in the new ideas. 
 
 4. Meanwhile the war-time results of the experts in mental 
 hygiene enumerated in paragraph 2 have given practical demon- 
 stration of the value of mental hygiene in a business partaking 
 largely of the nature of industry, namely, the business of war. 
 
 5. The earlier literature of industry conclusively shows that 
 the "mental hygiene of industry" is nothing new in its essence 
 (witness, many older references to the human element, etc.), but 
 to-day's contribution is the organization of older interests for a 
 systematic attack on industrial personnel problems. 
 
 6. The keynote of this systematic attack on industrial per- 
 sonnel problems by means of mental hygienic data and methods 
 is the pooling and co-operative combination of expert engineering 
 interests and expert medical and psychological and sociological 
 interests; in brief, the invoking by the expert in industrial personnel 
 of the aid of all available experts in personality, to the study of 
 which the whole personnel problem must reduce. 
 
 7. The interested personnel man or lay reader is implored not 
 to take sides for one or other claims or counterclaims by medical 
 men, psychologists and others concerning the virtues of special 
 
197 
 
 methods. The topic is growing and a little controversial, but 
 on the whole, the quarrels about method are superficial and the 
 unanimity of experts extraordinary (no doubt the trials of the 
 war served to mature and season the experts on all sides). 
 
 8. Another warning. Every time the world has tried to meas- 
 ure things more accurately many foolish persons have risen to 
 protest. Not a few medical men and psychologists will rise to 
 say over the same formula against the mental hygiene of industry. 
 It is to be hoped that, at this late date of the world's history, we 
 can jump this zone of senseless protest against what must in- 
 evitably succeed, namely, a program of more expert study of 
 anything whatever, including the human personality, wherever 
 at work. 
 
 9. The movement for a mental hygiene of industry is neither 
 an outgrowth of the efficiency movement (Taylorism and the 
 like) nor an outgrowth of the workmen's welfare movement 
 (economic interest in shorter hours, better working conditions 
 and the like), though mental hygiene does effectively combine 
 "efficiency" and "welfare" (as it were, F. W. Taylor and Jane 
 Addams). 
 
 10. On the contrary, a stream of independent developments in 
 our knowledge of personality (medical, psychological, illustrated, 
 for example, in the kind of insight into human nature displayed 
 by William James) is now pouring itself into a branch of engineer- 
 ing — personnel management — which has been running parallel 
 for some time. Let us think of the movement in the terms, not of 
 F. W. Taylor nor of Jane Addams, but in terms of William James. 
 
 11. The text contains sundry definitions and general statements 
 on these lines. Future papers will amplify the account. 
 
 12. Perhaps the argument for a mental hygiene of industry 
 may be put in a nutshell form as a question: Why should not 
 industrial managers seek the aid of (a) those who can measure 
 at least a few of our mental capacities and have shown their 
 abilities in the war work; of (6) those who are the best special- 
 ists we yet have in temperament and the best experts in griev- 
 ances yet developed; and of (c) others less professionally trained 
 who are capable of tracing out or helping to trace out the actual 
 situation of, e.g., labor "turn-over" as shown in the individual 
 instance? 
 
 13. In short, why not help to push on the movement for in- 
 dividualism in industry that everyone sees coming and ardently 
 hopes for? 
 
198 
 
 Southard, E. E., and Solomon, H. C. Morbi Neurales. An 
 Attempt to apply a Key Principle to the Differentiation of 
 the Major Groups. Archives, Neurology and Psychiatry, 
 1920, III, 219-229. 
 
 Summary. 
 
 The method of diagnosis by orderly exclusion, already proposed 
 for use in the diagnosis of mental diseases, is probably of equal 
 value in the field of nervous diseases. The writers have en- 
 deavored to gather the main types of nervous disease into a com- 
 paratively small number of groups for successive consideration 
 by the tyro, or even by the expert, in diagnostic elimination. 
 Experts may prefer a different order from the one proposed, but 
 it is unlikely that any neurologist fails to use, consciously or 
 unconsciously, some form of orderly diagnosis. 
 
 Yet the student is quite likely to be taught that the best pro- 
 cedure is to pick out some striking symptom in a case under con- 
 sideration, and to follow that symptom back to textbook models 
 for a suggestion as to the entity involved. He then endeavors 
 to match the data of the case in hand with the possibilities laid 
 down in the textbook. 
 
 We think that it is much more desirable to take the general 
 situation in the body at large into account, and to include, if 
 possible, first, the hypothesis of an infectious origin for the 
 symptoms. Secondly, we try to exclude, if possible, the effects 
 of coarse and otherwise destructive lesions of the nervous system- 
 (historrhexes), namely, in general, such conditions as show no 
 signs of infection, but exhibit reflex disorders and signs of 
 heightened intracranial pressure and the like, suggestive of focal 
 lesion. Thirdly, we come to the hypothesis of the existence of 
 one or other of those classic degenerations with which the neu- 
 rologist is familiar. If infection, historrhexis and classic degenera- 
 tions can be excluded, we then proceed, fourthly, to the hy- 
 pothesis of some kind of imbalance, perhaps metabolic or endocrine 
 or sympathetic. If the diagnosis cannot be made on these lines, 
 possibly the condition belongs in some miscellaneous and other- 
 wise undefined or highly specialized group. 
 
 Even when the disease seems to be limited to a peripheral 
 nerve, we consider that then the successive hypotheses of (1) 
 infection, (2) historrhexis, (3) specialized neuronatrophy, (4) 
 imbalance, can be preferably considered in that order. We think 
 that by the pursuit of some such method as this the neurologist 
 
199 
 
 can bring his work better into line with that of general medicine. 
 The method is, moreover, a very pragmatic method, since lines of 
 treatment are specially indicated for the different great groups 
 of disorders. But in so difficult a field we do not wish to dog- 
 matize, and shall be content if our communication arouses interest 
 in the application of the key or order principle to the diagnosis of 
 nervous diseases. 
 
 Southard, E. E. Trade-Unionism and Temperament. The 
 Psychiatric Point of View in Industry. Industrial Manage- 
 ment, April, 1920, LIX, 265-270. The Engineering Founda- 
 tion, Reprint, Series No. 2. 
 
 Southard, E. E. The Modern Specialist in Unrest: A Place 
 for the Psychiatrist in Industry. Journal of Industrial 
 Hygiene, 1920, II, 11-19. 
 
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